Study On Physical And Psychomotor Development And Some Related Factors Of Infants In Hue City-Vietnam, 2009-2010 – Hoang Thi Bach Yen

539 JOURNAL OF SCIENCE, Hue University, N0 61, 2010 STUDY ON PHYSICAL AND PSYCHOMOTOR DEVELOPMENT AND SOME RELATED FACTORS OF INFANTS IN HUE CITY - VIETNAM, 2009-2010 Hoang Thi Bach Yen, Hoang Anh Tien , Nguyen Van Dat, Dinh Thanh Hue College of Medicine and Pharmacy, Hue University SUMMARY Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. For children, good health is very important because it is the foundation for physical, psychomotor development. Nutrition for children in the first years plays an important role in the development process and quality of life of each individual. Insufficient nutrition in this period can lead to poor physical and mental development, and even diseases. This study was conducted with two objectives: To assess the physical, psychomotor development of infants in Hue City in 2009-2010; and to identify factors relating to physical, psychomotor development of infants. Methodology: A cross-sectional study was implemented with a combination of quantitative and qualitative methods. Results: The prevalence of underweight, stunting, and wasting malnutrition were 2.07%, 1.55% and 4.39%, respectively. Prevalence of delayed psychomotor development was 8.27%. There was a correlation between the time of having complementary feeding and weight-for-length (r= - 0.156, p<0.01) and length-for-age (r=0.108, p<0.05). Conclusion: Physical, psychomotor development of children should be assessed and monitored regularly, using WHO Anthro software and Denver 2 test. Key words: physical, psychomotor development, breastfeeding, complementary feeding 1. Introduction Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.. For children, good health is very important because it is the foundation for the physical, psychomotor development in the future. Brain cells increase the most rapidly before birth and during the first 5 or 6 months of a baby. To achieve maximum brain growth, the baby needs optimal nutrition. Severe protein- energy malnutrition in the last trimester of pregnant mother may decrease the number of brain cells by as much as 20 percent in the first 6 months of life of a baby. Nutrition for children in the first years play an important role in the development process and quality of life of each individual. Lack of breast-feeding, especially in the first 6 months of the life, and inadequate complementary feeding are common causes of 540 diseases and death of infants. Long-term consequences include bad results at school, low working productivity and delayed mental development. Moreover, during the first year of life, the immune system has not been fully developed. Insufficient nutrition in this period can lead to poor physical and mental development and even diseases. The Denver test has been applied in community in Vietnam. But in Hue city, it was just used to assess and follow the psychomotor development for children with health problems, not in community. The objectives of study are to assess the physical, psychomotor development of infants in Hue City in 2009-2010 and to identify factors in the relation with physical, psychomotor development of infants. 2. Methodology 2.1. Study design: This is a cross- sectional study with a combination of quantitative and qualitative methods. 2.2. The setting: Hue city -Vietnam 2.3. Study subjects: Infants live in Hue city and their mothers. 2.3.1. Sample size: With the 95% confidence level, Z 2/ =1.96 p =0.9: Estimated prevalence of normal physical and psychomotor development of infants. e = 0.03 Then n = 385. The sample size in this study is 387 infants and 387 mothers. 2.3.2. Sampling method: cluster random sampling Classify 27 precints of Hue city into North and South of Perfume River, then select randomly 4 clusters for sampling (2 precints from the North and 2 precints from the South). The selected four precints were Huong Long, Phu Thuan from the North and Phu Hoi, Thuy Xuan from the South. All of the infants within each cluster (about 80- 110 infants/precint) were study subjects. 