Neurodevelopmental Outcomes and Predictors Among Late Pre-Term Infants: A 6-Month Cohort Study

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Trivandrum Developmental Screening Tool (TDST) to assess neurodevelopmental status to identify impairments of child. Objective To identify neurodevelopmental delays in late preterm infants and track their developmental progress at 3 and 6 months of corrected age using the TDST, with inputs from both therapists and parents. Methods 60 late pre-term infants were identified and were screened using the TDST at the time of discharge, 3rd month, and 6th month. Both therapists and parents independently scored the infant’s milestone performance using the TDST. Data were analysed using the Wilcoxon signed rank test and linear regression to explore differences in identifying milestone predictors. Results The findings underscore the importance of consistent parental education in enhancing early intervention and monitoring. Therapists scored higher than parents at 3 and 6 months (p = 0.0002, p = 0.000). Despite increased awareness, parents underreported key motor milestones, such as rolling, turning to sound, and object transfer (r = 0.542 at 6 months). Conclusion Parents struggle to recognize complex motor skills, despite no significant differences from therapists at 3 months. By 6 months, significant discrepancies emerged, highlighting the need for early, structured parental education and consistent developmental follow-up in late preterm infants. Late preterm Motor Development Developmental Delay Early Screening Trivandrum Developmental Screening Tool (TDST) Figures Figure 1 Figure 2 Introduction According to the World Health Organization (WHO), preterm birth is defined as the birth of a baby before 37 completed weeks of gestation 1 . Preterm infants are further classified based on gestational age into three subcategories: extremely preterm (< 28 weeks), very preterm (28 to < 32 weeks), and moderate to late preterm (32 to < 37 weeks) 2 . Although they are often perceived as being at lower risk, late preterm infants still face significantly higher rates of morbidity and mortality compared to their full-term counterparts (Fig. 1 ). Their vulnerability is largely due to incomplete brain maturation during the final weeks of gestation, which predisposes them to long-term neurodevelopmental impairments 3 . In 2020, an estimated 13.4 million preterm births occurred globally, with India accounting for approximately 3 million (22%) of these cases. In the Indian state of Tamil Nadu, the preterm birth rate is reported to be as high as 14% 4 . While improvements in neonatal intensive care have increased survival rates, the risk of developmental impairments, particularly in neurological domains, remains high. Predicting neurodevelopmental outcomes in these children is challenging due to the complex interplay of biological, environmental, and psychosocial factors, among which parental involvement plays a pivotal role 5 . Parental inclusion is essential in optimizing neurodevelopmental outcomes for preterm infants. Actively involving parents in early screening, therapy, and follow-up enhances their ability to detect early warning signs and participate in decision-making regarding their child’s care 6 . Such engagement is particularly important in low-resource settings where parental awareness and participation can bridge service gaps. Early screening is critical for the timely identification of developmental abnormalities and the initiation of targeted interventions 6 . The first year of life is a crucial period for brain development, necessitating structured monitoring during this window. Neurodevelopmental assessments conducted at 3, 6, 9, and 12 months of age help identify delays in motor, cognitive, language, and social domains 7 . These periodic evaluations offer valuable opportunities to address emerging concerns and implement early interventions. To support early identification, the Trivandrum Developmental Screening Tool (TDST) has been developed as a culturally appropriate, valid, and easy-to-use tool for the Indian population 8 . It consists of a single pictorial page with developmental milestones across key domains and requires minimal training, making it suitable for administration by both healthcare professionals and parents. TDST's simplicity, affordability, and suitability for mass screening make it a preferred tool in Indian clinical and community settings. The success of early screening and intervention efforts also depends on the skills and training of healthcare professionals, including paediatricians, therapists, and primary care providers 9 . Proficiency in administering screening tools, interpreting results, and delivering family-centred care is essential. Continued professional development and multidisciplinary collaboration ensure that preterm infants receive comprehensive and individualized care 10 . While some developmental issues are evident in early infancy, others, particularly cognitive and executive function deficits, may not emerge until later in childhood or adolescence—a phenomenon known as “growing into deficit” 11 . Therefore, long-term monitoring and cognitive assessments are necessary to identify subtle but significant developmental challenges. Despite growing awareness, research on moderately and late preterm infants remains limited, with most long-term studies focusing on extremely preterm populations 12 . The findings from existing studies are often inconclusive; some report minimal deficits among late preterm infants, while others suggest a higher risk of behavioural and learning difficulties. This highlights the urgent need for structured cohort studies that track neurodevelopmental trajectories and identify risk and protective factors unique to this subgroup 13 . Although there is substantial literature on child development monitoring, many studies lack an integrated approach that includes the perspectives and active roles of both therapists and parents 14 . A triangular model that combines inputs from the child, therapist, and parent is essential for developing and implementing customized care plans. Within this framework, our study aims to contribute evidence that can inform such individualized, holistic strategies for developmental support in late preterm infants 15 . The current study adopts a cohort design to follow late preterm infants over the first six months of life, a key developmental period. This approach allows for systematic assessment of neurodevelopmental outcomes and exploration of predictors influencing early development 16 , 17 . The novelty of the study lies in its exclusive focus on late preterm infants in the Indian context, use of a locally validated screening tool - TDST, and inclusion of parental and environmental variables. These insights are vital for designing contextually appropriate early intervention strategies in low- and middle-income countries. Aim of the study: The study aims to identify neurodevelopmental delays in late preterm infants and track their developmental progress at 3 and 6 months of corrected age using the Trivandrum Developmental Screening Tool (TDST), with assessments conducted by both therapists and parents under a blinded protocol. Materials and methods Study Design This prospective, non-experimental cohort study focused on identifying the neurodevelopmental outcomes and their predictors among late preterm infants (33 ± 0 days to 36 ± 0 days) over the first six months of the child’s life. Each child’s timeline includes three main points: Initial enrolment (at the time of discharge), at the 3rd and 6th months of corrected age (Fig. 2 ). Study setting and participants The study was conducted from the Department of Pediatrics, SRM Medical College Hospital and Research Centre, Kattankulathur, Tamil Nadu, India. 60 late preterm infants and their primary caregivers have been recruited after a detailed explanation of the study within the first week of delivery. Inclusion criteria Infants eligible for inclusion in the study were those born between 33 and 36 completed weeks of gestation and were clinically stable at the time of discharge from the neonatal unit. Additionally, the presence of a primary caregiver, typically a parent, who was willing to participate in the scheduled follow-up assessments was required. 18 Exclusion criteria The child with congenital anomalies, genetic abnormalities, and a history of recurrent NICU admissions. Neurodevelopmental Assessment Developmental assessments were conducted using the Trivandrum Developmental Screening Tool (TDST), a culturally appropriate and pictorial tool designed for Indian children. The TDSC is validated with a sensitivity of 84.62%, specificity of 90.8%, and an interclass correlation coefficient of 0.77. It assesses four developmental domains: gross motor, fine motor, language, and social-personal skills at 3rd, 6th, 9 th, and 12 months. In this study, the TDST was administered at the 3rd and 6th months of corrected age. If a child failed to achieve one or more age-appropriate milestones, this was considered indicative of a developmental delay, warranting referral to a healthcare professional 19 . Blinding Procedure This study employed a dual-blinded methodology to reduce both observer and responder bias. At discharge, the primary investigator educated parents on how to use a simplified TDSC-based checklist to observe and score their child’s milestones at home. Parents completed this checklist at the 3rd month of corrected age and submitted it during the scheduled follow-up visit. The primary investigator collected the parent-reported scores and referred the infant to an evaluating therapist for a separate TDST assessment. The therapist was blinded to the parents’ scores, and likewise, the parents did not have access to the therapist’s evaluation. The same procedure was followed at the 6th-month follow-up. This allowed the primary investigator, who was the only person with access to both datasets, to compare parental and therapist scoring to assess any discrepancies and identify potential developmental delays. Ethical Approval Ethical clearance was obtained from the Institutional