RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DESSERTATION

1 Name of the candidate & address Dr. Priyanka.K.P

POST GRADUATE IN PAEDIATRICS,
BANGALORE MEDICAL COLLEGE AND RESEARCH
INSTITUTE, K R ROAD, FORT, BANGALORE-560002.

2 Name of the institution BANGALORE MEDICAL COLLEGE & RESEARCH

INSTITUTE, BANGALORE-560002

3 Course of study and subject M.D.PAEDIATRICS.

4 Date of admission to the course 16TH MAY 2018

DEVELOPMENTAL STATUS OF SEVERE ACUTE

5 Title of topic MALNOURISHED CHILDREN USING DEVELOPMENTAL
ASSESSEMENT SCALE FOR INDIAN INFANTS (DASII)
AND VINELAND SOCIAL MATURITY SCALE (VSMS) AT
TERTIARY CARE CENTER

6 Brief resume of intended work:

6.1 Need for study:
Worldwide 52 million children under 5 years of age are wasted, 17 million are
severely wasted and 155 million are stunted .Around 45% of deaths among children
under 5years of age are linked to undernutrition 1 .These mostly occur in low and
middle income countries1.
Children with SAM are known to be susceptible to nutritional problems such as
growth faltering, and have poor motor and cognitive outcomes due to maturation of
the brain being constrained in malnourished children. For the first time child
development is included in the new Sustainable Development Goals (SDGs)2
There is little information available on the neurodevelopmental status and outcome of
children with SAM. With SAM affecting 17 million children worldwide, this is an
important evidence gap.
Current guidelines recommend that SAM children those with complications should be
managed in Nutritional rehabilitation centers (NRC) and those without
complications should be managed in community.“Play therapy” is one of WHO’s “10
steps” in the treatment of inpatient SAM 3.These SAM children may also require
comprehensive early intervention to limit neurodevelopmental sequelae it is unclear
how many nutritional rehabilitation centers are actually managing to implement.
Although most children survive acute episodes of SAM, there are limited studies that
have examined long-term outcomes of SAM such as child growth and development.
In order to justify future developmental interventions in SAM children , further
evidence is needed on  the developmental outcomes of SAM .
  Developmental assessment scale for Indian infants (DASII ) is considered as the gold
standard for developmental assessment but can be done only for children below 30
months4,5. Social quotient obtained by Vineland social maturity scale shows good
correlation with development quotient of DASII6 and can be used from 0-15 years of
age.
Hence we planned to study the developmental status of children with SAM using
DASII and VSMS.

6.2 Review of Literature

Dwivedi D et al conducted a hospital based cross sectional study
between 2014 to 2015 at tertiary-care public hospital in central India where
 developmental status of 102 children with SAM was assessed using DASII
and compared with control group (well baby clinic) .It was found 87.3% and
94.1% of SAM children had delay in motor and mental domain respectively.
Abessa TG et al conducted cross sectional observational study where
development of 310 children admitted to NRC at Jimma University’s Hospital
was compared with that of 310 age and gender-matched, non-malnourished
healthy children using (1) the Denver II-Jimma, (2) the Ages and Stages
Questionnaires and found that SAM delays developmental performance on
GM, FM, PS and LA by 300%, 200%, 140%, 71.4% respectively in 1 year old
children whereas it is 80%, 50%, 50% and 28.6% in 3 year old SAM children.
Thus SAM has differential age effect on different domains of development.8.
Van den Heuvel M et al conducted cross sectional observational study
in 2015 at Blantyre Malawi .Developmental assessment done using Malawai
Developmental Assessment Tool and Strength and Difficulties Questionnare.
All SAM children were found to have profound delay in all domains – 80%
had delay in the gross motor domain. The prosocial behavior score was found
to be low in SAM children.9
Jacob A et al conducted a case - control study in Tamil Nadu where
intellectual development in 114 SAM children aged 12 to 72 months was
assessed using VSMS and 10th of study population (9.6%) had values to
suggest borderline/below average intelligence (SQ<89)10.
Nahar B et al conducted time lagged control study in Bangladesh
between 2002-2004 where development of 43 children (control) and 54
children (intervention-play sessions group) assessed using the Bayley Scales
of Infant Development. It was found that intervention group had improvement
more than the controls did by a mean of 6.9 mental and 3.1% motor raw scores
with P value <0.0511.