2.4. Measurement procedures - Quantitative method: Interview mothers using questionnaire, measuring weight, length, head circumference of the infants. Assess psychomotor development by Denver 2 test. 2 2 2 )1( e ppZn 541 - Qualitative method: 2 focus group discussions of mothers and 2 key informant interviews of head of commune health center were implemented at Huong Long and Phu Hoi. 2.5. Statistical methods Using SPSS 15.0 and Medcal to calculate p, 2,mean. Using WHO Anthro software for assessment of physical development. To assess breast feeding practice of mothers, we used a score scale with 1 mark for each right practice. The criteria of right practices were - Using breast milk as the first food after birth - The child is breast-fed - Breast feeding begin within the first hour of birth - Feeding a baby "on demand" - Technique of feeding is right (observed and assessed by investigator) - Exclusive breast feeding from 4-6 months. 3. Ethical issues Respondents will be informed the aims of the study and the results will be published anonymously. 4. Results This study was conducted on 387 infants (208 males (53.7%), 179 females (46.3%)) and 387 mothers. All of them were Kinh. 4.1. Physical and psychomotor development of infants in Hue City in 2009- 2010 4.1.1. Physical development Table 1. Classification of undernutrition Classification n % p Underweight 8 25.81 <0.0001 Stunting 6 51.61 Wasting 17 22.58 Total 31 100.0 There were 31 (8.01%) infants were malnutrition of 3 classifications, detailed as table 5.1. 542 4.1.2. Psychomotor development Table 2. Psychomotor development of infants Classification n % p Normal 355 91.73 < 0.0001 Delayed 32 8.27 Total 387 100.0 Table 3. Number of delayed domains of psychomotor development by gender Gender Number Male (1) Female (2) Total p (1,2) n % n % n % 1 12 37.50 12 37.50 24 75.00 >0.05 2 3 9.38 2 6.25 5 15.63 >0.05 3 2 6.24 1 3.13 3 9.37 >0.05 Total 17 53.12 15 46.88 32 100.0 Among 4 domains, gross motor and language accounted for the highest prevalence of the delay (51.16% and 23.26% respectively). Except for the personal – social domain, the rest ones showed the delay on male rather than female. A statistically-significant difference was observed between genders for all delayed domains. 4.2. Factors relating to physical and psychomotor development of infants 4.2.1. Characteristics of the infants during neonatal period Table 4. Characteristics of the infants during the neonatal period Characteristics n % Term Full-term 355 91.73 Pre-term 25 6.46 Post-term 7 1.81 Total 387 100.0 Way of delivery Vaginal delivery 255 65.89 Interventional birth 132 34.11 Total 387 100.0 Diseases during neonatal Yes 41 10.59 543 period No 346 89.41 Total 387 100.0 Which disease Severe jaundice 10 22.73 Neonatal infection 7 15.91 Others 24 61.36 Total 41 100.0 Weight at birth There were 24 (6.20%) of infants with a birth weight under 2500gr. Among of them 9 (2.33%) was pre-term. The weight at birth was 3100 ± 400 grams. 4.2.2. Feeding practice 4.2.2.1. Breastfeeding Table 5. Breastfeeding practice Breastfeeding practice n % The first food after birth Breast milk 205 52.97 Liquorice 8 2.07 Sugar 6 1.55 Infant formula 152 39.28 Others 16 4.13 Total 387 100.00 Breast feeding Yes 378 97.67 No 9 2.33 Total 387 100.00 Reasons for not breast feeding Insufficient supply of milk 7 77.78 Mother using Insulin 1 11.11 Non – protractile nipple 1 11.11 Total 9 100.00 Time of first breast feeding <30 minutes 36 9.52 30-60 minutes 72 19.05 60 minutes - <1 day 137 36.24 544 >1 day 133 35.19 Total 378 100.00 Feeding time On demand 318 84.13 On clock 60 15.87 Total 378 100.00 Duration of exclusive breastfeeding (month) <4 342 90.48 4-6 36 9.52 Total 378 100.00 Stopping of breast feeding Yes 21 5.56 Not yet 357 94.44 Total 378 100.00 Time of stopping (months) <4 10 47.63 4 – 6 6 28.57 >6 5 23.81 Total 21 100.0 Reasons for stopping breast feeding Mother do not know feeding technique 1 4.76 Infants stopped themselves 12 57.14 Insufficient breast milk 7 33.33 Mother gone away 1 4.76 Total 21 100.00 - Prevalence of breastfeeding and exclusive breast feeding for the first 4-6 months for the children according to head of Huong Long and Phu Hoi CHCs’ estimation were 95% - 40% and 30% - 