Ethics Committee (IEC) of SRM Medical College Hospital and Research Centre (Approval No: SRMIEC-ST0224-1174), and conducted following the Declaration of Helsinki. A written informed consent was obtained from all parents or legal guardians before enrollment. Data Collection The baseline child data, namely gestational age, birth weight, head circumference, APGAR scores at 1 and 5 minutes, and NICU stay duration, were collected at discharge. Parental demographic details such as age, educational status, socioeconomic status, and consanguinity marriage were also recorded. Statistical Analysis The data was processed with SPSS version 21. The demographic variables were descriptively analysed and iteratively checked for influence. Wilcoxson's sign rank test was conducted to investigate the significant difference between the parent and the therapist score at the 3 rd and 6 th months. Variables that showed statistical significance were further analysed using regression analysis to determine potential predictors of developmental delay. A p-value of less than 0.05 was considered statistically significant. Results This prospective, non-experimental cohort study followed 60 late preterm infants (born between 34 and 36 weeks of gestation) over six months, using corrected age for developmental assessment. Demographic Characteristics As detailed in Table 1, the mean paternal age was 30.5 ± 4.2 years, while the mean maternal age was 28.3 ± 3.9 years. Among the parents, 60% of fathers and 65% of mothers held graduate-level qualifications. Consanguineous marriages were reported in 12% of cases. In terms of socioeconomic classification, 50% of families were from middle-income backgrounds, 30% from low-income backgrounds, and 20% from high-income groups. All infants (N = 60) were enrolled at the time of discharge, with a follow-up retention of 68% (n = 41) at both the 3rd and 6th months. The cohort consisted of 55% male and 45% female infants. The mean birth weight was 2.4 ± 0.3 kg, and the average gestational age was 35.2 ± 1.2 weeks. The mean APGAR scores were 7.5 ± 0.9 at 1 minute and 8.8 ± 0.6 at 5 minutes, and the average NICU stay was 4.2 ± 2.1 days. A subgroup analysis revealed that among graduate fathers (n = 25), only 36% accurately identified motor milestones when cross-checked against therapist assessments, suggesting that formal education alone may not be sufficient to ensure accurate developmental monitoring. TABLE 1: Demographic data table Variable Mean (SD) / % Parental Age (years) 30.5 ± 4.2 Maternal Age (years) 28.3 ± 3.9 Paternal Literacy Level Highschool:40% Graduate: 60% Maternal Literacy Level Highschool:35% Graduate: 65% Consanguineous Marriage Yes:12% No: 88% Socioeconomic Status Low:30% Middle:50% High: 20% Participants Follow up At discharge: 100% (60 samples) At 3 rd month: 68% (41 samples) At 6 th month: 68% (41 samples) Infant Gender Boy:55% Girl: 45% Mean Birth Weight (kg) 2.4 ± 0.3 kg Mean Gestational Age (weeks) 35.2 ± 1.2 APGAR Score at 1 min 7.5 ± 0.9 APGAR Score at 5 min 8.8 ± 0.6 NICU Stay Duration (days) 4.2 ± 2.1 Table 2 : Wilcoxon Signed-Rank Test Comparing Therapist and Parent TDST Scores at 3 Months Component Z-value Asymp.Sig (2-tailed) Interpretation Social Smile 0.000 1.000 No significant difference Eye Follow -2.121 0.034* Significant difference Head Holding -2.887 0.004** Highly significant difference Overall TDST score (Therapist vs Parent) -1.155 0.248 No significant difference *p<0.05, **p<0.01 At the 3-month follow-up, Wilcoxon signed-rank tests were conducted to compare therapist and parent scores for individual developmental components. There was a statistically significant difference between therapist and parent ratings for eye-follow (Z = -2.121, p = 0.034) and head holding (Z = -2.887, p = 0.004), suggesting discrepancies in parental recognition of these milestones. However, no significant difference was observed in social smile (Z = 0.000, p = 1.000) or in the overall TDST score (Z = -1.155, p = 0.248). Table 3 : Wilcoxon Signed-Rank Test: Comparison of TDST Scores Between Therapist and Parent at 6 Months Component Z-value Asymp.Sig (2-tailed) Interpretation Social Smile 0.000 1.000 No significant difference Eye-follow 0.000 1.000 No significant difference Head holding 0.000 1.000 No significant difference Rolls from back to stomach -3.207 0.001** Highly significant difference Turns head to sound -1.134 0.257 No significant difference Transfers object from one hand to another -2.496 0.013* Significant difference Overall TDST score -3.477 0.001* Highly significant difference *p<0.05, **p<0.01 At the 6-month follow-up, the Wilcoxon signed-rank test revealed significant differences between parent-reported and therapist-assessed developmental milestone scores. Notably, discrepancies were found in the domains of rolling from back to stomach (Z = -3.207, p = 0.001), transferring objects from one hand to another (Z = -2.496, p = 0.013), and the overall TDST score (Z = -3.477, p = 0.001). These findings suggest parents may under- or overestimate certain milestones compared to therapists. However, no statistically significant differences were found in social smile , eye following , head holding , or turning head to sound , indicating consistency in these observations. Component-wise Comparison Between Therapist and Parent Scores at 3 Months At the 3-month corrected age follow-up, the Wilcoxon Signed-Rank Test was employed to compare therapist and parent scores for individual developmental milestones. Significant differences were observed in the eye-following milestone (Z = -2.121, p = 0.034) and head holding (Z = -2.887, p = 0.004), indicating discrepancies between parental reporting and therapist evaluation. However, no significant difference was found for social smile (Z = 0.000, p = 1.000), and the overall developmental score did not reach statistical significance (Z = -1.155, p = 0.248). Component-wise Comparison Between Therapist and Parent Scores at 6 Months By 6 months of corrected age, discrepancies between therapist and parent assessments became more pronounced. The Wilcoxon Signed-Rank Test showed statistically significant differences in: Rolling from back to stomach (Z = -3.207, p = 0.001), Transfer of objects from one hand to another (Z = -2.496, p = 0.013), Overall developmental score (Z = -3.477, p = 0.001). In contrast, no significant differences were noted in the following components: social smile (Z = 0.000, p = 1.000), eye follow (Z = 0.000, p = 1.000), head holding (Z = 0.000, p = 1.000), and turning head to sound (Z = -1.134, p = 0.257). Correlation Analysis Correlation analysis at the 6-month follow-up revealed a moderate positive correlation between therapist and parent scores (r = 0.542, p = 0.001). This indicates an improvement in parental awareness and scoring accuracy over time, although discrepancies persisted, particularly in motor domains. Regression Analysis The regression models conducted for the 6-month follow-up revealed that two developmental milestones— rolling from back to stomach and transferring objects hand to hand —were statistically significant predictors of overall developmental scores, as reported by both parents and therapists. These findings suggest that these specific motor milestones are robust indicators of broader developmental progress at this age. Multiple linear regression analysis was conducted only for the 6-month follow-up period, as regression at the 3rd month was not feasible. At 3 months, the component scores did not yield a meaningful distribution for modelling, as they resulted in simple summation of three milestone scores, which lacked sufficient variability and interpretive value for predictive analysis. At 6 months, two regression models were developed to identify predictors of developmental outcomes. For parental scores, significant predictors included rolling from back to stomach (β = 0.405, p = 0.001) and transfer of objects hand to hand (β = 0.689, p < 0.001). The model was statistically significant, F (2, 38) = 22.707, p < 0.001, explaining 54.4% of the variance (R² = 0.544). Parent Score (6 months) = 4.222 + 0.778(Rolling) + 0.778(Transfer) For therapist scores, the same two components were also significant predictors: rolling from back to stomach (β = 0.600, p < 0.001) and transfer of objects hand to hand (β = 0.660, p < 0.001). This model was highly significant, F(2, 38) = 107.626, p < 0.001, accounting for 85% of the variance (R² = 0.850). Predictive Equation: Therapist Score (6 months) = 3.930 + 0.951(Rolling) + 1.008(Transfer) The parental score model explained 54.4% of the variance, indicating a moderate level of predictability. In contrast, the therapist score model explained a substantial 85% of the variance, suggesting a stronger and more consistent relationship between these milestones and overall therapist-assessed development. These results highlight the importance of gross and fine motor skills, particularly the ability to roll over and transfer objects between hands, as reliable markers for developmental surveillance at 6 months of corrected age. The stronger predictive power in therapist assessments may reflect greater scoring consistency and observational expertise compared to parent-reported evaluations. Influence of demographic variables Statistical tests were conducted to examine whether these demographic and perinatal factors influenced developmental scores. Using the Mann–Whitney U test, no significant differences were found in developmental scores based on infant gender at either follow-up point for both parent and therapist assessments. Similarly, the Kruskal–Wallis test indicated no significant influence of mode of delivery on developmental scores at both 3rd and 6th months. The educational level of fathers also did not show a statistically significant impact. Furthermore, APGAR scores at both 1 and 5 minutes were not significantly associated with developmental scores, nor was socioeconomic status at any time point. Discussion This prospective cohort study aimed to assess neurodevelopmental outcomes among late preterm infants at the 3rd and 6th months of corrected age, focusing on comparisons between parental and therapist-reported