TITLE: To study the impact of Covid pandemic on growth and development

of preschool children in Nagpur city of Maharashtra

INTRODUCTION

Many children do not develop optimally in their early formative years as a

result of exposure to multiple contextual risk factors. It is being increasingly
realized that early identification of developmental problems and corrective
remedial action are among the most cost-effective interventions in the field of
preventive child health. In a developing country like India, the high prevalence
of under-nutrition, iodine deficiency, iron deficiency, and inadequate cognitive
stimulation are important risk factors for sub-optimal development. Yet, health
care providers at the primary level are mostly unaware of the importance of the
timely acquisition of developmental milestones by children under their care.
This is especially true for children belonging to the disadvantaged sections of
society. If such developmental problems are prevalent and there is a significant
delay in the acquisition of competencies by children, then a strong case can be
made for introducing the concept of developmental surveillance in primary
health care, as is done for physical growth for millions of young children in
India.1,2

Early childhood development is key to achieving the Sustainable Development

Goals and can be negatively influenced by many different adversities including
violence in the home, neglect, abuse and parental ill-health.3

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SCOPE OF THE STUDY

Optimal child development starts before conception and is dependent on

adequate nutrition for mother & child, protection from threats, provision of
learning opportunities, and caregiver-interactions that are stimulating,
responsive, & emotionally supportive. 4

The tools used to mitigate the threat of a pandemic such as COVID-19 may
very well threaten child growth and development. These tools - such as social
restrictions, shutdowns, and school closures - contribute to stress in parents and
children and can become risk factors that threaten child growth and
development and may compromise the Sustainable Development Goals. The
studies reviewed suggest that epidemics can lead to high levels of stress in
parents and children, which begin with concerns about children becoming
infected.5

This would be the first study of its kind in India. There are community-based
studies that assess impact of epidemics on growth and development. But there
is no study that reflects on the impact of COVID pandemic on growth and
development of preschool children.

The study shall be relevant in terms of impact of Covid pandemic on the WHO
standards of physical growth among the preschool children.

The study uses DMC for data collection where in the performance of child as
well as care givers response to each item is recorded. This shall take care of the
child’s inhibition in front of the unknown data collector.

Study findings shall throw light on the interventions that may be required to be
designed for the optimal growth and development of the preschool children
particularly in developing countries.

Today’s kids are tomorrow’s national health and wealth. So their normal
growth and development is most essential.

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NEED OF THE STUDY

Pediatricians are noting developmental delays as well as potential for long-term

health consequences, particularly for children from low-income households.

While Covid-19 is typically benign in children, the pandemic could have long-
lasting impacts on society’s youngest members. With childcare programs
closed and social distancing measures in place, many children are missing out
on opportunities for development.6

“Children are not getting the cognitive and social stimulation that they would
normally get outside their home,” said Dr. Michelle Aguilar, the head of
pediatrics at Venice Family Clinic in Los Angeles, California. Providers have
noted delays in speech and language as well as trouble sharing and being in
groups.6

They’re lacking from those social interactions that they would have normally
gotten from people outside their homes. They’re lacking that play time with
other children.5,6

During the pandemic, housing and food insecurity have skyrocketed, at the
same time as rates of domestic abuse and neglect have increased. These kinds
of stressful events, referred to as adverse childhood experiences, can have
long-term consequences.7

Families have had to separate when a caregiver or a family member becomes

ill. They’ve had to separate for some time to stay with other family members,
so they do not get exposed. Housing insecurity: having to move into multi-
generational homes that are now crowded.8

The child is a four or five-year-old enrolled in school and they’re going to

maybe start a little bit further behind in terms of that key foundational
academic knowledge or those kind of social, emotional skills. They have more
catch up to do.9

A systematic review of studies that examined the impact of epidemics or social

restriction on mental and developmental health in parents and
children/adolescents.10

3
REVIEW OF LITERATURE

A population-based study in rural India followed up mothers and their infants

through pregnancy and the first 18 months of life. The authors found that most
children faced one or more adversity and nearly 50% faced four or more of
these potential impediments to wellbeing. The key finding was that each extra
increase in childhood adversity was associated with both poorer growth and
also poorer development measured at 18 months, a crucial time for optimal
brain development and a key predictor of future health and wellbeing. 11

Geographical influences, nutrition and socio-economic status of the family are

among the key predictors of growth and development of the children in early
life.12 Current Corona pandemic has shattered the stability of these factors very
badly for most families.