0%, respectively. The results from quantitative data was 97.67% and 9.52%. - There were some local conceptions that can be barriers to breastfeeding such as early complementary feeding, and hard-work of mother, as reported by head of CHCs. - Time of first breast feeding was within 2 hours after birth (females, 36,39,23 years old -Huong Long; female, 24 years old, Phu Hoi), “I breastfed my daughter right after I came back to postnatal room, I did not care the time” (female, 34 years old, Huong Long), “ Breastfeeding after 2 hours because the mother is very tired after 545 delivery, she need time to rest before giving breastfeeding” (female, 35 years old, Huong Long). “Infants of mothers who had caesareans were often breast-fed after 1 day as the mother was isolated from the child” (females, 22, 32 years old, Phu Hoi). During that day, the child was fed by infant formula milk. Time of stopping breastfeeding for most mothers was from 1.5 to 2 years “normally 2 years as theory but it is not always true in reality because of work and the child” (female, 35 years old, Huong Long). “My two children stopped breastfeeding after 1.5 years because of my work and their starting of kindergarten. I had to work in the field,under the sun directly, so I thought that my breast milk was not good enough for my baby. therefore I stopped early. After stopping breastfeeding, my baby accepted to have complementary food and formula milk” (female, 34 years old, Huong Long). 4.2.3. Complementary feeding Table 6. Complementary feeding Complementary feeding practice n % When (month) < 4 40 15.27 4-6 208 79.38 >6 14 5.35 Total 262 100.0 First complementary food Rice powder 1 0.38 Cereals 167 64.23 Rice water 3 1.15 Fruit water 2 0.77 Grind gruel 60 23.08 Others 27 10.37 Total 260 100.0 Current food Grind gruel 144 57.83 Un-grind gruel 45 18.07 Cereals 59 23.69 Others 1 0.40 Total 249 100.0 How to feed By bottle 11 4.44 546 By spoon, cup 237 95.56 Total 248 100.0 About the half of mothers introduced complementary food when their infants were 4-5 month-of age (Huong Long, Phu Hoi). Some others were at 6 month-age as suggested by mothers-in-law (Huong Long). A few infants were fed with complementary food before 3 months because “my baby cried all day and all night because he was starved” (female, 22 years old, Huong Long; female, 29 years old, Phu Hoi) or “The economical status of family did not allow us to buy infant formula milk, we have to feed him complementary food when breast milk is not enough for him” (female, 24 years old, Phu Hoi). - Most of mothers used cereals as the first complementary food. - Preparation of complementary foods: stewing bones, beef, pork or boiling fish and mixing with rice; most of mothers added salt, red onion, fish sauce, and oil. Some of them also added monosodium glutamate, or dehydrated broth . However, some other mothers were against adding monosodium glutamate as “the food will be taste enough if we stew many things, the only thing to do is to add some salt” (female, 34 years old, Huong Long) 4.2.4. Knowledge of mothers about delayed psychomotor development Some mothers gave attention to the psychomotor development of their baby. “The delay means not to pronounce as fluently as usual. It will be good if the baby can repeat what the mother said” (female, 28 years old, Phu Hoi) or “The delay means not to reach some standards, based on the time. For instance, if a one year old baby can not walk, he is considered as having delayed development. These are applied for the height, weight, and intelligence” (male, 36 years old, Phu Hoi). “If a child can fight over the toys of other children, it will be good because he is active” (female, 35 years old, Huong Long). Addressing psychomotor development was a new area for even heads of the CHCs. Hence the CHCs do not have any activities for this. Some factors relating to infant’s development In term of factors relating to infant’s development, mothers gave the opinions of “everyday caring”, “many influenced factors such as genes, hygiene, nutrition, teaching environment; for example, inadequate diet in quantity and quality will affect the child’s development” (male, 36 years old, Phu