developmental scores and identifying key predictors of these outcomes. The findings revealed both areas of alignment and significant discrepancies in milestone recognition between parents and therapists, highlighting the critical need for enhanced caregiver education and early intervention strategies. At 3 months, parents and therapists demonstrated moderate agreement in overall developmental assessments, suggesting a baseline awareness of key early milestones among caregivers. However, domain-specific discrepancies were evident, especially in visual and motor behaviours such as eye-following and head-holding. These mismatches imply that while parents observe their infants closely, they may not fully interpret the developmental significance of these behaviours, particularly those involving postural control and visual-motor integration. Similar findings have been reported in Chinese samples, where parents and teachers showed low sensitivity in identifying motor difficulties, even among children performing below the 15th percentile (suspected Developmental coordination disorder) on the Movement ABC-2 performance test. 20 By 6 months, the divergence between parent and therapist assessments widened further, with statistically significant discrepancies noted in complex motor tasks such as rolling from back to stomach and transferring objects from hand to hand. These skills, which involve midline crossing and bilateral coordination, are known indicators of neurological maturation. Their under-recognition by parents may stem from the increasing complexity of motor milestones, consistent with global evidence showing that as task demands increase, parental accuracy declines. For example, in an Australian cohort, parent proxy reports explained only ~11% of the variance in actual motor performance assessed using the TGMD-3. 21 Similarly, Zysset et al. (2018) reported a weak correlation (r ≈ 0.23) between parental ratings and standardized scores using the Zurich Neuromotor Assessment (ZNA3–5), reinforcing that caregiver reports often lack precision in motor domains. 22 Regression analysis in our study revealed that rolling and object transfer were the most significant predictors of developmental outcomes at 6 months for both therapist- and parent-reported models. However, the variance explained was markedly higher in the therapist model (R² = 0.850) compared to the parent model (R² = 0.544), reflecting the advantages of structured training and standardized assessments in capturing developmental delays more reliably. Despite the moderate, statistically significant correlation observed between therapist and parent scores at 6 months, persistent mismatches—especially in motor domains—underscore the limitations of relying solely on observational learning. This is supported by previous research indicating that while parents may become more aware over time through repeated interactions with healthcare professionals, exposure alone is insufficient to develop the interpretive skills required for accurate milestone tracking. Even among graduate-educated caregivers in our sample, only 36% correctly identified early signs of motor delay, reinforcing that formal education does not equate to developmental literacy. 23 Several validated tools attempt to address these challenges. The Early Motor Questionnaire (EMQ) has shown promise in eliciting useful parental insights into motor development when milestones are clearly defined and contextualized (Libertus & Landa, 2013). 24 Similarly, Dite and Amick (2021) found that daily checklists improved recall accuracy for gross motor skills, though variability persisted without professional guidance. However, tools like the CDC Milestone Tracker and ASQ-3, unless accompanied by training and cultural adaptation, may fall short in low- and middle-income settings where developmental literacy is variable and milestone interpretation may be culturally influenced. 25 These results suggest that although parents’ awareness of developmental behaviours may improve over time, as reflected in the moderate positive correlation between parent and therapist scores at 6 months, gaps persist in identifying more complex or subtle motor skills. This is consistent with prior literature (Miller et al, 2017) comparing parent reports and direct assessments in toddlers, where greater alignment is observed in language or social-emotional domains, but motor skill reports are often less reliable, reflecting variability in caregiver perception and reporting accuracy. 26 Our analysis of demographic and perinatal variables—including child gender, mode of delivery, paternal education, APGAR scores, and socioeconomic status—revealed no statistically significant influence on developmental scores. This finding is consistent with earlier studies suggesting that, within medically stable late preterm populations, these variables may have limited predictive value. Taken together, these findings underscore the urgent need for structured, milestone-specific, and culturally adapted parental education. The critical window for neuroplasticity in the first 3 months of life suggests that interventions delayed beyond this period may miss the optimal opportunity for effective early intervention. 27 Importantly, parental expertise developed after the third month may be too late to detect delays during the most critical window of neuroplasticity. Therefore, proactive caregiver education before the 3-month mark is vital to ensuring timely recognition and intervention for developmental delays. A key strength of this study lies in its prospective design, standardized corrected age assessment, and dual-informant comparison (therapist and parent) across multiple time points. The use of non-parametric and regression analyses provided robust insights into milestone recognition and predictor validity. The limitations of the study are as follows: First, attrition to 68% follow-up may limit the generalizability of findings, particularly if the dropouts were not random. Second, the single-centre design and relatively modest sample size restrict external validity. Third, the study did not assess maternal mental health or parenting stress, factors known to influence caregiver developmental perceptions. Future recommendations The findings of this study, future research should consider extending the follow-up period beyond infancy to determine whether discrepancies between parent and therapist assessments continue into toddlerhood. Community-adapted milestone tools using illustrations and lay terms to improve usability among low-literacy populations. The effect of structured parental training modules on improving milestone recognition accuracy can be considered in the future. Clinical implications The 6-month follow-up serves as a critical checkpoint for identifying infants at risk who require longer-term developmental monitoring and support. Policy makers should emphasize training of primary care providers in the developmental surveillance protocol. Conclusion The first 1000 days of life offer a powerful window of opportunity to shape a child’s developmental future. This study adds to growing evidence that while many parents of late preterm infants are attentive and engaged, they may struggle to recognize early signs of developmental delays—especially as milestones become more complex. At 3 months, there was broad agreement between parents and therapists on general developmental progress. But by 6 months, clear gaps began to emerge, particularly in identifying motor skills like rolling over and transferring objects—key indicators of neurological growth. Even well-educated caregivers in our study sometimes missed these cues, reminding us that academic literacy doesn’t always translate into developmental literacy. The findings highlight a clear need: parents must be supported not only with information but with structured guidance tailored to their cultural and educational backgrounds. Tools like the EMQ, CDC Milestone Tracker, and ASQ-3 show promise, but only when used alongside training and professional support. Importantly, the study reinforces that early intervention is most effective when it begins before three months of age—while the brain is at its most adaptable. That’s why developmental monitoring can’t wait for signs of concern. It must begin proactively, starting at NICU discharge, and continue through regular, supportive follow-up. When parents and professionals work together—sharing knowledge, watching closely, and acting early—children, especially those born late preterm, have a far better chance to thrive. It’s not just about ticking off milestones; it’s about giving every child the best possible start. Abbreviations TDST Trivandrum Developmental Screening Tool IEC Institutional Ethical Committee Declarations Ethical approval and consent to participate: Ethical approval was obtained from the Institutional Ethics Committee (IEC) of SRM Medical College Hospital and Research Centre (Approval No: SRMIEC-ST0224-1174), and conducted following the Declaration of Helsinki. A written informed consent was obtained from all parents or legal guardians before enrollment. Clinical Trial Number : Clinical Trial number is not applicable Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Conflicts of interest: The Author declares no conflicts of interest to disclose. Funding: The authors received no funding for this study Author contributions: All authors have contributed, read, and approved the final manuscript. