The study revealed a very high prevalence of suspected developmental delays (61.1%) within severe acute malnourished children under-five. Malnutrition in children is one of the main reasons for developmental delay which is having a lifelong adverse impact on health [10, 22, ]. Undernutrition affects the child’s behaviour and temperament. It is one of the reasons for low economic productivity in adulthood [22, , ]. Because of being lethargic and apathetic, malnourished children have problems in understanding information and they are least interested in their surroundings. This results in delayed social interaction skills. Personal and social development in the initial years of life is the main factor responsible for desirable mental health and performance in adulthood. Therefore, the recognition of personal, social and behavioural problems in young children is very important []. Within this study, we found that in the domain of personal and social behaviour, almost half of the children (45.8%) have delayed developments, with an additional 16.3% being in the caution zone. This result is enforced by previously described theories and can, therefore, be generalized to other study settings [24, 25].
Children in our study were also found to be affected in language and motor adaptive skills. Previous research explained that due to malnutrition children are suffering from multiple micronutrient deficiencies (like calcium and vitamin D), which are important for skeletal muscle function. For that reason, a deficiency of these micronutrients affects motor skills [6]. Nutritional insufficiencies even in acute stage may damage the cognitive profile and entire auditory system in children resulting in verbal and written language problems. It has already been proved that height, weight and head circumferences are directly related to high incidence of delays in motor skills and the language domain [, ].
Child development proceeds through a gradual multifaceted interaction, probably by the parents or caregiver’s education level, living and working conditions, social circumstances, availability of health facilities, and the physical environment. An unconstructive social or external environment in early life years is mostly linked to compromised development. Every region or community has their own circumstances. For that reason, locally targeted research and interventions are needed to go forward [26]. In the present study, mother’s education, monthly income of a family, frequent hospital visits due to repeated illness, and family size were significantly linked to developmental delays in the bivariate analysis. This has also been shown in previous studies [1, 3, 10, 26]. Comparable research in the Indonesian slum area and in the United States revealed that low maternal education and low family income, is strongly associated with delayed development in young children [1, , ]. This is due to the fact that maternal education has a direct effect on proper medical follow-up in the antenatal period, effective family planning, optimal nutrition and child health care [22].
In our study, exclusive breastfeeding was significantly associated with normal child development. In addition, a strong correlation between breastfeeding and progressive developmental outcomes in children was proven previously. This can be explained by the nutritive value of breast milk and the strong emotional bonding between mother and child. Studies also relate breastfeeding with high score achievements in cognitive tests and in motor and mental development [, ]. A cluster-randomized trial did intervene for breastfeeding promotion and found significant results for children long-term outcomes in health and neuro-development [].
The risk of developmental delay was found to be increased in the first two years of age. It was also observed previously, that if an infant is suffering from malnutrition in early childhood the risk of developmental delay is enhanced. Furthermore, this is an indication of serious physical or psycho-social problems. Development in infancy and toddler period is fast and easily influenced by environmental and social-demographic variables [1, 30, 32].
In contrary to other studies, the history of a child’s close contact with a TB smear positive adult patient at home or in near surroundings is significant in the present study. For understanding this phenomenon, more in-depth research is required. One explanation might be that these children could have had an undiagnosed latent or active TB because of malnutrition, low immune status [2,10], or the contact with smear positive TB patients. Therefore, a complete physical examination along with laboratory investigations is required for the diagnosis of TB in these children.
Strengths and limitations
Besides the missing information on TB status of the children within this study, another major limitation is the cross-sectional design. Monitoring the child’s developmental and nutritional status over a longer time period would impart a better perceptiveness because of the dynamic nature of growth and development. The strength of our study is that we have used the Denver Developmental Screening Test II, which is a validated scale for developmental assessment of children. Furthermore, this assessment has been conducted by well-trained medical staff using established protocols. Moreover, to our knowledge, this is the first study in rural areas of Punjab, Pakistan, to investigate the loss of developmental potential in children with severe acute malnutrition.