Hoi), “enough and timely sleeping” (female, 27 years old, Phu Hoi). Some mothers thought that the child had delayed development because of adults’ thinking. “They did not allow their children to go out in order to avoid wind and dust, 547 which were considered reasons for sickness of a child. Therefore, we should bring them to the park to play with other children to be more active” (female, 26 years old, Phu Hoi). - According to mothers, “thin and stunting” (female, 32 years old, Phu Hoi), “low weight”, “low weight and short in height” (female, 27 years old, Phu Hoi)., “big head, small bottom, and swelling abdomen” (female, 34 years old, Huong Long) were signs of malnutrition. To prevent malnutrition, they suggested that the babies should be fed well and mỏnitoring continuously, prevented from illness and immunized as scheduled. 4.2.5. Caring the infant Most mothers fed their child directly. Some infants also were fed by their grandmothers. “The child will eat more if he was fed by his mother because she is patient enough to feed him” (female, 39 years old, Huong Long)., “It is really very hard to feed my baby, it takes me about 1.5 to 2 hours for a meal” (female, 24 years old, Phu Hoi).. Sometimes but it was very rare that the child was fed by his father as “he came home late after work”, “My husband said that I can ask him to do everything except for feeding the baby” (female, 24 years old, Phu Hoi).. Mothers also were the one who played and chatted to the infants. The others sometimes played with them. 4.2.6. Gender issue Table 5.7. Influence of gender issue on caring of the infant Gender issue n % Discriminating between boy and girl Yes (Male priority) 3 0.78 No 384 99.22 Total 387 100.0 Know gender of fetal before birth Yes 371 95.87 No 16 4.13 Total 387 100.0 Gender of fetal as desired Yes 286 77.09 No 66 17.79 Do not care 19 5.12 Total 371 100.0 Family’s reaction Happy 226 59.79 Sad, disappointed 17 4.50 548 No reaction 135 35.72 Total 378 100.0 Most mothers knew the gender of their child before birth. A few of them felt sad knowing having a girl while the others considered that boys or girls was the same. However, most of them cared for girls as much as boys, “Males and female are equal” ((female, 27 years old, Phu Hoi).., “Boys or girl is my child” (female, 24 years old, Phu Hoi)... Many families at Huong Long still wanted to have son, “Males or females are the same but males are preferred in rural areas” (female, 39 years old, Huong Long).., “everybody discriminates in favour of males”. This concept often derived from the husband, “depending on the husband’s family, if the husband is the first son of the family, the gender of infant will be a problem” (female, 24 years old, Phu Hoi)... According to two heads of CHCs, gender discrimination was still.a problem “the elders in feudal, backward or single-sex-child families often consider gender as an important issue” (Female, 52 years old, Huong Long). 4.3. Relationship There was relationship between weight-for-length, length-for-age and psychomotor development (χ2=3.688; p=0.055 and χ2 = 4.57; p<0.05; respectively) There was relationship between weight-for-age and weight-for-length, length- for-age (p<0.001). The time of introducing complementary food was significantly correlated with weight-for-length (r= - 0.156,; p<0.01), and length-for-age (r=0.108’ p<0.05). A negative statistically significant correlation between mother’s level of education and breastfeeding practice was found (r=-0.15; p<0.01). There were no significant differences between: - Weight at birth and weight-for-age, weight-for-length, length-for-age - Diseases of infants during neonatal period and psychomotor development - Breast feeding and psychomotor development - Gender discrimination and psychomotor development 5. Discussions 5.1. Physical, psychomotor development of infants in Hue City in 2009-2010 5.1.1. Physical development Comparing our results to other study 549 Classification Our results (n=387) Tu Ngu et al (Phu Tho - 2006) (n=150) p Underweight 25.81 27.6 >0.05 Stunting 51.61 41.4 <0.05 Wasting 22.58 15.1 >0.05 There was a statistically difference (p<0.05) of stunting between our study