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6775901","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":474706984,"identity":"7803540c-6774-473e-9ad9-7454097fb947","order_by":0,"name":"Shrisruthi Suresh","email":"","orcid":"","institution":"SRM College of Physiotherapy, Faculty of Medicine and Health Sciences,SRM Institute of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Shrisruthi","middleName":"","lastName":"Suresh","suffix":""},{"id":474706985,"identity":"93fd1e97-7882-4703-ba98-6aef497c0835","order_by":1,"name":"Vadivelan Kanniappan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIie3Ooa7CMBSA4aN6zZLaM8MzHNKkQSy5r7KGBMwEEoGYGoZkmre4CwY5sgTMCLY4EKAQ4CBZCB3Bwd3AIfqLpm365RTAZvvOKAVoES+3PjxWv54gueH9Mb1HoCQlfBzq3i+yJHP6KMRqufvbFAXwn4BgO60geaeXOTlKqbtSq4jAHR0IVP4/ccOAZuMIPakZ0yokIG2mqKiCxAdDruiJeM60XxD81hGOAaWnECVBxxBmpmAt2ffS4xwFakNUJBzMzU0VYbw9OfoDrxmbj63PRaPBh+1ke6kgTznlkn4AbDabzfaiG7G4UhjgYc6OAAAAAElFTkSuQmCC","orcid":"","institution":"SRM College of Physiotherapy, Faculty of Medicine and Health Sciences,SRM Institute of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Vadivelan","middleName":"","lastName":"Kanniappan","suffix":""},{"id":474706986,"identity":"516df78d-dce9-4384-9335-21d49966a104","order_by":2,"name":"Sushmitha Kannairam","email":"","orcid":"","institution":"SRM College of Physiotherapy, Faculty of Medicine and Health Sciences,SRM Institute of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Sushmitha","middleName":"","lastName":"Kannairam","suffix":""}],"badges":[],"createdAt":"2025-05-29 11:08:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6775901/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6775901/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12887-025-06391-0","type":"published","date":"2025-12-10T15:58:36+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85391169,"identity":"08a9a20a-cfa9-4108-beff-7e175756ad64","added_by":"auto","created_at":"2025-06-25 10:26:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":17027,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConceptual framework for neurodevelopmental problems for Preterm infants\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6775901/v1/016f852b85b2fb7683508fe8.png"},{"id":85391170,"identity":"a1abdd4a-4a10-438d-bd21-1c3833a2c047","added_by":"auto","created_at":"2025-06-25 10:26:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":6550,"visible":true,"origin":"","legend":"\u003cp\u003eDevelopmental Surveillance Timeline for Late Preterm Infants\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6775901/v1/704291cd78e5fcd3f252873e.png"},{"id":98244901,"identity":"b8484186-a0ef-4fc9-b01a-7c79edab1f77","added_by":"auto","created_at":"2025-12-15 16:15:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":918237,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6775901/v1/1c2343e6-3655-4a32-925c-29ab83366394.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eNeurodevelopmental Outcomes and Predictors Among Late Pre-Term Infants: A 6-Month Cohort Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAccording to the World Health Organization (WHO), preterm birth is defined as the birth of a baby before 37 completed weeks of gestation \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Preterm infants are further classified based on gestational age into three subcategories: extremely preterm (\u0026lt;\u0026thinsp;28 weeks), very preterm (28 to \u0026lt;\u0026thinsp;32 weeks), and moderate to late preterm (32 to \u0026lt;\u0026thinsp;37 weeks) \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Although they are often perceived as being at lower risk, late preterm infants still face significantly higher rates of morbidity and mortality compared to their full-term counterparts (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Their vulnerability is largely due to incomplete brain maturation during the final weeks of gestation, which predisposes them to long-term neurodevelopmental impairments \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn 2020, an estimated 13.4\u0026nbsp;million preterm births occurred globally, with India accounting for approximately 3\u0026nbsp;million (22%) of these cases. In the Indian state of Tamil Nadu, the preterm birth rate is reported to be as high as 14% \u003csup\u003e4\u003c/sup\u003e. While improvements in neonatal intensive care have increased survival rates, the risk of developmental impairments, particularly in neurological domains, remains high. Predicting neurodevelopmental outcomes in these children is challenging due to the complex interplay of biological, environmental, and psychosocial factors, among which parental involvement plays a pivotal role \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eParental inclusion is essential in optimizing neurodevelopmental outcomes for preterm infants. Actively involving parents in early screening, therapy, and follow-up enhances their ability to detect early warning signs and participate in decision-making regarding their child\u0026rsquo;s care \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Such engagement is particularly important in low-resource settings where parental awareness and participation can bridge service gaps.\u003c/p\u003e \u003cp\u003eEarly screening is critical for the timely identification of developmental abnormalities and the initiation of targeted interventions \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. The first year of life is a crucial period for brain development, necessitating structured monitoring during this window. Neurodevelopmental assessments conducted at 3, 6, 9, and 12 months of age help identify delays in motor, cognitive, language, and social domains\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. These periodic evaluations offer valuable opportunities to address emerging concerns and implement early interventions.\u003c/p\u003e \u003cp\u003eTo support early identification, the Trivandrum Developmental Screening Tool (TDST) has been developed as a culturally appropriate, valid, and easy-to-use tool for the Indian population \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. It consists of a single pictorial page with developmental milestones across key domains and requires minimal training, making it suitable for administration by both healthcare professionals and parents. TDST's simplicity, affordability, and suitability for mass screening make it a preferred tool in Indian clinical and community settings.\u003c/p\u003e \u003cp\u003eThe success of early screening and intervention efforts also depends on the skills and training of healthcare professionals, including paediatricians, therapists, and primary care providers \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Proficiency in administering screening tools, interpreting results, and delivering family-centred care is essential. Continued professional development and multidisciplinary collaboration ensure that preterm infants receive comprehensive and individualized care \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWhile some developmental issues are evident in early infancy, others, particularly cognitive and executive function deficits, may not emerge until later in childhood or adolescence\u0026mdash;a phenomenon known as \u0026ldquo;growing into deficit\u0026rdquo; \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Therefore, long-term monitoring and cognitive assessments are necessary to identify subtle but significant developmental challenges.\u003c/p\u003e \u003cp\u003eDespite growing awareness, research on moderately and late preterm infants remains limited, with most long-term studies focusing on extremely preterm populations \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. The findings from existing studies are often inconclusive; some report minimal deficits among late preterm infants, while others suggest a higher risk of behavioural and learning difficulties. This highlights the urgent need for structured cohort studies that track neurodevelopmental trajectories and identify risk and protective factors unique to this subgroup \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAlthough there is substantial literature on child development monitoring, many studies lack an integrated approach that includes the perspectives and active roles of both therapists and parents \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. A triangular model that combines inputs from the child, therapist, and parent is essential for developing and implementing customized care plans. Within this framework, our study aims to contribute evidence that can inform such individualized, holistic strategies for developmental support in late preterm infants\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe current study adopts a cohort design to follow late preterm infants over the first six months of life, a key developmental period. This approach allows for systematic assessment of neurodevelopmental outcomes and exploration of predictors influencing early development \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. The novelty of the study lies in its exclusive focus on late preterm infants in the Indian context, use of a locally validated screening tool - TDST, and inclusion of parental and environmental variables. These insights are vital for designing contextually appropriate early intervention strategies in low- and middle-income countries.\u003c/p\u003e\n\u003ch3\u003eAim of the study:\u003c/h3\u003e\n\u003cp\u003eThe study aims to identify neurodevelopmental delays in late preterm infants and track their developmental progress at 3 and 6 months of corrected age using the Trivandrum Developmental Screening Tool (TDST), with assessments conducted by both therapists and parents under a blinded protocol.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis prospective, non-experimental cohort study focused on identifying the neurodevelopmental outcomes and their predictors among late preterm infants (33\u0026thinsp;\u0026plusmn;\u0026thinsp;0 days to 36\u0026thinsp;\u0026plusmn;\u0026thinsp;0 days) over the first six months of the child\u0026rsquo;s life. Each child\u0026rsquo;s timeline includes three main points: Initial enrolment (at the time of discharge), at the 3rd and 6th months of corrected age (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy setting and participants\u003c/h3\u003e\n\u003cp\u003eThe study was conducted from the Department of Pediatrics, SRM Medical College Hospital and Research Centre, Kattankulathur, Tamil Nadu, India. 60 late preterm infants and their primary caregivers have been recruited after a detailed explanation of the study within the first week of delivery.