CDC Kerala 4: TDSC Items Based Developmental Therapy Package Among Low Birth Weight Babies – Outcome at 18 months Using DASII

Abstract

Objective

To assess the effectiveness of Trivandrum Developmental Screening Chart (TDSC) items based intervention package developed at Child Development Centre, Kerala on the developmental outcome of children at 18 mo of age using Developmental Assessment Scale for Indian Infants (DASII) and compare the same in different birth weight groups.

Methods

Five hundred consecutive discharges from the Neonatal Intensive Care Unit (NICU), Sree Avittam Thirunal hospital, were recruited and followed up till 18 mo of age including 240 low birth weight (LBW;<2,500 g) babies and 260 normal birth weight babies. All 240 LBW babies were offered early intervention at monthly intervals till 12 mo of age, whereas the normal birth weight (NBW) group received only immunization service as per the routine of the hospital. The early intervention package for the low birth weight group was designed based on Trivandrum Developmental Screening Chart (TDSC 0–2 y) items delay. At 18 mo of age both the groups were offered developmental assessment using DASII by specially trained and experienced developmental therapists who were blind to the intervention status of the babies.

Results

It was observed that the LBW (<2,500 g) group, who received intervention had a DASII mental age of 18.31 as against 18.16 in the NBW (≥2,500 g) group and mental DQ 101.84 (LBW group) and 98.65 (NBW group) and the observed differences were not statistically significant. Similarly, the LBW, who received intervention group had a DASII motor age of 18.68 as against 18.47 in the NBW group and motor DQ 139.40 (LBW group) and 135.39 (NBW group) and the observed differences were not statistically significant.

Conclusions

The results of this TDSC based intervention package among low birth weight babies showed that at 18 mo of age there was no statistically significant difference in the developmental outcome using DASII, between low birth weight babies on intervention and the normal birth weight babies without any intervention.

CDC Kerala: TDSC Items Based Developmental Therapy Package (Appendix)