6.3 Objectives of the study:

1 .To assess the developmental quotient of SAM children using Developmental
Assessment Scale for Indian Infants and Vineland social maturity scale.
2. To correlate the Social quotient of SAM children on VSMS  with the mental
development quotient of SAM children on DASII
3.To determine the factors influencing developmental delay in SAM children.

Materials And Methods:

7.1 Source of data:
NRC of PAEDIATRIC Department Vanivilas children Hospital, BMCRI
7.2 Methods Of Collection Of Data:
A. Study design:  prospective crosssection Study
B. Study period: 1.5 yrs(November 2018 to November 2019)
C. Place of study: Department of Paediatrics, Vanivilas children Hospital
attached to BMCRI, Bangalore.
D. Sample size:

N=Z2α σ 2 / D 2
Where,
d=allowable error(5-20% of P)
zα Standard table value for 95% CI 1.96
σ Standard deviation 6.05

D Absolute precision 1.5

N Minimum sample size 65

E. Inclusion Criteria :
1. Age -1month to 3 years
2. Parents willing to give informed consent.
3. Children diagnosed SAM as per WHO guidelines.
F. Exclusion Criteria:
1. Patient not willing to give informed consent.
2. SAM children born preterm or  with low birth weight.
3. SAM children with any underlying chronic illness as secondary cause
of malnutrition.
G. Methodology:
 After obtaining approval and clearance from the institutional ethics committee,
in-patients of NRC  fulfilling the inclusion criteria will be enrolled for the
study after obtaining informed consent. (Annexure 1)
  The enrolled children shall be managed in NRC as per standard national/WHO
guidelines which includes play therapy also(annexure3) .The Developmental
assessment of enrolled children shall be done after the child is stabilized
before starting play therapy  using DASII and VSMS by a single trained
examiner.
 After assessment of children, motor development quotient (DMoQ) and mental
development quotient (DMeQ) shall be calculated as per manual of DASII
scale(annexure 4). The composite DQ is derived as an average of DMoQ and
DMeQ.  Developmental delay shall be defined as development quotient (DQ)
≤70 (≤2SD) in either the mental or motor scale. Children shall further
classified as mild, moderate, and severe delay. All the children shall be further
assessed in all the clusters of both domains to evaluate for the specific areas of
development affected by malnutrition.
 After assessment a social quotient  shall be calculated as per manual of VSMS
scale(annexure 5). Socioeconomic status shall be assessed using revised
kuppuswamy classification(annexure 6) The details of patient like age ,sex
,history, examination findings, investigations(done as per standard
guidelines ),socioeconomic status (as per revised kuppuswamy scale)
,Developmental quotient as per DASII and Social quotient as per VSMS shall
be recorded on a pretested structured proforma (annexure 2)
 Developmental quotient <70 is considered delayed.

 PRIMARY OUTCOME
1.motor development quotient (DMoQ) and mental development quotient (DMeQ)
as per DASII
2. Social quotient (SQ) as per VSMS
 SECONDARY OUTCOME
1. correlation between the SQ of VSMS and DMeQ of DASII
2. correlation between  age ,sex, anemia ,birth order, socioeconomic scale and
developmental delay

H. STATISTICAL ANALYSIS:
   Data will be analyzed by descriptive statistics such as mean, median, standard
deviation, interquartile range, percentages, tables and graphs wherever
applicable.
 Students t test will be used to determine the significant difference and chi-
square test will bw used to determine association between qualitative
variables. SPSS Version 17 software shall be used for data analysis.
 P<0.05 will be considered statistically significant.

7.3 Does the study require any investigation to be conducted on patients or

animals specify?
No
7.4 Has ethical clearance been obtained from ethics committee of your institution
in case of 7.3?
“YES”. Ethics clearance has been obtained from Institutional ethics committee of
BANGALORE MEDICAL COLLEGE & RESEARCH INSTITUTE, BANGALORE.