and Tu Ngu et al. 5.1.2. Psychomotor development Prevalence of delayed psychomotor development in our study was 8.27%. A statistically significant difference (p< 0.0001) was showed between normal and delayed infants. Among 4 domains, gross motor and language accounted for the highest prevalence of the delay (51.16% and 23.26%). According to Han Nguyet Kim Chi et al (1999), the psychomotor development of children from 0 to 24 months follows common rules but is not the same for all children and all domains. During the first year, the infants had delayed gross motor and language but the development of all 4 domains would be good in the second year. Our study showed the same characteristics as this author for the first year. 5.2. Factors in the relation with physical and psychomotor development of infants 91.73% infants of our study were delivered at full-term and 6.46 % were delivered pre-term. Low birth weight of pre-term infants might be a risk factor for physical development because the development of their bodies would not be completed. However, our study showed no relationship between birth weight and physical development. It is possible our sample size was not sufficient. Within 34.11% of intervened birth, 7.58% of mothers wanted to deliver their babies by active Cesarean because of traditional perceptions that girls who were born in the year of the Tiger (lunar calendar) will be miserable, so they wanted to have them earlier. There were 9 infants (2.33%) who were fed by breast milk. The estimation of breastfeeding and exclusive breastfeeding prevalence from heads of CHCs did not fit well with the actual number founded by our study. The CHCs should strengthen their roles to promote breastfeeding for all children as suggested. Our study showed only 9.52% of infants were exclusive breastfed within the first 4-6 months. Mean duration of exclusive breastfeeding in our study was 3.25± 1.25 months. This number according to Tu Ngu et al (2006) was 2.94 ± 1.52. There was a 550 statistically significant difference (p<0.05) between two studies. The first foods after birth in our study compared with Dang Oanh et al were breast milk and sugar or infant formula were 52.97% vs 57.8% (p>0.05), 1.55% vs 6.3% (p<0.01), 39.28% vs 32.5% (p<0.05), respectively. The study showed that 5.56% of infants had stopped breastfeeding. According to Han Nguyet Kim Chi et al. (1999) ceasing breastfeeding early also influenced the both physical and mental development of children We found the prevalence of having complementary food at 4-6 month-age and before 4 months were 79.38% and 15.27%, respectively. The two heads of CHCs confirmed that early introduction of complementary food still occurs in their areas. Dang Oanh et al studied on 1170 under 36 month-age children founded that 34.1% had complementary food before 3 months (8.8% at the first month; 25.3% at the second or third month), 65.9% from the fourth month. Some of the mothers who attended focus group discussions added monosodium glutamate when preparing food for infants. The National Institute of Nutrition suggest that monosodium glutamate should not be added to the food of children under 3 as it artificially sweetens the food, the infants will depend on that sweet and deny other foods that are necessary for their development. Moreover, toxicity can occur with overuse. There were 0.78% of families who discriminated between boy and girl children (son preference). A few of mothers felt sad knowing that they were having a girl. The two heads of CHCs confirm that gender discrimination was still a problem. According to Han Nguyet Kim Chi et al, gender discrimination, especially from mothers will affects psychomotor development of the child. 6. Conclusion This study showed the prevalence of undernutrition was 31 (8.01%) and delayed psychomotor was 32 (8.27%). A negative statistically significant correlation between mother’s level of education and breastfeeding practice was found (r=-0.15; p<0.01). The time of introducing complementary food was significantly correlated with weight- for-length (r= - 0.156,; p<0.01), and length-for-age (r=0.108’ p<0.05). 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