Evaluation of ASQ in Singapore - Low and High Risk Cohorts

Dr. Pratibha Agarwal

KK Women's and Children's Hospital SingHealth

Background on KK Women’s and Children’s Hospital

• Founded in 1858
• National leader in Obstetrics, Gynaecology, Paediatrics and Neonatology
• 830 bed hospital providing tertiary services to manage high-risk conditions in women and children in Singapore

Hospital Statistics

• Largest tertiary care perinatal center in Singapore (NICU– 40 beds, Level 2 – 60 beds)
• Annual deliveries: 11,000 per year
• Very Low Birth Weight (VLBW): 200 per year
• Extremely Low Birth Weight (ELBW): 90 per year
• Care for >2/3 of ELBW infants in Singapore

Risk Factors for High-Risk Newborns

• Low birth weight
• Gestational age <28 weeks

Use of ASQ in KKH

High Risk Newborns

• Postnatal conditions leading to increased risks:
  • Neonatal seizures
• Any newborn with a greater than average chance of morbidity or mortality due to conditions overlaid on typical birth events and postnatal adaptation

Follow-Up Programs

1. VLBW Follow-Up Program
   • Ongoing since 1990
   • Structured program of neurodevelopmental and medical follow-up for VLBW babies
   • Data collection & entry up to 8 years of life
   • Psychometric assessment at 2, 5½ & 8 years
   • Assessment of academic performance and learning disabilities

Assessment Protocol

Introduction to Study 1

High-Risk Preterm VLBW Population

• Objective: Evaluate the concurrent validity of Ages & Stages Questionnaires® (ASQ®‐3) with Bayley Scales of Infant & Toddler Development III (BSID‐III) in Preterm Very Low Birth Weight Infants
• Significance of study: Preterm infants require close neurodevelopmental surveillance and early intervention to optimize developmental outcomes.

Primary Aim

• Evaluate if ASQ3 can validly monitor the development of PT/VLBW infants compared with BSID-III at corrected age of 24 months.

Secondary Aims

1. Provide optimal referral cutoffs for ASQ3 total scores using ROC curves at 24 months corrected age for suspected (Bayley III score <85) and significant delays (Bayley score <70).
2. Evaluate predictive values of ASQ3 at 9, 12, and 18 months against BSID III at 24 months.

Study Population Description

• 140 preterm VLBW infants with birth weight ≤1250g without major congenital malformations born from Jan 2010 to Dec 2011 at KK Women’s and Children’s Hospital.

Follow-Up Protocol

• Multidisciplinary team following up at 9, 12, and 18 months:
  1. Familial interviews to gather socioeconomic data.
  2. Medical history review and physical examination by a neonatologist.
  3. Psychometric assessment by a blinded psychologist.

Outcome Measures

• ASQ3: Parent-completed questionnaires covering critical developmental domains such as communication, gross and fine motor skills, problem solving and personal social skills. Relevant screening scores and definitions for developmental delays were outlined.

Statistical Analysis Methods

• Diagnostic agreement estimations using Kappa, Sensitivity, and Specificity calculated across various domains using BSID-III as a standard.

Results Presentation

Demographic Characteristics of Participants

ASQ3 Results at 24 months

• Communication: Normal (n=85, 61%), 1-2 SD (n=26, 19%), <2 SD (n=29, 21%)
• Gross Motor: Normal (n=99, 71%), 1-2 SD (n=18, 13%), <2 SD (n=23, 16%)
• Detailed results also provide insights into Gross Motor and Fine Motor skills across the developmental standards.

Conclusions of Study 1

• ASQ3 is validated as a reliable screening tool for identifying developmental delays in high-risk preterm infants.
• Recommendations on implementation of ASQ3 to enhance early identification process.

Study 2: Low Risk Term Infants

Aims

• Evaluate the reliability and validity of ASQ3 for low-risk Singaporean children and compare findings with norms from the US and Korea.

Methodology Overview

• Data collection at 9, 18, and 24 months with ASQ3 questionnaires filled by mothers, and collection method enhanced by follow-up support.

Comparative Results

• ASQ3 scores across various cohorts highlighted internal consistency and significant differences with the US and Korean data suggesting the necessity for localized standards in Singapore.

Conclusion of Study 2

• ASQ3 proved effective for broader cohort applicability aligned with Singapore’s unique cultural context and population diversity. Recommendations for further research and adaptation alongside targeted screening measures were provided.