8. LIST OF REFERENCES:
1. World Health Organization. Fact sheets on malnourishment.
2.United Nations. Sustainable development goals 2015. Available:
https://sustainabledevelopment.un.org/?menu=1300
3. World Health Organization. WHO guideline: updates on the managementof severe
acute malnutrition in infants and children. . Geneva(Switzerland): World Health
Organization; 2013 .Availablefromhttp://www.ncbi.nlm.nih.gov/books/NBK190328/.
United Nations. Sustainable development goals 2015. Available:
https://sustainabledevelopment.un.org/?menu=1300
4. Pathak P. Developmental assessment scales for Indian Infants (DASII)
Manual.1997;1-7.
5. Pathak P, Mishra N. Developmental assessment Scales for Indian Infants (DASII)
1-30 months-Revision of Baroda Norm with indigenious material.Psycho
Stud.1996;41:55-6.
6. Bhave A, Bhargava R, Kumar R. Correlation between developmental quotient
(DASII) and social quotient (Malin’s VSMS) in Indian children aged 6 months to 2
years. J Paediatr Child Health.2011 Mar;47(3):87-91.doi:10.1111/j.1440-1754.
7. Dwivedi D, Singh S, Singh J, Bajaj N. Neurodevelopmental Status of children aged
 6-30 months with Severe Acute Malnutrition.Indian Pediatr.2018 Feb 15;55(2):131-
133.
8. Abessa TG,Bruckers L,Kolsteren P, Granitzer M. Developmental performance of
hospitalized severly acutely malnourished under-six children in low-income
setting.BMC Pediatr,2017;17(1):197.Published 2017 Nov 28.doi:10.1186/s12887-
017-0950-5
9. Van den Heuvel M, Voskuiji W, Chidzalo K, et al. Developmental and behavioral
problems in children with severe acute malnutrition in Malawai:A cross-sectional
study. J Glob Health.2017;7(2):020416
10. Jacob A, Thomas L, Stephen K, Marconi S, et al. Nutritional status and
intellectual development in children:A community-based study. Natl Med J India.
2016 Mar-Apr;29(2):82-4.
11. Nahar B, Hossain MI, Hamadani JD, et al. Effects of a community-based
approach of food and psychosocial stimulation on growth and development of
severely malnourished children in Bangladesh: a randomised trial. Eur J ClinNutr.
2012;66(6): 701-9

9 SIGNATURE OF
THE CANDIDATE

10 REMARKS OF THE
GUIDE
11 NAME AND DR.DAKSHAYANI.B
ASSISTANT PROFESSOR
DESIGNATION OF DEPARTMENT OF PEDIATRICS, BMC&RI,
BENGALURU
11.1 GUIDE

11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE
 11.5 HEAD OF DR. SARALA SABHAPATHY
PROFESSOR AND HOD
THE DEPARTMENT OF PEDIATRICS, BMC&RI,
DEPARTMENT BENGALURU

11.6 SIGNATUR
E

12 12.1 REMARKS OF
CHAIRMAN AND
PRINCIPAL
12.2
SIGNATURE

ANNEXURE I

INFORMED CONSENT

I have been explained, in a language understood by me about the study entitled “A CROSS SECTIONAL
STUDY OF DEVELOPMENTAL STATUS OF SEVERE ACUTE MALNOURISHED CHILDREN
USING DEVELOPMENTAL ASSESSEMENT SCALE FOR INDIAN INFANTS (DASII) AND
VINELAND SOCIAL MATURITY SCALE (VSMS) AT TERTIARY CARE CENTER.” conducted by
Dr. Priyanka.K.P under the guidance of Dr.Dakshayani.B
I have been explained about the procedures and investigations that will be done during this study. I
have no objections to sharing my medical information and details in case records with the investigators of this
study. Personal identity will not be revealed but data may be used for publication / dissertation purpose.

I understand that my participation in this study is entirely voluntary and I am willing to take part in this
study.

