Indian J Pediatr (2010) 77:975980

DOI 10.1007/s12098-010-0151-9

ORIGINAL ARTICLE

Global Developmental Delay and Its Determinants

Among Urban Infants and Toddlers: A Cross
Sectional Study
Sandeep Sachdeva & Ali Amir & Seema Alam &
Zulfia Khan & Najam Khalique & M. A. Ansari

Received: 15 December 2009 / Accepted: 15 June 2010 / Published online: 24 August 2010
# Dr. K C Chaudhuri Foundation 2010

Abstract
Objective To estimate the prevalence of global developmental delay among children under 3 years of age and
study the determinant factors.
Methods Cross sectional descriptive study was conducted
in field practice areas of the Department of Community
Medicine, JN Medical College, Aligarh, India. A total of
468 (243 boys and 225 girls) children aged 03 years were
included. Developmental screening was performed for each
child. A multitude of biological and environmental factors
were analysed.
Results As many as 7.1% of the children screened
positive for global developmental delay. Maximum delay
was observed in the 012 months age group (7.0%).
Undernutrition and prematurity were the two most
prevalent etiological diagnoses (21% each). Stunting
and maternal illiteracy were the microenvironmental
predictors on stepwise binary logistic regression while
prematurity and a history of seizures emerged significant
biological predictors.
Conclusions Developmental delay can be predicted by
specific biological and environmental factors which
would help in initiating appropriate interventions.
Keywords Global developmental delay . Biological .
Microenvironmental factors

S. Sachdeva (*) : A. Amir : S. Alam : Z. Khan : N. Khalique :

M. A. Ansari
JN Medical college, AMU,
Aligarh, India
e-mail: sandeepsemail@rediffmail.com

Introduction
More than 200 million children under 5 years of age in
developing countries do not reach their developmental
potential [1]. Children, especially infants and toddlers
constitute the most disadvantaged group as far as
psychosocial development is concerned. This is attributable to the greater vulnerability of the developing brain
in the early formative years. Besides biological determinants, family environments of young children are major
predictors of cognitive and socioemotional abilities.
Early identification and timely intervention in populations with established risk can go a long way towards
improving their functional capacity [2]. The present
study is an attempt to assess the magnitude of global
developmental delay among children under 3 years of
age and to analyse the impact of important biological and
ambient environmental factors on their psychosocial
development.

Material and Methods

Study Areas and Subjects
This community based cross sectional study was conducted (during the period of August 2007 to June 2008)
in the field practice areas of the Department of
Community Medicine, J N Medical College, Aligarh,
India. The urban health training center (U.H.T.C) has
four registered peri-urban localities with 1410 households and a registered population of 9,250. A community
based household survey was conducted in the registered
areas.

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Indian J Pediatr (2010) 77:975980

Sample Size and Sampling Method

Microenvironmental Factors

The estimated sample size was calculated according to

the formula: N=4pq/d2 where p is the prevalence of
global developmental delay, q=1-p, and d is relative error.
Taking the prevalence of Global Developmental Delay
(GDD) in children under 3 years of age as p=11.1% [3]
and relative precision d as 5% of p, the sample size
calculated was 157. It was however decided to inflate this
estimated sample size to the order of almost trebling to
around 500 in order to augment validity. Among the 1410
households surveyed, a total of 1496 children in this age
group were listed. A systematic sample consisting of every
third child listed was pre-selected for developmental
screening [4]. In terms of demographic characteristics,
the systematic sample was representative of the overall
population of children surveyed. The final sample
however comprised of 468 children (225 females and
243 males) as 32 kids from the initial cohort did not
participate because of parental refusal and, their probable
lack of awareness regarding benefits of developmental
screening.

The microenvironmental factors assessed were the type of

family, dwellings, caste, parental literacy, single parenting
and social class.

Study Instruments

The impact of the following biological factors was

assessed: consanguinity, mode of delivery, gestation at
birth, birth asphyxia, multiple gestation, neonatal jaundice,
seizures and facial dysmorphism. If the child was born
prematurely, the age was corrected by subtracting the
number of weeks of missed gestation from present
(chronological) age. For this study, children born before
34 weeks gestation fulfilled the criterion for prematurity.

The ICMR Developmental Screening Test questionnaire

[5] developed and standardized on more than 13,000
children aged 06 years was used for developmental
screening of the children. The screening test comprised
of five major developmental areas, namely (i) gross motor,
(ii) vision and fine motor, (iii) hearing, language and
concept development, (iv) personal skills and (v) social
skills. The age of attainment of skills in each of these
developmental areas was compared with the average
age of attainment (50th centile) of a milestone and any
lag from this reference was deemed as a delayed
milestone. Global Developmental Delay was operationally
defined as a significant delay, below the mean in two
or more domains (gross/fine motor skills, cognition,
speech/language, personal/social skills, or activities in
daily living) [6].
General Information
The exact age of the child was computed from the childs
date of birth. When data on the exact date of birth was not
available, the age as told by the mother was used, corrected
to the nearest month. A regional local-events calendar was
used to assist the mothers for better recall. The social class
of the childs family was determined using the Modified
Prasad Scale [7]. Social classes I, II and III of the modified
Prasads classification were categorized as upper class and
IV and V as lower classes.