\u003c/p\u003e\n\u003ch3\u003eInclusion criteria\u003c/h3\u003e\n\u003cp\u003eInfants eligible for inclusion in the study were those born between 33 and 36 completed weeks of gestation and were clinically stable at the time of discharge from the neonatal unit. Additionally, the presence of a primary caregiver, typically a parent, who was willing to participate in the scheduled follow-up assessments was required.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003eThe child with congenital anomalies, genetic abnormalities, and a history of recurrent NICU admissions.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eNeurodevelopmental Assessment\u003c/h2\u003e \u003cp\u003eDevelopmental assessments were conducted using the Trivandrum Developmental Screening Tool (TDST), a culturally appropriate and pictorial tool designed for Indian children. The TDSC is validated with a sensitivity of 84.62%, specificity of 90.8%, and an interclass correlation coefficient of 0.77. It assesses four developmental domains: gross motor, fine motor, language, and social-personal skills at 3rd, 6th, 9\u003csup\u003eth,\u003c/sup\u003e and 12 months. In this study, the TDST was administered at the 3rd and 6th months of corrected age. If a child failed to achieve one or more age-appropriate milestones, this was considered indicative of a developmental delay, warranting referral to a healthcare professional\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eBlinding Procedure\u003c/h3\u003e\n\u003cp\u003eThis study employed a dual-blinded methodology to reduce both observer and responder bias. At discharge, the primary investigator educated parents on how to use a simplified TDSC-based checklist to observe and score their child\u0026rsquo;s milestones at home. Parents completed this checklist at the 3rd month of corrected age and submitted it during the scheduled follow-up visit. The primary investigator collected the parent-reported scores and referred the infant to an evaluating therapist for a separate TDST assessment. The therapist was blinded to the parents\u0026rsquo; scores, and likewise, the parents did not have access to the therapist\u0026rsquo;s evaluation. The same procedure was followed at the 6th-month follow-up. This allowed the primary investigator, who was the only person with access to both datasets, to compare parental and therapist scoring to assess any discrepancies and identify potential developmental delays.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from the Institutional Ethics Committee (IEC) of SRM Medical College Hospital and Research Centre (Approval No: SRMIEC-ST0224-1174), and conducted following the Declaration of Helsinki. \u0026nbsp;A written informed consent was obtained from all parents or legal guardians before enrollment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe baseline child data, namely gestational age, birth weight, head circumference, APGAR scores at 1 and 5 minutes, and NICU stay duration, were collected at discharge. Parental demographic details such as age, educational status, socioeconomic status, and consanguinity marriage were also recorded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data was processed with SPSS version 21. The demographic variables were descriptively analysed and iteratively checked for influence. Wilcoxson\u0026apos;s sign rank test was conducted to investigate the significant difference between the parent and the therapist score at the 3\u003csup\u003erd\u003c/sup\u003e and 6\u003csup\u003eth\u003c/sup\u003e months. Variables that showed statistical significance were further analysed using regression analysis to determine potential predictors of developmental delay. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis prospective, non-experimental cohort study followed 60 late preterm infants (born between 34 and 36 weeks of gestation) over six months, using corrected age for developmental assessment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs detailed in Table 1, the mean paternal age was 30.5 \u0026plusmn; 4.2 years, while the mean maternal age was 28.3 \u0026plusmn; 3.9 years. Among the parents, 60% of fathers and 65% of mothers held graduate-level qualifications. Consanguineous marriages were reported in 12% of cases. In terms of socioeconomic classification, 50% of families were from middle-income backgrounds, 30% from low-income backgrounds, and 20% from high-income groups.\u003c/p\u003e\n\u003cp\u003eAll infants (N = 60) were enrolled at the time of discharge, with a follow-up retention of 68% (n = 41) at both the 3rd and 6th months. The cohort consisted of 55% male and 45% female infants. The mean birth weight was 2.4 \u0026plusmn; 0.3 kg, and the average gestational age was 35.2 \u0026plusmn; 1.2 weeks. The mean APGAR scores were 7.5 \u0026plusmn; 0.9 at 1 minute and 8.8 \u0026plusmn; 0.6 at 5 minutes, and the average NICU stay was 4.2 \u0026plusmn; 2.1 days.\u003c/p\u003e\n\u003cp\u003eA subgroup analysis revealed that among graduate fathers (n = 25), only 36% accurately identified motor milestones when cross-checked against therapist assessments, suggesting that formal education alone may not be sufficient to ensure accurate developmental monitoring.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 1:\u0026nbsp;\u003c/strong\u003eDemographic data table\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"598\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 400px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD) / %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParental Age (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 400px;\"\u003e\n \u003cp\u003e30.5 \u0026plusmn; 4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal Age (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 400px;\"\u003e\n \u003cp\u003e28.3 \u0026plusmn; 3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePaternal Literacy Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 400px;\"\u003e\n \u003cp\u003eHighschool:40%\u0026nbsp;\u003cbr\u003e\u0026nbsp;Graduate: 60%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal Literacy Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 400px;\"\u003e\n \u003cp\u003eHighschool:35%\u0026nbsp;\u003cbr\u003e\u0026nbsp;Graduate: 65%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConsanguineous Marriage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 400px;\"\u003e\n \u003cp\u003eYes:12%\u0026nbsp;\u003cbr\u003e\u0026nbsp;No: 88%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocioeconomic Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 400px;\"\u003e\n \u003cp\u003eLow:30%\u0026nbsp;\u003cbr\u003e\u0026nbsp;Middle:50%\u0026nbsp;\u003cbr\u003e\u0026nbsp;High: 20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants Follow up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 400px;\"\u003e\n \u003cp\u003eAt discharge: 100% (60 samples)\u003c/p\u003e\n \u003cp\u003eAt 3\u003csup\u003erd\u003c/sup\u003e month: 68% (41 samples)\u003c/p\u003e\n \u003cp\u003eAt 6\u003csup\u003eth\u003c/sup\u003e month: 68% (41 samples)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInfant Gender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 400px;\"\u003e\n \u003cp\u003eBoy:55%\u0026nbsp;\u003cbr\u003e\u0026nbsp;Girl: 45%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Birth Weight (kg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 400px;\"\u003e\n \u003cp\u003e2.4 \u0026plusmn; 0.3 kg\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Gestational Age (weeks)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 400px;\"\u003e\n \u003cp\u003e35.2 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAPGAR Score at 1 min\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 400px;\"\u003e\n \u003cp\u003e\u0026nbsp;7.5 \u0026plusmn; 0.9 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAPGAR Score at 5 min\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 400px;\"\u003e\n \u003cp\u003e8.8 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNICU Stay Duration (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 400px;\"\u003e\n \u003cp\u003e4.2 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e:\u0026nbsp;Wilcoxon Signed-Rank Test Comparing Therapist and Parent TDST Scores at 3 Months\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eComponent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eZ-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eAsymp.Sig (2-tailed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eInterpretation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eSocial Smile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eNo significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eEye Follow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e-2.121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.034*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eSignificant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eHead Holding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e-2.887\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.004**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eHighly significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eOverall TDST score (Therapist vs Parent)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e-1.155\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.248\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eNo significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.05, **p\u0026lt;0.01\u003c/p\u003e\n\u003cp\u003eAt the 3-month follow-up, Wilcoxon signed-rank tests were conducted to compare therapist and parent scores for individual developmental components. There was a statistically significant difference between therapist and parent ratings for \u003cem\u003eeye-follow\u003c/em\u003e (Z = -2.121, p = 0.034) and \u003cem\u003ehead holding\u003c/em\u003e (Z = -2.887, p = 0.004), suggesting discrepancies in parental recognition of these milestones. However, no significant difference was observed in \u003cem\u003esocial smile\u003c/em\u003e (Z = 0.000, p = 1.000) or in the \u003cem\u003eoverall TDST score\u003c/em\u003e (Z = -1.155, p = 0.248).