Infant and Toddler Development: An Outcomes Study of Early Detection Workshops

INTRODUCTION

Paediatricians play a critical role in monitoring, guiding, and supporting the growth and development of children through routine surveillance and screening protocols. According to the Indian Academy of Pediatrics, there are at least twelve vaccination visits in the first 24 months, which present easy opportunities for developmental surveillance.^[1] While evidence documenting trends for developmental surveillance in India is scant, lack of implementation of professional guidelines on a national level, variability in attitudes and practices of professionals, culture-based myths, and poor parental competencies are some of the barriers that result in missed opportunities for surveillance.^[2,3]

A paediatrician’s role in the surveillance process is irreplaceable, given their easy access to infants and toddlers as part of well-baby visits and the trust established with the families. They also serve as valuable team members in early intervention services by providing anticipatory guidance, support for parents, and education during these visits.^[4,5] A familiar example of this is the discussion surrounding the use of baby walkers among families. Although evidence-based recommendation strongly discourages the use of baby walkers, many parents often need a discussion with their paediatricians to accept the information.^[6] In contrast, a survey showed gaps in knowledge among paediatricians, but the ones who saw injuries related to baby walkers were more likely to have this discussion with families.^[7]

Most commonly, paediatricians use generic milestone checklists to inform their surveillance practices. However, these milestone checklists are often limited in the number of skills across domains, especially in the early months when development is nuanced.^[8] Additionally, not all milestone ranges coincide with the age of well-baby visits, which shifts the responsibility of close monitoring at-risk infants back to the paediatricians.^[9] Lack of in-depth knowledge about development has been reported as a self-identified barrier by paediatricians.^[10,11] Paediatricians are the initiators and driving forces behind improved surveillance rates, yet very few studies have examined gaps in developing these core competencies among them through continuing education, with none in the Indian literature.^[12,13]

Allied health professionals, such as physical therapists, speech-language pathologists, and occupational therapists, possess in-depth knowledge to identify developmental differences before they become apparent and can provide anticipatory guidance to reduce functional limitations at an early stage. There is progressively more evidence suggesting the importance of interdisciplinary teamwork in clinical practice.^[14,15] To strengthen this process, the contributions of allied health professionals for interdisciplinary teamwork need to be introduced in the early stages of professional medical education.

A few years ago, the introduction of a functional observation-based surveillance protocol, developed by the authors’ team, in a high-risk follow-up clinic at a tertiary hospital in an urban setting led to improved surveillance and early referrals.^[16] Seeing the value of an easy, multi-domain surveillance protocol, the team was invited to conduct a one-day workshop by various local chapters of the Indian Academy of Pediatrics in Maharashtra.

This paper aims to document the outcomes of four such workshops based on knowledge surveys conducted before and after the workshop. Incidental information about present developmental surveillance trends followed by paediatricians in Maharashtra was obtained.

MATERIAL AND METHODS

The Institutional Ethics Committee of the affiliated institution reviewed the study protocol. Preliminary information related to their work settings and practices was collected prior to the workshop, and feedback was collected after the workshop. A ten-item knowledge survey was used for the pre- and post-tests.

RESULTS

While reporting on the current practices, 48% participants reported “ruling out ill health” to be their primary concern, in contrast to a meagre 9% reporting “development” to be the primary concern at well-baby visits. Similarly, to judge development, 46% said they relied on history and patient examination, while 35% relied solely on the latter. Only 13% of the participants used a combination of history, patient examination, and patient report. Most paediatricians (75%) assessed development without using standardised tools, and 71% stated that they referred to only medical textbooks for information on development.

Pretest frequency analysis revealed that Q1 (appropriate age of rolling) and Q10 (use of adjusted age) elicited the maximum number of correct responses, while Q2 (Language check at 18 months) and Q5 (stacking a tower of 4 blocks) elicited the highest number of incorrect responses.

An independent sample t-test revealed no significant difference in the total number of correct responses between genders (t=0.55, p=0.057 or type of practice (t= 0.09; p=0.92). However, a Chi-square test revealed a significant association (Chi square= 7.86; p=0.049) between the proportion of correct responses to pre-test question 8 (age of referral for delayed walking) and types of practice. Specifically, 77% of private practitioners responded correctly to this item as compared to 50% of professionals working in hospital settings.

A paired t-test revealed a significant increase in the total number of correct responses post the workshop (t=6.5; p<0.001). Table 1 presents the mean and SD values of total scores before and after the workshop, across the types of practice of the respondents.

Along similar lines, changes in response trends post the workshop were analysed individually for each of the ten questions. McNemar’s test revealed a significant increase in the proportion of correct responses to Q2 (p=0.001), Q4 (p<0.001), Q5 (p=0.001), Q7 (p<0.001), and Q9 (p<0.001) post the workshop. Table 2 shows the change in the proportion of correct responses post the workshop for each of these items.

To determine whether the gender of participants or type of practice influenced the change in the total number of correct responses after the workshop, a split-plot ANOVA (SPANOVA; mixed between-within-subjects ANOVA) was conducted, with gender or type of practice as a between-subjects variable and total score as a within-subjects variable. The results revealed no significant interaction between the gender of participants and workshop outcome [F (1,86) = 0.38; p=0.53] or type of practice and workshop outcome [F (1,81) = 0.81, p=0.49].