TDSC items	Developmental therapy techniques (him means her also)
Item 1: Social smile	For visual stimulation : (i) use simple and cheap things like a piece of red cloth, different pieces of clothes of different colors, merry-go-round or other mobiles etc.; (ii) hang these articles on both sides of the baby and above; (iii) stimulate the baby by mother’s voice and action; (iv) try to make other children in the family also participate.
Item 2: Eye follow pen/pencil	For eye fixation: (i) if the baby is looking at a particular object try to move the object slowly to both sides so that the eyes will move; (ii) hang a bulb above the baby and then swing the bulb so that the baby will follow the movements of the bulb.
Item 3: Head control	For head control : (i) stimulate the baby to hold head by carrying the baby in an upright position by supporting the infant’s head as and when possible and gradually withdraw; (ii) while playing and talking with the baby, lift the baby by supporting his upper arm and chest thereby stimulating him to lift and hold his head; (iii) gradually bring him to the sitting position, then slowly put him back to the lying position; (iv) the baby must be made to lie on his stomach and is guided on his elbows (a roll can be used if necessary) and encourage the baby to lift and hold his head by showing a colorful toy; (iv) stimulate the baby on stomach lying position (prone position) guiding on his hands on the surface, encourage the baby to lift and hold his head and then rotate laterally showing a colorful toy; (v) encourage the baby to lift and hold head by pulling him to sitting position in a playful manner and then gradually putting him back to lying position.
Item 4: Turn over	For turn over : (i) when the baby is in prone position, let the mother sit by the side of the baby smiling and help the baby to the side-lying position; (ii) keep the baby in the side lying position, place pillows on the back of the baby so that the baby may not go back to the supine position and then just push the baby so that he will turn over; (iii) when the baby is in supine position, call him from a distant position, the person being in the field of vision of the baby so that the baby can see the person also stimulating him for turnover; (iv) keep some colorful or sound making objects on the side of the baby just beyond the arm’s reach of the baby, the baby will try to catch it by turning over to that particular side and repeat this many times.
Item 5: Turning head in the direction of the sound	For helping to turn head in the direction of the sound: (i) whenever the baby is being fed or being bathed, try to speak to the baby, sing songs and attract his attention, speak to the baby in different and varying tone, so that the baby can differentiate various frequencies of sound; (ii) let the baby experience different types of sound by showing and making sounds with different types of objects, for example- crumpling paper, rattle, tin, clicking tongue, whistling…. etc.; (iii) sound producing anklets is also a continuous stimulus since the baby moves the legs while awake, (iv) record the sounds made by the baby and play it back to him so that he gets the feel of his own sounds; (v) keep the baby in the veranda so that the baby will look and hear different sounds from the environment; (vi) always call the baby specifically by a ’single name’.
Item 6: Transfer of objects hand to hand	For helping to transfer objects: (i) make the baby hold the objects of various size, shape and texture like ball of cloth, sponge, spoon, bangles and also vegetables like brinjal, bitter gourd and lady’s finger etc., (ii) help the baby to wrap his fingers around the objects, show him how to transfer the objects and if he cannot do independently, help him to do so; (iiI) keep the objects in the particular hand which the baby is not using frequently, so that the baby will transfer the object to the more frequently used hand; (iv) if the baby is not holding an object in the hand, show even more beautiful and attractive objects, so that the baby will transfer the previous object to the hand, in order to get the shown object.
Item 7: Raises self to sitting position	For helping to raise self to sitting position: (i) when the baby is in the supine position, stimulate him to come to the sitting position by pulling the hands and try to repeat it several times; (ii) once the baby can sit, support him by keeping pillows around him and gradually withdraw the amount of support given; (iii) when the mother is sitting on a chair with the baby on the floor, keep him in sitting position by placing the baby in between the legs of the mother and keep the baby in this position for a long time by offering some toys and gradually remove the quantum of support; (iv) try to make the baby come in the quadruped position (all fours) and keep a pillow under the stomach; (v) try to help the baby to come to sitting position by leaning on to the side with bearing weight on that hand and repeat this maneuver on the opposite side.
Item 8: Standing up by the furnitur	For helping to stand: (i) hold the baby at the waist, bounce him up and down facing a mirror, meanwhile touch the feet on the ground several times; (ii) make the baby to stand, holding on a low stool initially giving support at the waist and gradually wean the support; (iii) if the baby can crawl, keep an attractive colourful object over a low-stool and stimulate him to reach for that object by holding on to the stool; (iv) when the baby is lying on the back, make him sit by pulling the hands (pull to sit), then from sitting position, help him to stand by pulling again the hands (pull to stand); (v) use of a walker is ideal at this stage, because without fear of falling baby can stand up and even take steps.
Item 9: Fine prehension pellet	For pincer - grasp: (i) give the baby small objects of various size, shape and texture, keep these objects in front of the baby and ask him to take these objects by showing gestures demonstrating how to take the items using the index-finger and thumb only; (ii) small ball of cotton, beads, bengal-gram, raisins mixture of dough made of maida and powdered wheat etc. can be used; (iii) stimulate him to take small beads, pebbles by pincer grasp and ask him to give it to another person in a playful manner; (iv) if the baby is still using all the fingers to take these objects, put a sticking plaster around the fingers leaving the index finger and thumb alone free.
Item 10: Pat-a-cake or Clapping hands	For midline hand movement: (i) sit in front of the baby and show him how to clap and stimulate him to do the same; (ii) when the baby is making a clapping attempt, praise him by saying “good”, “good boy”, nice” etc. and whenever the baby does an interesting play item or succeeds any task, praise him by clapping hands.
Item 11: Walk with help	For walking initiation: (i) support the arm pit region from behind and give pressure downwards and forward so as to help the baby to alternate the legs and if needed give support to the pelvic girdle also; (ii) after training the baby to walk with help holding the hand, reduce the hold to just a “finger-tip hold”; (iii) then hold the hand and make him walk from one place to the other and while doing this another person should attract and call the baby by sitting in front and showing some colourful objects; (iv) give some colourful items or toys and ask him to give to another person (walking game) and in this game it is better that both the parents participate; (v) ask the baby to walk to and fro, holding a tight rope tied across and after this trial, when the baby has gained control over his body, loosen the rope and encourage him to walk; (vi) the baby can be encouraged to walk holding and pushing a three-wheeled wooden-toy-walker or be put in a baby-walker.
Item 12: Throws ball	For releasing and throwing ball: (i) give a ball of the size of a small orange and ask him to throw the ball overhead and if needed demonstrate how to do it; (ii) ask him to give it to a person by throwing it and the person keep changing positions, so that the baby can change the direction of throw; (iii) keep a basket at a particular distance and ask him to throw the ball into it several times.
Item 13: Walks alone	For independent walking: (i) if a baby can’t walk, look whether the baby can walk with help and if he can’t do the maneuvers described in item No.11; (ii) encourage him to walk to and fro by calling him, offering some colourful toys from a distance in front etc.
Item 14: Says two-words	For speech stimulation: (i) if the baby cannot say two words other than pappa, mamma, all possible efforts should be made to stimulate language development, starting even from cooing/‘babbling; (ii) look, close into the face of the baby and produce sounds like “ah”, p,b,m (sounds with lips) and if the baby produces any sounds, repeat the same sound before the baby; (iii) produce various sounds of different frequencies like clicking the tongue, lip-whistle, clapping, crumpling paper etc. or this can be produced by sound producing toys; (iv) first teach him how to say mama”, and then simple, common words and sing songs (lullaby) talk to him and cuddle him; (v) talk in different tones so that the baby gets a feel of different frequencies of sound; (vi) teach him different parts of the body like eyes, nose etc.; (vii) make him experience the sounds in the environment like crowing of a crow, barking of a dog etc. and when an activity is being done, repeat naming the activity.
Item 15: Walk backwards	For walking backwards: (i) once a baby can walk forwards well, he will try to walk backwards and also to the sides; (ii) he may carry small boxes, chair etc. across the floor by walking backwards- and if not, encourage him to do so; (iii) show him how to walk backwards. (iv) offer him some “pull-toys” (train) he will try to pull it by walking backwards and looking at the toy.
Item 16: Walk upstairs with help	For walking upstairs with help: (i) first the baby may crawl over a step, then he may try to climb a stair by keeping both the legs on a step at the same time, initially with help and later without help; (ii) stimulate the baby by making him to crawl over an object (pillow) or can be asked to climb a stair case of the house by keeping some colourful objects at the top of the stairs and calling him, (iii) offer him support by holding the hands or let him climb with the help of the railings.
Item 17: Points to parts of a doll	For teaching parts of a doll: (i) give the baby knowledge about nose, eyes, mouth etc. by showing these parts of the mother or doll; (ii) this can be repeated by showing the parts in the mirror image of baby while the baby is being seated in front of the mirror.