Signature of the Doctor: Signature of the parent:

Name of the Doctor: Name of the parent:

Place: Name of the subject:

Date:Time:

ANNEXURE I

INFORMED CONSENT

ದಿನಾಂಕ:

ಸ್ಥಳ:

ನಾನುಶ್ರೀ / ಶ್ರೀಮತಿ ____________________________________________________ ವರ್ಷಗಳವಯಸ್ಸಿನ

___________________________ನಮಗ / ಮಗಳು / ಪತ್ನಿನಾನು.ನನಗೆVANI VILAS/ LADY COURZO-

BOWRING ಆಸ್ಪತ್ರೆಗಳ PAEDIATRICS ವಿಭಾಗದ “A CROSS SECTIONAL STUDY OF

DEVELOPMENTAL STATUS OF SEVERE ACUTE MALNOURISHED CHILDREN USING

DEVELOPMENTAL ASSESSEMENT SCALE FOR INDIAN INFANTS (DASII) AND VINELAND
SOCIAL MATURITY SCALE (VSMS)AT A TERTIARY CARE CENTER. .”

ಎಂಬಅಧ್ಯಯನದಬಗ್ಗೆನನಗೆಅರ್ಥವಾಗುವಭಾಷೆಯಲ್ಲಿವಿವರಿಸಲಾಗಿದೆ .ನಾನು ಈ

ಅಧ್ಯಯನದಸಂಶೋಧನೆಯದಾಖಲೆಗಳುಮತ್ತುನನ್ನರೋಗಿಯವೈದ್ಯಕೀಯಮಾಹಿತಿಮತ್ತುವಿವರಗಳನ್ನುಹಂಚಿಕೊಳ್ಳಲುಯಾವುದೇಆಕ್ಷೆ

ೕಪಣೆಗಳನ್ನುಹೊಂದಿಲ್ಲ. ಯಾವುದೇಹಣಕಾಸಿನಪ್ರೋತ್ಸಾಹವನ್ನುಹಂಚಬಾರದುಎಂದುನನಗೆತಿಳಿಸಲಾಗಿದೆ.

ವೈಯಕ್ತಿಕಗುರುತನ್ನುತೋರಿಸಲಾಗುವುದಿಲ್ಲಮತ್ತುಡೇಟಾಪ್ರಕಟಣೆ / ಪ್ರೌಢಪ್ರಬಂಧದಲ್ಲಿಉದ್ದೇಶಕ್ಕಾಗಿಬಳಸಬಹುದು.

ನನ್ನರೋಗಿಯು, ಈಅಧ್ಯಯನದನಿರ್ದಿಷ್ಟಪಡಿಸಿದಅವಧಿಯಲ್ಲಿ,

ಭಾಗವಹಿಸುವುದುಸಂಪೂರ್ಣವಾಗಿವೈಯಕ್ತಿಕವಾಗಿದ್ದುಮತ್ತುಉದ್ದೇಶಪೂರ್ವಕವಾಗಿ.
ಕೇರ್ಕೊಡುವವನುಸಹಿ

ರೋಗಿಯಸಂಬಂಧ ವೈದ್ಯರಸಹಿ

ANNEXURE 1

INFORMED CONSENT

तारीख:

जगह:

मैंश्री / श्रीमती _________________________________________________

आयु,औरमेरेपुत्र/पुत्री___________________________ सालका/कीहै।विक्टोरियाअस्पतालऔरबोरिं गऔरलेडीकर्जनअस्पताल

,बंगलौरकित्वचाविज्ञान, रतिजरोगऔरकुष्ठरोगविभागमें“A CROSS SECTIONAL STUDY OF DEVELOPMENTAL

STATUS OF SEVERE ACUTE MALNOURISHED CHILDREN USING DEVELOPMENTAL

ASSESSEMENT SCALE FOR INDIAN INFANTS (DASII) AND VINELAND SOCIAL MATURITY

SCALE (VSMS) AT TERTIARY CARE CENTER.”