Nutrition
Variables pertinent to nutrition were appropriateness of
breast feeding, underweight, stunting, wasting and pallor. A
precise history of dietary intake of the child was elicited
from the mother (recall of food items consumed in last
24 h). Anthropometry was carried out for each child and
stigmata of micronutrient deficiencies were sought for.
Height and weight measurements were recorded following
standard techniques. Indices for wasting and stunting were
used to evaluate the nutritional status of the subjects as per
the Centre for Disease Control 2000 norms. Age and sex
specific2 z-scores were followed to define wasting and
stunting.
Biological Factors

Statistical Analysis
Analysis was performed using SPSS version 10.0 (SPSS,
Chicago, IL). Continuous variables were expressed as mean
standard deviation (Gaussian distribution) or range and
qualitative data was expressed as percentage. Chi square
test and Fishers exact test were used for univariate
analysis. All p values were two tailed and values of <0.05
were considered to indicate statistical significance All
confidence intervals were calculated at 95% level. Binary
logistic regression was used to do the multivariate analysis.

Results
The majority (186/39.7%) of children were seen in the 0
12 months age group and the least (120/25.6%) in the 24
36 months age group (Fig. 1). Female children constituted
48.08% of the study group. Around 10% children were
born preterm. Half (51.46%) of the children belonged to
Muslim families and rest were from Hindu families. Sixty

Indian J Pediatr (2010) 77:975980

977

Fig. 1 Bar chart representing age and gender distribution of the study
population

percent were living in nuclear families. Eighty-three percent

children were living in overcrowded dwellings and 76.5%
belonged to the lower socio economic class. There were an
aggregate of 13 (of 186), 10 (of 162) and 4 (of 120)
children with developmental delay in each of the age
groups of 012, 1224 and 2436 months respectively. The
trend therefore was of a marginal decline in the proportion
of this group of children (from 7.0% to 6.2%) as the age
group progressed from 012 months to 1224 months, only
to exhibit a steep fall to 3.5% in the 2436 months age
group (Table 1).
More girls were affected in comparison to boys among
the 012 months age group. The relative distribution of the
most probable etiologies to the developmental lapses
observed in the study population is illustrated in the pie
chart below (Fig. 2). Undernutrition (PEM) and prematurity
could be attributed as the major causes (21% each) whereas
in as many as 28% of cases, a definitive clinical condition
could not be discerned. Birth asphyxia (9%), sequelae of
(meningo) encephalitides, varying degrees of hearing loss,
visual impairment (vitamin A deficiency in our case),
maternal deprivation (3% each) and dysmorphic syndromes
(9%) contributed to the rest. Undernutrition was a common
denominator in almost half of the children with history of
premature birth, and in children with maternal deprivation
Table 1 Age and sex distribution of normal and delayed
development in the study
population

Discussion
As many as 7.1% of the children screened positive for
global developmental delay in the present study. Comparable rates were observed by workers from the UAE [8] who
observed a prevalence of 8.4% of GDD in children under
3 years of age. Investigators from Korea reported a
prevalence of 11.1% [3] of questionable development in
children under 2 years of age. Workers from India [9]
Age group (months)

Development

012 months

Normal

Female
76
(89.5)
9
(10.5)
85
(100)

Delayed
Total
Numbers in parentheses indicate
percentages

and Downs syndrome. Child with Downs syndrome

phenotype had history of birth asphyxia as well. Nutrition
related factors, particularly chronic energy deficiency
manifesting in the form of decreased height for age. (OR=
2.2; 95% CI 1.1 to 4.6) and pallor (OR=2.3; 95% CI 1.2
to 4.7) were significantly associated with poor developmental performance on univariate analysis.
Variables pertaining to home environment like social class
(OR=3.7;95% CI 1.4 to 9.7), pucca dwellings(OR=2.5;95%
CI 1.1 to 5.9) and literate mother (OR=3.09;95% CI 1.25 to
7.63) were found to be positive deviants towards developmental performance in these children, whereas single parenting (OR=2.5;95% CI 1.3 to 5.2) correlated with poor outcome.
(Table 2) Amongst the biological factors analysed in the
univariate analysis; facial dysmorphism, (OR=62.2; 95% CI
6.7 to 574.67), seizures (OR=45; 95% CI 4.5 to 446.3) and
birth asphyxia(OR=21.65; 95% CI 3.48 to 134.56) in
decreasing order of their relative risks, were associated with
developmental lag. A history of consanguinity among parents
and prematurity, too were predictors of poor developmental
performance among the children studied. (Table 3).
The model for binary logistic regression of important
predictor variables obviated the effect of a few factors found
significant on univariate analysis except for maternal literacy
(Adjusted OR=4.44) and stunting (Adjusted OR=5.69). The
biological factors of significance that were brought into fore
were gestational age (Adjusted OR=3.66) and seizures
(Adjusted OR=6.62). (Table 4). Factors as pallor and pucca
dwellings significant on univariate analysis did not emerge
significant on binary logistic regression analysis.