The studies reviewed suggest that epidemics can lead to high levels of stress in
parents and children, which begin with concerns about children becoming
infected. These studies describe several potential mental and emotional
consequences of epidemics such as COVID-19, H1N1, AIDS, and Ebola:
severe anxiety or depression among parents and acute stress disorder, post-
traumatic stress, anxiety disorders, and depression among children. These data
can be related to adverse childhood experiences and elevated risk of toxic
stress. The more adverse experiences, the greater the risk of developmental
delays and health problems in adulthood, such as cognitive impairment,
substance abuse, depression, and non-communicable diseases.13

How children grow and develop depend on both internal and external
environmental factors, some of which we have no control over. Having a good
understanding of what children need at each stage of their growth and
development helps us raise them better. 14

The environment plays a critical role in the development of children and it

represents the sum total of physical and psychological stimulation the child
receives. Some of the environmental factors influencing early childhood
development involve the physical surroundings and geographical conditions of
the place the child lives in, as well his social environment and relationships

4
with family and peers. It is easy to understand that a well-nurtured child does
better than a deprived one; the environment children are constantly immersed
in contributes to this. A good school and a loving family builds in children
strong social and interpersonal skills, which will enable them to excel in other
areas such as academics and extracurricular activities. This will, of course, be
different for children who are raised in stressful environments. 15

Where you live also has a great influence on how your children turn out to be.
The schools they attend, the neighbourhood they live in, the opportunities
offered by the community and their peer circles are some of the social factors
affecting a child’s development. Living in an enriching community that has
parks, libraries and community centres for group activities and sports all play a
role in developing the child’s skills, talents, and behaviour. Uninteresting
communities can push some children to not go outside often but play video
games at home instead. Even the weather of a place influences children in the
form of bodily rhythms, allergies and other health conditions. 16

A study by Deki Pem reported the prevalence rate of cognitive development

problem in Bhutan is 15%, 33.5% of children less than five years are stunted
and 9.9% of infants are born with low weight of less than 2,500 grams. Five
main factors identified in contributing to growth and development at early
childhood are nutrition, parent’s behaviours, parenting, social and cultural
practices, and environment.17

There are three main channels through which children are affected by this
crisis: infection with the virus itself; the immediate socioeconomic impacts of
measures to stop transmission of the virus and end the pandemic; and the
potential longer-term effects of delayed implementation of the Sustainable
Development Goals. All of this is affecting children in multiple ways:

> Falling into poverty: An estimated 42-66 million children could fall into
extreme poverty as a result of the crisis this year, adding to the estimated 386
million children already in extreme poverty in 2019.

Exacerbating the learning crisis: 188 countries have imposed countrywide

school closures, affecting more than 1.5 billion children and youth. The
potential losses that may accrue in learning for today’s young generation, and

5
for the development of their human capital, are hard to fathom. More than two-
thirds of countries have introduced a national distance learning platform, but
among low-income countries the share is only 30 percent. Before this crisis,
almost one third of the world’s young people were already digitally excluded.

> Threats to child survival and health: Economic hardship experienced by

families as a result of the global economic downturn could result in hundreds
of thousands of additional child deaths in 2020, reversing the last 2 to 3 years
of progress in reducing infant mortality within a single year. And this alarming
figure does not even take into account services disrupted due to the crisis – it
only reflects the current relationship between economies and mortality, so is
likely an under-estimate of the impact.

> Rising malnutrition is expected as 368.5 million children across 143

countries who normally rely on school meals for a reliable source of daily
nutrition must now look to other sources. The risks to child mental health and
well being are also considerable. Refugee and internally displaced children as
well as those living in detention and situations of active conflict are especially
vulnerable.

Risks for child safety: Lockdowns and shelter in place measures come with
heightened risk of children witnessing or suffering violence and abuse.
Children in conflict settings, as well as those living in unsanitary and crowded
conditions such as refugee and IDP settlements, are also at considerable risk.
Children’s reliance on online platforms for distance learning has also increased
their risk of exposure to inappropriate content and online predators. 18

During the preschool years, it is important to help children discover what has
been termed as their ecopsychological self—the child’s natural sense of self in
relation to the natural world (Phenice & Griffore 2003). Many authorities
believe that due to humans’ evolution in the natural world, we possess nature-
based genetic coding and instincts, that children are born with a natural sense
of relatedness to nature and this innate and developmental tendency towards
empathy, biophilia or affiliation with nature needs to be nurtured starting in
their earliest years.19