नामकअध्ययनकेबारे मेंमुझेउसभाषामेंसमझायागयाहैजिसेमस
ैं मझताहू ँ।

मुझेइसअध्ययनकेदौरानप्रदर्शनकियेजानेवालेप्रक्रियाओंऔरजांचकेबारे मेंविस्तारसेबतायागयाहै।

मैंइसअध्ययनकेजांचकर्ताओंकेसाथमामलेकेरिकॉर्डमेंमेरेपुत्र /पुत्री
कीचिकित्साकीजानकारीऔरजानकारीसाझाकरनेकेलिएकोईआपत्तिनहींहै।

ू तकियागयाहैकिमैंकिसीभीआर्थिकप्रोत्साहनबांटनेमेभागनहींलूँगा।व्यक्तिगतपहचानउजागरनहींकियाजाएगाऔरडे टाप्रकाशन /
मुझेसचि

शोधप्रबंधउद्दे श्यकेलिएइस्तेमालकियाजासकताहै।इसअध्ययनमें , निर्दिष्टअवधिकेलिए, मेरेपुत्र /पुत्रीकीभागीदारीपूरीतरहस्वैच्छिकहै।

देखभालदाताकेहस्ताक्षर

मरीजकेसाथसंबंधचिकित्सककेहस्ताक्षर
ANNEXURE 2

BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE BANGALORE

DEPARTMENT OF PEDIATRICS

STUDY PROFORMA:

1. NAME:

2. AGE:

BIRTH ORDER

3. SEX:

4. ADDRESS

5. PHONE NO.

6. SOCIOECONOMIC STATUS

7. EXAMINATION:

HEART RATE:

BLOOD PRESSURE:

RESPIRATORY RATE:

ANTHROPOMETRY :

STANDARD DEVIATION (Z
SCORES)
WEIGHT
HEIGHT/ LENGTH
WEIGHT FOR HEIGHT
MUAC
HEAD CIRCUMFERENCE
PEDAL EDEMA
VISIBLE MUSCLE WASTING

8. HEAD TO TOE EXAMINATION:

 • EYES, NOSE EARS
• ORAL CAVITY
• NECK
• CHEST
• ABDOMEN
• LIMBS
• GENITALIA

9. SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM

CARDIOVASCULAR SYSTEM

ABDOMINAL EXAMINATION

CENTRAL NERVOUS SYSTEM

10. DEVELOPMENT ASSESSMENT

DASII
MOTOR AGE
MOTOR DQ
MENTAL AGE
MENTAL DQ

VSMS
SOCIAL AGE
SOCIAL QOUTIENT

11. RELEVANT INVESTIGATIONS

Hb
MCV
MCH
MCHC
Vit B12

ANNEXURE-3 (WHO guidelines for management of SAM children)

Severe Acute malnutrition  criteria (6 months to 60 months) any one of the following
Visible severe wasting
Weight for height < -3SD
Mid upper arm circumference < 11.5 mm
Bilateral pitting pedal edema

PLAY THERAPY
SAM children reduce their activities, don’t play or cry, doesn’t complain or show normal
emotions. Due to lack of interaction and play SAM children have delayed mental and
Annexure 4
Developmental assessment scale for Indian infants (DASII) .

Developmental Assessment Scales for Indian Infants (DASII) is an Indian adaptation of the Bayley
Scales of Infant Development (BSID) originally devised by Nancy Bayley. The DASII Scale in its
present form is a revision of the Baroda norms with a major modification, where indigenous test
materials are used for standardization and published in 1996[3]. The contents of the DASII are the
same as used in the original study. The general approach in administration is retained. It also allows
calculation of mental age and motor age of infants between one month and 30 months of age and also
gives a developmental quotient (DQ). The DASII scale is divided into motor scale and mental scale.
The motor scale consists of 67 items and mental scale consists of 163 items.The age placement of the
item at the total score rank of the scale is noted as the child’s developmental age. This converts the
child’s total scores to his motor age (MoA) and mental age (MeA). The respective ages are used to
calculate his / her motor and mental development quotients respectively by comparing them with his
chronological age (CA) and multiplying it by 100. (DMoQ = MoA/CA x 100 and DMeQ = MeA/CA
x 100). The composite DQ is derived as an average of DMoQ and DMeQ.