1224 months
Male
97
(96.1)
4
(3.9)
101
(100)

Female
80
(96.4)
3
(3.6)
83
(100)

2436 months
Male
72
(91.2)
7
(8.8)
79
(100)

Female
55
(96.5)
2
(3.5)
57
(100)

Male
61
(96.8)
2
(3.2)
63
(100)

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Indian J Pediatr (2010) 77:975980

term asphyxic newborns without causing adverse neurodevelopment at 2 years. This could explain an otherwise
normal developmental outcome in several of the home
deliveries with history of delayed cry at birth. Chronic
undernutrition manifest in the form of stunting was
observed in as many as 59% of children. Several other
studies have also shown that stunted growth adversely
affects a childs cognitive ability later in childhood [1921].
Reduced school performance has been observed in stunted
children in Guatemala [22]. In another Indian study, it was
noted that development of gross motor milestones was
Table 2 Univariate analysis of microenvironmental and co morbidity
related determinants of developmental performance
S.No
Fig. 2 Pie chart showing relative proportions of different etiologies of
developmental delay among children in the study population.
Coexistent etiologies are depicted in similar colours

observed the same to be of the order of 2.5% in children

under 2 years from deprived urban settlements of Hyderabad city. There is limited information regarding prevalence
of neurodevelopmental delay in developing nations, including India. The prevalence of developmental delay reported
by various authors in different studies varies over a wide
range. This could be a result of a lack of uniformity in the
instruments employed to assess developmental performance. The decline in the rate of developmental faltering
with age corroborates with the observation made by Persha
and Arya et al. [10]. This indicates a positive impact of
certain factors that accumulate with age, as for example
better child rearing practices on part of the mother.
However, this view has been refuted by few other workers
[11, 12]. Nearly a third of the children could not be
assigned a specific etiology of their delayed development.
This has been confirmed in other studies [13, 14]. Analysts
from Canada have also confirmed that etiologic yield in an
unselected series of young children with global developmental delay is close to 40% overall and 55% in the
absence of any coexisting autistic features [15]. Investigators have opined that ultimate developmental potential is
multifactorial and is a function of a multitude of genetic and
environmental factors. This interplay of nature vs nurture
renders identification a difficult task [16]. The maximum
detriment to child development was posed by undernutrition and prematurity as observed in other studies as well
[10, 17]. Besides, a minor proportion was afflicted with
easily remediable impairments as deafness. Although a
history of delayed birth cry was common, birth asphyxia
was not the most prevalent of the recognizable etiologies as
in other studies [10]. Randomised clinical trials conducted
at several centres including India [18] have proven that
room air is as good as 100% oxygen for resuscitation of

10

11

12

Variable

Social class
Lower
Upper
Caste
Upper
Lower
Family
Nuclear
Joint
Dwellings
Katcha
Pucca
Mother
Illiterate
Literate
Father
Illiterate
Literate
Single parenting
Yes
No
Breastfeeding
Appropriate
Inappropriate
Weight for age
Normal
Underweight
Height for age
Normal
Stunted

Development
Normal

Delayed

OR(95% CI)

262
173

28
5

3.7(1.4 to 9.7)

152
283

8
25

0.6 (0.3 to1.4)

272
163

19
14

0.7 (0.4 to 1.6)

392
43

27
6

2.5 (1.1 to 5.9)

258
177

27
6

3.1 (1.3 to 7.6)

273
162

23
10

0.7 (0.4 to 1.6)

118
317

16
17

2.5 (1.3 to 5.2)

262
173

15
18

0.5 (0.3 to 1.2)

320
115

19
14

1.8 (0.9 to 3.9)

312
123

17
16

2.2 (1.1 to 4.6)

30
3

0.7 (0.2 to 3.5)

19
14

2.3 (1.2 to 4.7)

Weight for height

Normal
402
Wasted
33
Pallor
Present
162
Absent
273

OR Odds ratio

Indian J Pediatr (2010) 77:975980

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Table 3 Univariate analysis of biological determinants of developmental performance

S.No

Variable

Consanguinity
Yes
No
Delivery
Normal
Caesarean
Gestation
Term
Preterm

Development
Normal

Delayed

OR(95% CI)

