This cross-sectional study was carried out in Severe malnutrition therapeutic unit of a tertiary-care public hospital in central India from December 2014 to December 2015, after approval from the Institutional Ethical Committee.

Consecutive children aged between 6-30 months, admitted in the unit, as screened by the WHO criteria for identification of SAM were enrolled in the study. Children who were malnourished due to organic causes like congenital heart disease, cerebral palsy, malabsorption syndrome, genetic syndromes etc were excluded from the study. Further, those children who were clinically unstable to participate in the DASII test at the time of admission were also excluded from the study. Control group constituted children from well baby clinic of the institute in similar age group and of similar socioeconomic background. Parents were explained about the purpose of the study and a written informed consent was obtained.

Statistical analysis: Data were entered in Excel spreadsheets and analyzed using SPSS 20.0. Various clinical factors were compared by the Chi-square test. Mean DQ and cluster scores were compared by the Student’s t test. A P value less than 0.05 was considered significant.

After exclusion of 98 children due to organic causes, refusal of consent or for being clinically unstable, we enrolled 102 children with severe acute malnutrition and 101 controls. Baseline characteristics were similar in both the cases and controls (Table I).

Table I Baseline Characteristics of the Sample Studied

The mean DQ was significantly lower in children with SAM as compared to controls (P<0.0001) in both domains (Table II). No statistically significant differences were noted between the DQ of rural and urban children, or between MoDQ and MeDQ of SAM children. Other factors like gender, socioeconomic status and type of family also did not show any statistically significant differences (data not shown). Most of the SAM children had mild delay, and few had moderate delay. Mild delay (DQ 50-70) in motor domain was seen in 87.3% of study children and 10% of controls, whereas it was 94.1% and 12% in the mental domain. For moderate delay (DQ 35-50), these proportions were 12.7% and 1%, and 5.9% and 0% for motor and mental DQ, respectively. None of the SAM children had severe delay in any domain.

TABLE II	Showing Mental and Motor Score and DQ* in Cases and Controls

We also studied clusters in motor and mental domain and compared them with controls. It was seen that in motor domain there was no statistically significant difference in scores of neck control cluster but there was significant difference between the two groups in all other clusters, with lower scores in SAM children (Web Table I). Similar finding were seen in mental clusters with no significant difference in cognizance (visual and auditory) between SAM children and controls but scores were significantly lower in all other mental clusters with SAM (Web Table I).

In this hospital-based cross-sectional study of 102 children with SAM, assessed by DASII, all children with SAM had low Motor and Mental DQ. Most of the SAM children had mild delay in development. Those clusters which were acquired in early phase of life were not delayed, but those acquired in later infancy were delayed.

The limitations of this study are its small sample size, and absence of follow-up to assess improvement with intervention. Other psychosocial factors like over-crowding, and lack of education in parents, were not assessed in this study, which may have an effect on development of the children.

There is a significant difference in motor and mental DQ of SAM children in this study as compared to controls, which shows impact of malnutrition on child development, as also shown by other studies in literature [6-8]. Literature suggests that if malnutrition occurs in the vulnerable period of brain development, it can result in neurodevelopmental sequelae [8-10]. Prevention and early treatment of malnutrition may protect these children from this calamity.

Further we studied various clusters of motor and mental scales and found that SAM children had normal scores in those clusters that had items of early part of infancy like neck holding and visual and auditory cognizance. However, there was significant failure in those clusters which had items of later part of childhood. This finding may show that these children had inherent potential for normal development as they developed normally in early infancy but as they were affected by severe malnutrition in later life they had development delay. This has been mentioned before also by various authors that malnutrition typically affects child around 6-18 months and can cause developmental problems and decreased work capacity as adults [11,12].

Delayed development has lifelong implications but if identified early and intervened timely, many children can be saved from disabilities. Treatment programs designed for severe acute malnutrition should also have robust early intervention protocol for prevention of neuro-developmental disabilities in these children.

Contributors: NB, DD: conceived and planned the study, and supervised the conduct of the study and preparation of the manuscript; SS: enrolled subjects, did the neurodevelopmental assessment, analyzed data, and prepared the initial draft of the manuscript; DD: supervised the neurodevelopmental assessment and prepared the initial draft of manuscript. JS, HPS: assisted in the planning of the study and preparation of the manuscript. All authors approved the final manuscript for publication.

Funding: None; Competing interest: None stated.

1. Prado EL, Dewey KG. Nutrition and brain development in early life. Nutr Rev. 2014;72:267-84.

2. Singh K, Badgaiyan N, Ranjan A,　 Dixit HO,　 Kaushik A,　 Kushwaha KP, et al. Management of children with severe acute malnutrition: Experience of nutrition rehabilitation centres in Uttar Pradesh, India. Indian Pediatr. 2014;51:21-5.

3. Shapiro BK, Batshaw ML. Intellectual Disability. In: Kliegman, Stanton, St Geme, Schor, editors, Nelson Textbook of Pediatrics. 20th　edition　vol. 1 New Delhi: Elsevier; 2015. p.216-22.　

4. Pathak P. Developmental assessment scales for Indian Infants (DASII) Manual.1997; 1-7.

5. Phatak P, Misra N. Developmental Assessment Scales for Indian Infants (DASII) 1-30 months -Revision of Baroda Norm with indigenous material. Psychol Stud. 1996; 41:55-6.

6. Kulkarni A, Metgud D. Assessment of gross motor development in infants of age 6 to 18 months with protein energy malnutrition using Alberta infant motor scale: a cross sectional study. Int J Physiother Res. 2014;4: 616-20.

7. Darrah J, Piper M, Watt M. Assessment of gross motor skills of at-risk infants: predictive validity of the Alberta Infant Motor Scale. Dev Med Child Neurol.1998;40: 485-91.

8. Chowdhury SD, Wrotniak BH, Ghosh T. Nutritional and socioeconomic factors in motor development of Santal children of the Purulia district, India. Early Hum Dev. 2010;86:779-84.

9. Fronio JDS, Rabbit AR, Lillian AT, Ribeiro LC. Nutritional status and gross motor development of infants between six and eighteen months of age. Rev Bras Crescimento Desenvolv Hum. 2011;21:30-8.

10. Bartel PR, Griesel RD, Burnett LS, Freiman I, Rosen EU, Geefhuysen J. Long-term effects of kwashiorkor on psychomotor development. S Afr Med J. 1978;53:360-2.

11. Black RE,　Victora CG,　Walker SP,　Bhutta ZA,　Christian P,　de Onis M, et al. Maternal and child under-nutrition and overweight in low-income and middle income countries. Lancet. 2013;382:427-51.