Annexure 5

The Vineland Social Maturity Scale (VSMS) measures the differential social capacities of an
individual. It provides an estimate of Social Age (SA) and Social Quotient (SQ), and shows high
correlation (0.80) with intelligence. It is designed to measure social maturation in eight social areas:
Self-help General (SHG), Self-help Eating (SHE), Self-help Dressing (SHD), Self direction (SD),
Occupation (OCC), Communication (COM), Locomotion (LOM), and Socialization (SOC). The
scale consists of 89 test items grouped into year levels. VSMS can be used for the age group of 0-15
years.
 0-1 Year 29. Goes about hours or yard

1. "Crows", Laugh 30. Discriminates edible substances from non-

2. Balance head edibles

3. Grasps objects within reach 31. Uses names of familiar objects

4. Reaches for familiar persons 32. Walks upstairs unassisted

5. Rolls over, (unassisted) 33. Unwraps sweets, chocolates

6. Reaches for nearby objects 34. Talks in short sentences
7. Occupies self-upright
2-3 Years
8. Sits unsupported
35. Signals to go to toilet
9. Pulls self upright
36. Initiates own play activities
10. "Talks", imitates sounds
37. Removes shirt to or frock if unbuttoned
11. Drinks from cup or glass assisted
38. Eats with spoon/hands (food)
12. Moves about on floor (creeping,
crawling) 39. Gets drink (water) unassisted
13. Grasps with thumb and finger 40. Dries own hands
14. Demands personal attention 41. Avoids simple hazards
15. Stands alone 42. Puts on short or frock unassisted (need not
16. Does not drool button)
17. Follows simple instructions 43. Can do paper folding
1-2 Year 44. Relates experience
18. Walks about room unattended
3-4 Years
19. Marks with pencil or crayon or
45. Walks downstairs, one step at a time
chalk
20. Masticates (chews) solid or semi- 46. Plays co-operatively at kindergarten level.
solid food 47. Buttons shirt or frock
21. Pulls off clothes
48. Helps at little household tasks
22. Transfers objects
49. "Performs" for others
23. Overcomes simple obstacles
50. Washes hands unaided
24. Fetches or carries familiar objects
25. Drinks from cup or 4-5 Years

glass 51. Cares for self at toilet

26. Walks without 52. Washes face unassisted

support 53. Goes about neighborhood
27. Plays with other children Unattended

28. Eats with own hands (biscuits,

bread, etc.)
54. Dresses self expect for trying 10-11 Years
55. Uses pencil or crayon or chalk for drawing 78. Distinguishes between friends any play
56. Plays competitive exercise games mates

5-6 Years 79. Makes independent choice of shops

80. Does small remunerative work; makes
57. Uses hoops, flies kites, or uses knife
articles
58. Prints (writes) simple words
59. Plays simple games which require talking 81. Follows local current events

turns 11-12 Years

60. Is trusted with money 82. Does simple creative work
61. Goes to school unattended 83. Is left to care for self or others
6-7 Years 84. Enjoys reading books, newspapers and
62. Mixes rice "properly unassisted magazines

63. Use pencil or chalk for waiting 12-15 Years

64. Bathes self assisted
85. Plays difficult games
65. Goes to bed unassisted
86. Exercises complete care of dress
7-8 Years 87. Buys own clothing accessories
66. Can differentiate between AM & PM
88. Engages of adolescent group activities
67. Helps himself during meals
89. Performs responsible routine chores
68. Understands and keeps family secrets
69. Participants in pre-adolescent
70. Combs or burses hair

8-9 Year
71. Uses tools or utensils

72. Does routine household tasks

73. Reads on own initiative
74. Bathes self unaided

9-10 Years
75. Cares for self at meals
76. Makes minor purchase
77. Goes about home town freely
ANNEXURE 6- MODIFIED KUPPUSWAMY’S SOCIO ECONOMIC SCALE