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e:\u0026nbsp;Wilcoxon Signed-Rank Test: Comparison of TDST Scores Between Therapist and Parent at 6 Months\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eComponent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eZ-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eAsymp.Sig (2-tailed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eInterpretation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eSocial Smile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eNo significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eEye-follow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eNo significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eHead holding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eNo significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eRolls from back to stomach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e-3.207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eHighly significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eTurns head to sound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e-1.134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.257\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eNo significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eTransfers object from one hand to another\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e-2.496\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.013*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eSignificant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eOverall TDST score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e-3.477\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eHighly significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.05, **p\u0026lt;0.01\u003c/p\u003e\n\u003cp\u003eAt the 6-month follow-up, the Wilcoxon signed-rank test revealed significant differences between parent-reported and therapist-assessed developmental milestone scores. Notably, discrepancies were found in the domains of \u003cem\u003erolling from back to stomach\u003c/em\u003e (Z = -3.207, p = 0.001), \u003cem\u003etransferring objects from one hand to another\u003c/em\u003e (Z = -2.496, p = 0.013), and the overall TDST score (Z = -3.477, p = 0.001). These findings suggest parents may under- or overestimate certain milestones compared to therapists. However, no statistically significant differences were found in \u003cem\u003esocial smile\u003c/em\u003e, \u003cem\u003eeye following\u003c/em\u003e, \u003cem\u003ehead holding\u003c/em\u003e, or \u003cem\u003eturning head to sound\u003c/em\u003e, indicating consistency in these observations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComponent-wise Comparison Between Therapist and Parent Scores at 3 Months\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt the 3-month corrected age follow-up, the Wilcoxon Signed-Rank Test was employed to compare therapist and parent scores for individual developmental milestones. Significant differences were observed in the eye-following milestone (Z = -2.121, p = 0.034) and head holding (Z = -2.887, p = 0.004), indicating discrepancies between parental reporting and therapist evaluation. However, no significant difference was found for social smile (Z = 0.000, p = 1.000), and the overall developmental score did not reach statistical significance (Z = -1.155, p = 0.248).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComponent-wise Comparison Between Therapist and Parent Scores at 6 Months\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy 6 months of corrected age, discrepancies between therapist and parent assessments became more pronounced. The Wilcoxon Signed-Rank Test showed statistically significant differences in: Rolling from back to stomach (Z = -3.207, p = 0.001), Transfer of objects from one hand to another (Z = -2.496, p = 0.013), Overall developmental score (Z = -3.477, p = 0.001).\u003c/p\u003e\n\u003cp\u003eIn contrast, no significant differences were noted in the following components: social smile (Z = 0.000, p = 1.000), eye follow (Z = 0.000, p = 1.000), head holding (Z = 0.000, p = 1.000), and turning head to sound (Z = -1.134, p = 0.257).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelation Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrelation analysis at the 6-month follow-up revealed a moderate positive correlation between therapist and parent scores (r = 0.542, p = 0.001). This indicates an improvement in parental awareness and scoring accuracy over time, although discrepancies persisted, particularly in motor domains.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegression Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe regression models conducted for the 6-month follow-up revealed that two developmental milestones\u0026mdash;\u003cem\u003erolling from back to stomach\u003c/em\u003e and \u003cem\u003etransferring objects hand to hand\u003c/em\u003e\u0026mdash;were statistically significant predictors of overall developmental scores, as reported by both parents and therapists. These findings suggest that these specific motor milestones are robust indicators of broader developmental progress at this age.\u003c/p\u003e\n\u003cp\u003eMultiple linear regression analysis was conducted only for the 6-month follow-up period, as regression at the 3rd month was not feasible. At 3 months, the component scores did not yield a meaningful distribution for modelling, as they resulted in simple summation of three milestone scores, which lacked sufficient variability and interpretive value for predictive analysis.\u003c/p\u003e\n\u003cp\u003eAt 6 months, two regression models were developed to identify predictors of developmental outcomes. For parental scores, significant predictors included rolling from back to stomach (\u0026beta; = 0.405, p = 0.001) and transfer of objects hand to hand (\u0026beta; = 0.689, p \u0026lt; 0.001). The model was statistically significant, F (2, 38) = 22.707, p \u0026lt; 0.001, explaining 54.4% of the variance (R\u0026sup2; = 0.544).\u003cbr\u003e\u003cem\u003eParent Score (6 months) = 4.222 + 0.778(Rolling) + 0.778(Transfer)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor therapist scores, the same two components were also significant predictors: rolling from back to stomach (\u0026beta; = 0.600, p \u0026lt; 0.001) and transfer of objects hand to hand (\u0026beta; = 0.660, p \u0026lt; 0.001). This model was highly significant, F(2, 38) = 107.626, p \u0026lt; 0.001, accounting for 85% of the variance (R\u0026sup2; = 0.850).\u003cbr\u003ePredictive Equation: \u003cem\u003eTherapist Score (6 months) = 3.930 + 0.951(Rolling) + 1.008(Transfer)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe parental score model explained 54.4% of the variance, indicating a moderate level of predictability. In contrast, the therapist score model explained a substantial 85% of the variance, suggesting a stronger and more consistent relationship between these milestones and overall therapist-assessed development.\u003c/p\u003e\n\u003cp\u003eThese results highlight the importance of gross and fine motor skills, particularly the ability to roll over and transfer objects between hands, as reliable markers for developmental surveillance at 6 months of corrected age. The stronger predictive power in therapist assessments may reflect greater scoring consistency and observational expertise compared to parent-reported evaluations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInfluence of demographic variables\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical tests were conducted to examine whether these demographic and perinatal factors influenced developmental scores. Using the Mann\u0026ndash;Whitney U test, no significant differences were found in developmental scores based on infant gender at either follow-up point for both parent and therapist assessments. Similarly, the Kruskal\u0026ndash;Wallis test indicated no significant influence of mode of delivery on developmental scores at both 3rd and 6th months. The educational level of fathers also did not show a statistically significant impact. Furthermore, APGAR scores at both 1 and 5 minutes were not significantly associated with developmental scores, nor was socioeconomic status at any time point.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis prospective cohort study aimed to assess neurodevelopmental outcomes among late preterm infants at the 3rd and 6th months of corrected age, focusing on comparisons between parental and therapist-reported developmental scores and identifying key predictors of these outcomes. The findings revealed both areas of alignment and significant discrepancies in milestone recognition between parents and therapists, highlighting the critical need for enhanced caregiver education and early intervention strategies.\u003c/p\u003e\n\u003cp\u003eAt 3 months, parents and therapists demonstrated moderate agreement in overall developmental assessments, suggesting a baseline awareness of key early milestones among caregivers. However, domain-specific discrepancies were evident, especially in visual and motor behaviours such as eye-following and head-holding. These mismatches imply that while parents observe their infants closely, they may not fully interpret the developmental significance of these behaviours, particularly those involving postural control and visual-motor integration. Similar findings have been reported in Chinese samples, where parents and teachers showed low sensitivity in identifying motor difficulties, even among children performing below the 15th percentile (suspected Developmental coordination disorder) on the Movement ABC-2 performance test.\u003csup\u003e20\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eBy 6 months, the divergence between parent and therapist assessments widened further, with statistically significant discrepancies noted in complex motor tasks such as rolling from back to stomach and transferring objects from hand to hand. These skills, which involve midline crossing and bilateral coordination, are known indicators of neurological maturation. Their under-recognition by parents may stem from the increasing complexity of motor milestones, consistent with global evidence showing that as task demands increase, parental accuracy declines. For example, in an Australian cohort, parent proxy reports explained only ~11% of the variance in actual motor performance assessed using the TGMD-3.