86
349

12
21

2.1 (1.1 to 4.5)

285
150

21
12

1.1 (0.5 to 2.3)

396
39

26
7

2.7 (1.2 to 6.7)

23
10

0.6 (0.3 to 1.4)

3
30

21.6 (3.5 to 134.5)

4
29

45 (4.5 to 446.3)

2
31

2.5(0.5to11.7)

5
28

62.2 (6.7 to 574.7)

Multiple gestation
Yes
262
No
173
Birth asphyxia
Yes
2
No
433
Seizures
Yes
2
No
433
Jaundice
Yes
11
No
424
Facial dysmorphism
Yes
1
No
434

delayed in significantly high percentage of stunted infants

with H/A<2S.D (22.2%) compared to normal H/A (5.6%,
p value=0.003) [23]. This is because poor linear growth
creates an overall comparative disadvantage in an already
deprived environment. Either a lack of adequate total
calories or a deficiency of protein may impede the
development of the neurological system. Another possibility is that the poorly nourished child, pre-and post-partum,
has insufficient energy to take advantage of opportunities
for social contacts and learning. Finally, it may be that
adults and older children treat the larger child as a more
mature individual, which leads to increased social learning
Table 4 Model for logistic
regression of significant predictor variables for developmental
performance

opportunities. Pallor is a usual accompaniment of undernutrition and was significant in the univariate analysis.
Several workers have reported an independent association
between nutritional anemia and developmental outcome
[24, 25] but this was not found in our case. Another
determinant that emerged significant in the logistic regression was maternal illiteracy which was noted by several
other investigators as well. Maternal schooling was believed to affect childrens cognitive development by means
of environmental organization, parental expectations and
practices, provision of materials for childs cognitive
stimulation, and variety in daily stimulation [26]. The
results of our analysis suggest that both the nutritional and
social domains are related to cognitive development, and
that their relative importance depends, probably on the
particular domain of development. We, however, have not
studied the effect of these factors on individual spheres of
development. Apart from the above microenvironmental
factors, the biological factors also deserve mention as two
of them were independently significant with developmental
outcome. Because a majority of the informers had no record
of the birth weight, prematurity of less than 34 weeks
gestation was operationally used as a marker to indicate
significantly small size at birth. A highly significant
association with the outcome variable in the present study
was elicited. With state of the art intensive care, the survival
of extremely preterm/ELBW neonates is improving. It is
therefore undesirable to neglect the developmental prognosis of these children. Preterm neonates faltered significantly
in psychomotor development as found in the present study
as well as in other contemporary works [27, 28]. Morris BH
et al. in their prospective longitudinal study also demonstrated a greater length of time required to reach full enteral
feeding and mental developmental outcome at 24 months
corrected age [29]. Preterm births secondary to congenital
infections/malformations may develop CNS complications.
Complications like intraventricular hemorrhage peculiar to
the premature state could well be responsible for developmental problems including cerebral palsy among survivors.
Recurrent seizures in the neonatal or early childhood period
can cause chronic brain hypoxia resulting in poor brain
development. The spectrum of etiology could include

Variable

Estimated coefficient

S.E of estimate

Odds ratio

Significance (p)

Stunting
Single parenting
Gestation
Pallor
Pucca dwellings
Maternal literacy
Seizures

1.55
12.04
5.88
2.55
12.70
8.88
6.48

0.65
29.43
0.55
28.90
30.86
1.20
2.45

5.69
0.63
3.66
0.89
0.59
4.44
6.62

0.02
0.68
0.04
0.84
0.68
0.03
0.01

980

varied causes like epilepsy or sequelae to encephalitides/birth

asphyxia. A significant independent association with seizures
as in our case was observed by Barnard C and coworkers who
concluded that 34% of children with refractory epilepsy
demonstrated developmental deterioration [30]. However, in
a large European cohort study, it was noted that the outcome
in children after lengthy febrile convulsions and status
epilepticus was better than reported from studies of selected
groups and seems determined more by the underlying cause
than by the seizures themselves [31].

Indian J Pediatr (2010) 77:975980

9.
10.

11.

12.

13.

Conclusion

14.

Developmental performance of children is a function of

several biological and social factors. The proximate factors
in the childs mileu such as nutrition, gestation and seizures
were more significant than the distal factors; thereby
making a case for their easy and cost effective prevention.
Children exposed to these factors are at risk of developmental delay. It is cost effective to detect early developmental lags (including hearing impairment) in at risk
children through simple screening tests. Research is
required to investigate the hidden etiologies of developmental delay. The study falls short of not being able to
study correlates of individual domains of child development. Its retrospective design is a limitation as well.
However, the study attempts at being a sensitizing exercise
for health care providers towards this extremely crucial
issue of the lives of our future generation.

15.

16.
17.

18.
19.

20.
21.

22.
23.

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