Post-workshop feedback data revealed that 94% of the participants found the content easy to understand and retain, while 51% of participants expressed the need to have online resources at hand for future reference. About a quarter of the participants also suggested online resources for parents to access directly. The open-ended comments were transcribed verbatim and classified into themes by the first author in concurrence with the second author. Table 3 shows the keywords used to group the comments under one of the six themes.

A majority (51%) of the participants expressed the need to have online resources at hand for future reference, followed closely by online parent resources.

DISCUSSION

Current trends described by the participants clearly demonstrate poor implementation of guidelines for development surveillance also seen in other parts of the world.^[19] Accessing medical textbooks is not sufficient to provide the latest, updated information, nor does it translate to better clinical skills for surveillance.^[20] During the interactive sections of the workshop, many participants expressed concerns related to the additional time required for using screening tools and the lack of parent-administered screening tools in local languages.^[21,22]

Pre-test scores indicated three questions that had the most correct responses (Age of rolling, W-sitting, and use of adjusted age) were gross motor-related knowledge questions, while the three questions that received the least correct responses (language check at 18 months, stacking a 4-block tower and language development for 0-6 months) were related to knowledge about speech and language domain. The findings suggest that paediatricians are well-informed about easily visible or observable developmental milestones in the gross motor domain and need more education about associated skills in other domains at the same age. Indian studies investigating the referral patterns for delays found that language delays have a higher proportion of domain-specific delays.^[23,24] A Dutch study also found biases towards boys and bilingual families.^[25]

Post-test score improvements were significant in five questions, 4 of which related to language and fine motor skills, indicating the need for more knowledge about development in these domains. The fifth item with a significant improvement was the early initiation of the prone position for play and development, referencing the gap between knowledge and practice.

The questions where participants had to identify the age at which a milestone like rolling or walking was achieved showed insignificant improvement in scores for the group. It is worth noting that scores for these questions showed considerable performance pre-test. There were 82% correct pre-test responses for the age of rolling and 64% for the age of walking. However, questions that asked about what activities are required to get to milestones, like “age of starting prone for play (tummy time)” or “Stacking a tower of 4 blocks” and addressing common myths like” bilingualism causes speech delays” showed significant improvement. Pre-test performance for these questions was lower than 35%. This may be because medical textbooks only provide information about the distinct age range for milestones, not addressing the continuity of development as a spectrum.^[26,27]

Scores for two questions related to the age of referral for further investigation by therapists (referral for walking and hearing referral for regression of babbling) worsened significantly. For the motor milestone (Q8: Age of referral for the delay in walking), the number of correct responses (18 months) dropped from 64% to 42%. However, post-test responses for most participants indicated that they chose an age for referral earlier than the one chosen for the pre-test. 54% of the participants who had responded correctly (chosen to refer at 18 months for walking) would now refer earlier at 12-15 months. It is also important to note that all participants who had previously chosen to wait till 24 months for referral chose the 15–18-month option in the post-test. Evidence shows that walking requires practice time to synthesise and coordinate the sensory-motor system to gain proficiency as well as opportunities within their environment.^[28–31] An earlier referral might serve as a preventive measure by providing families with play suggestions and environmental modifications to encourage independent walking. We consider the reduction in the number of correct responses to be a positive sign for the workshop content and facilitation.

Similarly, for the question pertaining to a reduction in babbling (Q6), although findings show that the percentage of participants who gave correct responses reduced from 33.33% pre-test to 26.96% post-test, a closer look at the frequency distribution of responses reveals an important positive outcome of the workshop. The workshop emphasised that the child begins a transition from babbling toward the first word at around 9 months. Retention of this knowledge was reflected in a positive shift in the number of respondents who chose option a (“Nothing. This is just a transition phase from babbling to single words.”). In other words, while the number of participants who chose option c (“A hearing evaluation”) reduced from pre-test to post-test, the number of respondents who chose option A increased from 13.33% to 17.97%. Option c (“A swallowing evaluation”) was the least preferred response pre-test (3.33%) and post-test (2.24%), indicating that the workshop content did not mislead participants into selecting an irrelevant response option. It must, however, be noted that most of the participants chose option d (“Increasing the amount and frequency of interaction with the child.”) pre-test (48.88%) as well as the post-test (49.43%). India has a national newborn screening program that emphasises early hearing screening as the most effective before 6 months.^[32,33] The results indicate a change in the teaching module to further emphasise the importance of hearing evaluation and the relationship between hearing and speech. Although this was covered in a short segment of the workshop, it might need to be emphasised with experiential or hands-on examples in the future.

The workshop was designed to prevent a “wait and watch” response and missing opportunities for early referrals by strengthening observation skills, appreciating the complexities of development and the impact of missing critical everyday experiences required to build milestones. To the authors’ knowledge, therapist-led development-related workshops for medical professionals are rare. The workshop design addressed situations encountered in practice by the participants with a culturally appropriate, resource-limited outlook. Participants were encouraged to view development through a broader lens, considering experiences provided by the environment and parents, as well as their role in guiding such experiences for all infants under their care.

CONCLUSION

The positive outcomes of these workshops are encouraging. If paediatricians can implement the knowledge gained in their practice, it could lead to the early detection of concerns and facilitate timely intervention.