6
Regular physical activity promotes growth and development and has multiple
benefits for physical, mental, and psychosocial health that undoubtedly
contribute to learning. Specifically, physical activity reduces the risk for heart
disease, diabetes mellitus, osteoporosis, high blood pressure, obesity, and
metabolic syndrome; improves various other aspects of health and fitness,
including aerobic capacity, muscle and bone strength, flexibility, insulin
sensitivity, and lipid profiles; and reduces stress, anxiety, and depression.
Physical activity can improve mental health by decreasing and preventing
conditions such as anxiety and depression, as well as improving mood and
other aspects of well-being. Physical activity programming specifically
designed to do so can improve psychosocial outcomes such as self-concept,
social behaviors, goal orientation, and most notably self-efficacy. These
attributes in turn are important determinants of current and future participation
in physical activity.20

Exposure to domestic violence at any age can create delays in the

accomplishment of important developmental tasks. 21

In a cross-sectional survey, 3746 children aged less than 6 years residing in 47

randomly selected villages of district Ambala (India), were studied to find out
the environmental risk factors influencing psychosocial development. Findings
revealed that per capita income, education of mother, nutritional status of the
child, number of rooms and environmental hygiene in the house, presence of a
high school within easy travel distance, availability of a caretaker when mother
is busy, child attending a nursery (anganwadi), households having access to
newspaper, child having toys or toy substitutes, TV, books, story telling by the
mother were found to have a significant association with psychosocial
development of preschool children.22

Children from families of higher socioeconomic classes are taller than their
coevals in the lower socioeconomic groups. Urbanization also has a positive
effect on growth. Better child care is supported by sufficient food supply,
appropriate health and sanitation services, and a higher level of education. 23

A cross-sectional study was done to assess the prevalence of growth and global
developmental delay and the predisposing factors among children aged three

7
years residing in rural communities of India. About 530 children at three years
were assessed for growth and developmental delay. The results showed that the
prevalence of global developmental delay assessed by ASQ was 19.8%.
Children displayed delay in personal-social (42.5%), gross motor (38.1.1%)
and problem-solving skills (34.9%). Maternal educational level was positively
associated with communication and problem-solving skills (P=0.000) while
monthly household income was positively associated with communication,
gross motor and problem-solving skills (p=0.000). The results suggest a high
prevalence of developmental delay and poor child health in this rural
population. Implementing early intervention programs may ameliorate the
long-term consequences of these developmental disorders. 24

The review of the literature revealed that family features, such as

socioeconomic status, mother’s educational level, and the existence of siblings
can affect children’s motor competence. Preschool centers have also become
important for children’s development, due to the large amount of time children
spend at them nowadays. Moreover, the social cultural context in which a child
is reared forms certain demands for his/her motor behavior, favoring specific
aspects of motor development and impairing others. A very influential factor
(and consequently a very significant educational means) is the use of
intervention movement programs.25

A child’s brain during the first 3 years of life is rapidly developing through
generation of neurons, synaptogenesis, axonal, and dendric growth and
synaptic pruning each of which build upon each other. Any interruption in this
process, such as trauma, stress, under-nutrition or lack of nutrients can have
long-term effects on the brain’s structure and on the child’s socio-emotional
development. Children’s development is essentially cumulative in nature and
hence, the early years of life are the foundation for later development.
Influences upon children’s development tend to be specific in nature and
developmental influences rarely operate in isolation from each other.
Developmental risk factors tend to cluster together thereby, interventions
designed to facilitate development must be multifocal in nature, integrating
influences from different domains. 26

8
A cross-sectional study was done in 30 Anganwadi centers, 450 children aged
2 months–6 years to identify the predictors for DDs (domain wise). Results
showed that 16.2% children were found to have DDs and 13.3% children had
the global DDs. About 20.0% children had cognitive delay, followed by 9.6%
children who had delay in speech and language area. About 8.9% children had
social delay while 6.4% children had hearing and vision impairment. Gross
motor delay was seen in 5.3% children and 5.3% children had fine motor delay.
Gestational age, complications during delivery, meconium aspiration, and child
never breastfed were strong predictors for the delay in different domains of
developmental milestones. Socio-economic, ante-natal, natal and post-natal
factors should be considered for prompt identification and initiation of
intervention for DDs.27