\u003csup\u003e21\u003c/sup\u003e Similarly, Zysset et al. (2018) reported a weak correlation (r \u0026asymp; 0.23) between parental ratings and standardized scores using the Zurich Neuromotor Assessment (ZNA3\u0026ndash;5), reinforcing that caregiver reports often lack precision in motor domains.\u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eRegression analysis in our study revealed that rolling and object transfer were the most significant predictors of developmental outcomes at 6 months for both therapist- and parent-reported models. However, the variance explained was markedly higher in the therapist model (R\u0026sup2; = 0.850) compared to the parent model (R\u0026sup2; = 0.544), reflecting the advantages of structured training and standardized assessments in capturing developmental delays more reliably.\u003c/p\u003e\n\u003cp\u003eDespite the moderate, statistically significant correlation observed between therapist and parent scores at 6 months, persistent mismatches\u0026mdash;especially in motor domains\u0026mdash;underscore the limitations of relying solely on observational learning. This is supported by previous research indicating that while parents may become more aware over time through repeated interactions with healthcare professionals, exposure alone is insufficient to develop the interpretive skills required for accurate milestone tracking. Even among graduate-educated caregivers in our sample, only 36% correctly identified early signs of motor delay, reinforcing that formal education does not equate to developmental literacy.\u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eSeveral validated tools attempt to address these challenges. The Early Motor Questionnaire (EMQ) has shown promise in eliciting useful parental insights into motor development when milestones are clearly defined and contextualized (Libertus \u0026amp; Landa, 2013).\u003csup\u003e24\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimilarly, Dite and Amick (2021) found that daily checklists improved recall accuracy for gross motor skills, though variability persisted without professional guidance. However, tools like the CDC Milestone Tracker and ASQ-3, unless accompanied by training and cultural adaptation, may fall short in low- and middle-income settings where developmental literacy is variable and milestone interpretation may be culturally influenced.\u003csup\u003e25\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThese results suggest that although parents\u0026rsquo; awareness of developmental behaviours may improve over time, as reflected in the moderate positive correlation between parent and therapist scores at 6 months, gaps persist in identifying more complex or subtle motor skills. This is consistent with prior literature (Miller et al, 2017) comparing parent reports and direct assessments in toddlers, where greater alignment is observed in language or social-emotional domains, but motor skill reports are often less reliable, reflecting variability in caregiver perception and reporting accuracy. \u003csup\u003e26\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOur analysis of demographic and perinatal variables\u0026mdash;including child gender, mode of delivery, paternal education, APGAR scores, and socioeconomic status\u0026mdash;revealed no statistically significant influence on developmental scores. This finding is consistent with earlier studies suggesting that, within medically stable late preterm populations, these variables may have limited predictive value.\u003c/p\u003e\n\u003cp\u003eTaken together, these findings underscore the urgent need for structured, milestone-specific, and culturally adapted parental education. The critical window for neuroplasticity in the first 3 months of life suggests that interventions delayed beyond this period may miss the optimal opportunity for effective early intervention.\u003csup\u003e27\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eImportantly, parental expertise developed after the third month may be too late to detect delays during the most critical window of neuroplasticity. Therefore, proactive caregiver education before the 3-month mark is vital to ensuring timely recognition and intervention for developmental delays.\u003c/p\u003e\n\u003cp\u003eA key strength of this study lies in its prospective design, standardized corrected age assessment, and dual-informant comparison (therapist and parent) across multiple time points. The use of non-parametric and regression analyses provided robust insights into milestone recognition and predictor validity.\u003c/p\u003e\n\u003cp\u003eThe limitations of the study are as follows: First, attrition to 68% follow-up may limit the generalizability of findings, particularly if the dropouts were not random. Second, the single-centre design and relatively modest sample size restrict external validity. Third, the study did not assess maternal mental health or parenting stress, factors known to influence caregiver developmental perceptions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFuture recommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings of this study, future research should consider extending the follow-up period beyond infancy to determine whether discrepancies between parent and therapist assessments continue into toddlerhood. Community-adapted milestone tools using illustrations and lay terms to improve usability among low-literacy populations. The effect of structured parental training modules on improving milestone recognition accuracy can be considered in the future.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 6-month follow-up serves as a critical checkpoint for identifying infants at risk who require longer-term developmental monitoring and support. Policy makers should emphasize training of primary care providers in the developmental surveillance protocol.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe first 1000 days of life offer a powerful window of opportunity to shape a child\u0026rsquo;s developmental future. This study adds to growing evidence that while many parents of late preterm infants are attentive and engaged, they may struggle to recognize early signs of developmental delays\u0026mdash;especially as milestones become more complex. At 3 months, there was broad agreement between parents and therapists on general developmental progress. But by 6 months, clear gaps began to emerge, particularly in identifying motor skills like rolling over and transferring objects\u0026mdash;key indicators of neurological growth.\u003c/p\u003e\n\u003cp\u003eEven well-educated caregivers in our study sometimes missed these cues, reminding us that academic literacy doesn\u0026rsquo;t always translate into developmental literacy. The findings highlight a clear need: parents must be supported not only with information but with structured guidance tailored to their cultural and educational backgrounds. Tools like the EMQ, CDC Milestone Tracker, and ASQ-3 show promise, but only when used alongside training and professional support.\u003c/p\u003e\n\u003cp\u003eImportantly, the study reinforces that early intervention is most effective when it begins before three months of age\u0026mdash;while the brain is at its most adaptable. That\u0026rsquo;s why developmental monitoring can\u0026rsquo;t wait for signs of concern. It must begin proactively, starting at NICU discharge, and continue through regular, supportive follow-up.\u003c/p\u003e\n\u003cp\u003eWhen parents and professionals work together\u0026mdash;sharing knowledge, watching closely, and acting early\u0026mdash;children, especially those born late preterm, have a far better chance to thrive. It\u0026rsquo;s not just about ticking off milestones; it\u0026rsquo;s about giving every child the best possible start.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTDST\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTrivandrum Developmental Screening Tool\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIEC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInstitutional Ethical Committee\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate:\u0026nbsp;\u003c/strong\u003eEthical approval was obtained from the Institutional Ethics Committee (IEC) of SRM Medical College Hospital and Research Centre (Approval No: SRMIEC-ST0224-1174), and conducted following the Declaration of Helsinki. \u0026nbsp;A written informed consent was obtained from all parents or legal guardians before enrollment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e: Clinical Trial number is not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u0026nbsp;\u003c/strong\u003eThe\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAuthor declares no conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe authors received no funding for this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003eAll authors have contributed, read, and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the parents of late pre-term infants who participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWalani SR. Global burden of preterm birth. International Journal of Gynecology \u0026amp; Obstetrics. 2020 Jul;150(1):31-3.\u003c/li\u003e\n \u003cli\u003eSharma D, Padmavathi IV, Tabatabaii SA, Farahbakhsh N. Late preterm: a new high-risk group in neonatology. The Journal of Maternal-Fetal \u0026amp; Neonatal Medicine. 2021 Aug 18;34(16):2717-30.\u003c/li\u003e\n \u003cli\u003eSelvanathan T, Smith JM, Miller SP, Field TS. Neurodevelopment and cognition across the lifespan in patients with single-ventricle physiology: abnormal brain maturation and accumulation of brain injuries. Canadian Journal of Cardiology. 2022 Jul 1;38(7):977-87.\u003c/li\u003e\n \u003cli\u003eLiang X, Lyu Y, Li J, Li Y, Chi C. Global, regional, and national burden of preterm birth, 1990\u0026ndash;2021: a systematic analysis from the global burden of disease study 2021. Eclinicalmedicine. 