A longitudinal birth cohort study investigated the association between early

childhood infections and subsequent development of asthma. The authors
concluded that Repeated viral infections other than lower respiratory tract
infections early in life may reduce the risk of developing asthma up to school
age.28

On March 10th, 2020, the COVID-19 pandemic was declared a state of

emergency in Massachusetts. Within the next two weeks, schools and child
care programs were closed, and a stay-at-home advisory was issued. In the
months that followed, the need for social distancing meant youth ages 5-18
were kept at home and away from their peers, unable to attend school for in-
person K-12 education.29

The pandemic creates substantial barriers to high-quality parent-child

relationships. The stress of losing a job, housing, or food security; the loss of
social support; increased depression and anxiety—all of these factors have the
potential to negatively impact the interactions that children have in their
homes.30

COVID-19 and the pandemic response have had considerable effects on an

entire generation of children—and recovery could take years. Here are areas
where the pandemic has left its mark on the nation’s children and how

9
children’s hospitals can help our youngest generations now and into the future.
Adult stress developmental issues, widening education gap, adverse childhood
experiences, rare related illnesses, fewer wellness visits, and lingering physical
challenges are the seven areas that are influenced by the current pandemic. 31

OBJECTIVES

1. To study the growth parameters of preschool children.

2. To study the developmental parameters of preschool children.
3. To estimate the impact of Covid pandemic on the growth parameters of
preschool children.
4. To evaluate the impact of Covid pandemic on developmental milestones of
preschool children.
5. To study the relationship between the impact on growth and impact on
developmental parameters among the preschool children.

HYPOTHESIS

H0: Covid pandemic does not influence the growth and development of the
preschool children.

H1: Covid pandemic may influence the growth and development of the
preschool children.

METHODOLOGY

 Research Approach: Descriptive exploratory study

 Research Design: Community Based survey
 Study setting: Community – Nagpur district
 Study population: Children in 3 to 6 years of age, both genders
 Sample size: 300
 Sampling technique: Purposive sampling

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 Operational definitions:
1. Growth: In this study growth means the physical growth milestones of
preschool children as described by the WHO and as assessed with
DMC
2. Development: In this study development means the cognitive and
psychomotor skills performance of the preschool children.
3. COVID pandemic: Current corona virus infections

 Method of selection of sample subjects:

Sample subjects shall be chosen purposively through non probability
sampling. Subjects having residence in the containment zones and those
who are affected by Covid pandemic in any way (A family member had
Covid-19 infection or the child himself/herself had corona infection) shall
be selected for the study.

 Inclusion criteria:
o Children in the age group of 3 to 6 years
o Both male and female preschool children
o Those residing in covid affected areas

 Exclusion criteria:
o Those suffering from problems related to developmental delay
o Those born with congenital malformations that affect growth and
development.
o Those suffering from Cerebral palsy
o Those suffering from autism
o Those diagnosed with intellectual deficit
o Those diagnosed with mental illness

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 Variables under study:
o Growth of preschool children,
o Development of Preschool children

 Instrument:
o Demographic data sheet
o WHO standard chart of growth and development
o Developmental Milestones Checklist

 Ethical consideration:
Informed consent by the parent guardian of the child will be taken. Each
child will have a code and the data shall be saved under lock and key by the
investigator.

 Pilot study:
Shall be conducted on 10% of sample size. These children shall not be
included in main study.

 Data collection method:

Each child shall be visited at residence. Anthropometric data shall be
collected. Then the child shall be asked to perform the activities appropriate
for his/her age. Information about since when the child is able to perform
the activity shall be recorded.

 Data analysis:
Data Shall be analyzed based on the objectives of the study. Descriptive
statistics of mean, percentage and standard deviation shall be used to
describe the population. Inferential statistics of One-Way ANOVA shall be
used to establish the association of demographic factors with the growth
and development scores.

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WORK PLAN

Year Research 2020-21 2021-22 2022-23

Activity
Month April July Oct. – Jan April July Oct. Jan April July Oct. Jan
– – Dec. – – – – – – – – –
June Sept. Mar. June Sept. Dec. Mar. June Sept. Dec. Mar.
Synopsis
Preparation &
Submission
1
DRC topic
presentation
Pilot Study
Publication of
pilot study data
2 Main study data
collection
Data Analysis
Thesis
Manuscript
writing
Submission of
3 Thesis
Viva
Preparation
Viva
Presentation

13
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