2024 Oct 1;76.\u003c/li\u003e\n \u003cli\u003eBush NR, Wakschlag LS, LeWinn KZ, Hertz-Picciotto I, Nozadi SS, Pieper S, Lewis J, Biezonski D, Blair C, Deardorff J, Neiderhiser JM. Family environment, neurodevelopmental risk, and the environmental influences on child health outcomes (ECHO) initiative: looking back and moving forward. Frontiers in psychiatry. 2020 Jun 19;11:547.\u003c/li\u003e\n \u003cli\u003eLipkin PH, Macias MM, Norwood KW, Brei TJ, Davidson LF, Davis BE, Ellerbeck KA, Houtrow AJ, Hyman SL, Kuo DZ, Noritz GH. Promoting optimal development: identifying infants and young children with developmental disorders through developmental surveillance and screening. Pediatrics. 2020 Jan 1;145(1).\u003c/li\u003e\n \u003cli\u003eHadders-Algra M. Early diagnostics and early intervention in neurodevelopmental disorders\u0026mdash;age-dependent challenges and opportunities. Journal of clinical medicine. 2021 Feb 19;10(4):861.\u003c/li\u003e\n \u003cli\u003eShekhawat DS, Gupta T, Singh P, Sharma P, Singh K. Monitoring tools for early identification of children with developmental delay in India: an update. Child Neuropsychology. 2022 Aug 18;28(6):814-30.\u003c/li\u003e\n \u003cli\u003eUchitel J, Alden E, Bhutta ZA, Cavallera V, Lucas J, Oberklaid F, Patterson J, Raghavan C, Richter L, Rikard B, Russell RR. Role of pediatricians, pediatric associations, and academic departments in ensuring optimal early childhood development globally: position paper of the International Pediatric Association. Journal of Developmental \u0026amp; Behavioral Pediatrics. 2022 Oct 1;43(8):e546-58.\u003c/li\u003e\n \u003cli\u003eSchuetz Haemmerli N, von Gunten G, Khan J, Stoffel L, Humpl T, Cignacco E. Interprofessional Collaboration in a New Model of Transitional Care for Families with Preterm Infants\u0026ndash;The Health Care Professional\u0026rsquo;s Perspective. Journal of Multidisciplinary Healthcare. 2021 Apr 23:897-908.\u003c/li\u003e\n \u003cli\u003eDen Heijer AE, Jansen AS, van Kersbergen M, van Dokkum NH, Reijneveld SA, Spikman JM, de Kroon ML, Bos AF. Neurocognitive outcomes in moderately preterm born adolescents. Early Human Development. 2024 Jun 1;193:106020.\u003c/li\u003e\n \u003cli\u003eCheong JL, Doyle LW. Long term outcomes in moderate and late preterm infants. Emerging topics and controversies in neonatology. 2020:403-13.\u003c/li\u003e\n \u003cli\u003eWilson N, Gajwani R, Fleming M, Findlay M, Stocks H, Walker G, Corcoran N, Minnis H. Physical health trajectories of young people with neurodevelopmental conditions: a protocol for a systematic review of longitudinal studies. BMJ open. 2025 Apr 1;15(4):e090823.\u003c/li\u003e\n \u003cli\u003eFrosch CA, Schoppe-Sullivan SJ, O\u0026rsquo;Banion DD. Parenting and child development: A relational health perspective. American journal of lifestyle medicine. 2021 Jan;15(1):45-59.\u003c/li\u003e\n \u003cli\u003eWang G, Wignall J, Kinard D, Singh V, Foster C, Adams S, Pratt W, Desai AD. An implementation model for managing cloud-based longitudinal care plans for children with medical complexity. Journal of the American Medical Informatics Association. 2021 Jan;28(1):23-32.\u003c/li\u003e\n \u003cli\u003eBaker S, Kandasamy Y. Machine learning for understanding and predicting neurodevelopmental outcomes in premature infants: a systematic review. Pediatric Research. 2023 Jan;93(2):293-9.\u003c/li\u003e\n \u003cli\u003eSchickedanz A, Halfon N. Evolving roles for health care in supporting healthy child development. The Future of children. 2020;30(2):143.\u003c/li\u003e\n \u003cli\u003eAhnfeldt AM, Stanchev H, J\u0026oslash;rgensen HL, Greisen G. Age and weight at final discharge from an early discharge programme for stable but tube‐fed preterm infants. Acta Paediatrica. 2015 Apr;104(4):377-83.\u003c/li\u003e\n \u003cli\u003eNair MK, Nair GH, George B, Suma N, Neethu C, Leena ML, Russell PS. Development and validation of Trivandrum Development Screening Chart for children aged 0-6 years [TDSC (0-6)]. The Indian Journal of Pediatrics. 2013 Nov;80:248-55.\u003c/li\u003e\n \u003cli\u003eKe L, Barnett AL, Wang Y, Duan W, Hua J, Du W. Discrepancies between parent and teacher reports of motor competence in 5\u0026ndash;10-year-old children with and without suspected developmental coordination disorder. Children. 2021 Nov 9;8(11):1028.\u003c/li\u003e\n \u003cli\u003eMaher SJ, Schott N, Lander NJ, Hinkley T, Barnett LM. A comparison of parent report and actual motor competence in young children. Australian occupational therapy journal. 2018 Oct;65(5):387-94.\u003c/li\u003e\n \u003cli\u003eZysset AE, Kakebeeke TH, Messerli-B\u0026uuml;rgy N, Meyer AH, St\u0026uuml;lb K, Leeger-Aschmann CS, Schmutz EA, Arhab A, Ferrazzini V, Kriemler S, Munsch S. The validity of parental reports on motor skills performance level in preschool children: a comparison with a standardized motor test. European journal of pediatrics. 2018 May;177:715-22.\u003c/li\u003e\n \u003cli\u003eBrown KA, Parikh S, Patel DR. Understanding basic concepts of developmental diagnosis in children. Translational pediatrics. 2020 Feb;9(Suppl 1):S9.\u003c/li\u003e\n \u003cli\u003eLibertus K, Landa RJ. The Early Motor Questionnaire (EMQ): a parental report measure of early motor development. Infant Behavior and Development. 2013 Dec 1;36(4):833-42.\u003c/li\u003e\n \u003cli\u003eBodnarchuk JL, Eaton WO. Can parent reports be trusted?: Validity of daily checklists of gross motor milestone attainment. Journal of Applied Developmental Psychology. 2004 Jul 1;25(4):481-90.\u003c/li\u003e\n \u003cli\u003eMiller LE, Perkins KA, Dai YG, Fein DA. Comparison of parent report and direct assessment of child skills in toddlers. Research in autism spectrum disorders. 2017 Sep 1;41:57-65.\u003c/li\u003e\n \u003cli\u003eChorna O, Cioni G, Guzzetta A. Principles of early intervention. InHandbook of clinical neurology 2020 Jan 1 (Vol. 174, pp. 333-341). Elsevier.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Late preterm, Motor Development, Developmental Delay, Early Screening, Trivandrum Developmental Screening Tool (TDST)","lastPublishedDoi":"10.21203/rs.3.rs-6775901/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6775901/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eLate preterm infants (33\u0026ndash;36 weeks gestation) are at increased risk of neurodevelopmental delays, yet early identification is often missed due to irregular follow-up and subtle symptom presentation. Trivandrum Developmental Screening Tool (TDST) to assess neurodevelopmental status to identify impairments of child.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo identify neurodevelopmental delays in late preterm infants and track their developmental progress at 3 and 6 months of corrected age using the TDST, with inputs from both therapists and parents.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e60 late pre-term infants were identified and were screened using the TDST at the time of discharge, 3rd month, and 6th month. Both therapists and parents independently scored the infant\u0026rsquo;s milestone performance using the TDST. Data were analysed using the Wilcoxon signed rank test and linear regression to explore differences in identifying milestone predictors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe findings underscore the importance of consistent parental education in enhancing early intervention and monitoring. Therapists scored higher than parents at 3 and 6 months (p\u0026thinsp;=\u0026thinsp;0.0002, p\u0026thinsp;=\u0026thinsp;0.000). Despite increased awareness, parents underreported key motor milestones, such as rolling, turning to sound, and object transfer (r\u0026thinsp;=\u0026thinsp;0.542 at 6 months).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eParents struggle to recognize complex motor skills, despite no significant differences from therapists at 3 months. By 6 months, significant discrepancies emerged, highlighting the need for early, structured parental education and consistent developmental follow-up in late preterm infants.\u003c/p\u003e","manuscriptTitle":"Neurodevelopmental Outcomes and Predictors Among Late Pre-Term Infants: A 6-Month Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-25 10:26:51","doi":"10.21203/rs.3.rs-6775901/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-04T09:50:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-31T17:27:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-30T11:22:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282703331934026300570191109712089442213","date":"2025-07-14T23:52:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78317164720998293212311545017512070512","date":"2025-07-13T09:49:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123591911643992750260952240065775035068","date":"2025-07-11T10:42:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"196766760767918528113120091137741807880","date":"2025-07-11T09:12:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-10T17:10:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123288364727092022468205646733422757760","date":"2025-06-27T09:33:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-19T08:48:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-19T08:27:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-17T05:33:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-16T08:16:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-06-16T08:13:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8792ebca-9578-4efc-be9f-194366185c26","owner":[],"postedDate":"June 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:11:01+00:00","versionOfRecord":{"articleIdentity":"rs-6775901","link":"https://doi.org/10.1186/s12887-025-06391-0","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2025-12-10 15:58:36","publishedOnDateReadable":"December 10th, 2025"},"versionCreatedAt":"2025-06-25 10:26:51","video":"","vorDoi":"10.1186/s12887-025-06391-0","vorDoiUrl":"https://doi.org/10.1186/s12887-025-06391-0","workflowStages":[]},"version":"v1","identity":"rs-6775901","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6775901","identity":"rs-6775901","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}