Growth and Development Status of Children Post–COVID-19 Infection: Cross-Sectional Questionnaire Study

Introduction

COVID-19 in children is generally milder than in adults [1], although comorbidities can worsen outcomes. Data indicate that 50.9% of children had mild symptoms, and 38.3% experienced moderate symptoms, with infants being the most likely to develop acute or critical illness, followed by preschool-aged children [2]. Beyond the direct health effects, the pandemic has also posed significant threats to children’s growth and development.

COVID-19 has affected various developmental domains, including language [3,4], independence, and motor skills [4]. Growth and developmental trajectories are influenced by gender across all ages [5]; during the pandemic, gender also shaped behavioral responses, with adolescent girls particularly prone to depression and loneliness [6-8].

Lockdown measures contributed to increased screen time among children and adolescents [9,10], limiting social interactions and increasing risks of acute stress disorder, anxiety, and depression [11-14]. Isolation also led to weight gain due to reduced physical activity and overeating [4,9,11].

To date, no studies have comprehensively addressed the effects of COVID-19 on children’s growth and development. This study aims to identify factors associated with post–COVID-19 growth and development in children.

Methods

Study Design

This was an analytical cross-sectional study.

Sample

The study sample included 292 children selected with the purposive sampling method. Inclusion criteria were: under five years of age, three months post–COVID-19 infection, negative PCR test results, and hospitalization for COVID-19 between July 2021 and December 2022. If a respondent had passed away or their parents declined participation, they were excluded from the study.

Instrument

The instruments used included a demographic questionnaire and the Prescreening Developmental Questionnaire (PDQ), based on age groups.

Data Collection

Respondent data were retrieved from the medical records of a top referral hospital in Jakarta. Addresses were provided to enumerators for direct data collection at each respondent’s home. This study involved 15 enumerators, who underwent training sessions covering PDQ administration, weight and height measurements. Inter-rater reliability was assessed using Cohen κ, with values ranging from 0.61 to 1. The lowest κ value recorded among the enumerators was 0.783, indicating a high degree of consistency between the researcher and enumerators.

Data Analysis

The data were analyzed using SPSS software (version 25.0; IBM Corp). Normality testing was conducted using the Kolmogorov-Smirnov test for numerical data, which yielded P<.05, indicating non-normal distribution. Bivariate analysis of categorical data was performed using the χ² test. Numerical-categorical data were analyzed using the Mann-Whitney test. Multivariate analysis was conducted by multiple logistic regression.

Ethical Considerations

Ethical approval was obtained from the Fakultas Kedokteran Universitas Indonesia (FKUI) - Cipto Mangunkusumo Hospital Ethical Committee (approval number: KET-668/UN2.F1/ETIK/PPM.00.02/2023). Informed consent was obtained from the parents, and all patients’ identities were kept confidential. To protect participant privacy and confidentiality, all personal identifiers were removed during data collection, and the data were fully anonymized before analysis. Access to the raw data was restricted to authorized research personnel only. Participation in the study was entirely voluntary, and no compensation was offered for involvement.

Results

The characteristics of the respondents and their growth and developmental status post–COVID-19 infection are presented in Table 1.

Most respondents had normal weight-for-age (n=186, 63.7%) and length/height-for-age (n=157, 53.8%). However, 192 (65.8%) of respondents identified as having a potential health concern classified as atypical according to the PDQ.

Further analysis was conducted to identify the correlation between physiological factors (ie, age, gender, severity, comorbidities) as well as situational factors (eg, length of stay) and children’s growth and developmental status. As shown in Table 2, underweight status was the most common among children aged 25‐36 months (n=43, 48.9%), male sex (n=60, 37.5%), no comorbidities (n=46, 38.3%), and with severe to critical illness (n=18, 43.9%); only age was significantly associated with weight-for-age growth (P<.05).

As shown in Table 3, short stature was the most common among children aged 12‐24 months (n=43, 48.3%), boys (n=77, 48.1%), those with comorbidities (n=82, 47.2%), and those with mild to moderate illness (n=110, 46.8%).

According to Table 4, atypical development was most frequently observed among children aged 37‐48 months (n=44, 68.8%), boys (n=111, 69.4%), those with comorbidities (n=121, 70.3%), and those with severe to critical illness (n=32, 78%).

Multivariate models refined these findings, as presented in Tables 5-7 regarding growth and development status. For weight-for-age, age remained the sole independent predictor. After adjustment, children aged 25‐36 months had approximately five times the odds of being underweight compared to those aged 12‐24 months (P<.001), and children aged 49‐60 months had about 3 times the odds. No other factors were retained.

For length-for-age, the final model included an age–gender interaction: boys aged 25‐36 months were significantly more likely to be short-statured than older boys (adjusted odds ratio [aOR] 2.49, P=.05). The other age or sex subgroups or any comorbidity or severity variables did not have a significant effect on stature after adjustment.

Regarding developmental status, children with comorbid conditions had significantly higher odds of atypical development (aOR 1.72, 95% CI 1.05‐2.82). Additionally, each extra hospital day slightly increased this risk (aOR 1.10, 95% CI 1.01‐1.20) per day. Age, sex, and illness severity were not significant predictors of development in the adjusted model.

The severity variable was excluded from the final multivariate model as it was not a candidate for retention due to P value >.25, exceeding the usual cutoff for inclusion in the multivariate model (as described in Table 4).

Discussion

Principal Findings

This study found no significant association between age and child development, contrasting with prior findings linking nutritional status to early developmental outcomes. Galasso & Wagstaff [15] reported a positive correlation between nutrition and development in children under 5 years of age [15], while Shrestha et al [16] emphasized the risks of wasting and underweight status [16]. Although early malnutrition is associated with poor cognitive and motor outcomes [17], our null findings may reflect differences in age distribution, sample characteristics, or developmental assessments.

In contrast to Androutsos et al [9] and Xiao et al [18], who found behavioral issues in children aged 6‐7 years during and after lockdowns, we found no link between age or COVID-19 severity and development. This discrepancy could be due to milder illness in our cohort or differing definitions of severity.

While previous literature often shows gender disparities—such as boys being more prone to stunting due to biological and sociocultural factors [5,8]—we found no significant gender effect. This may be attributed to our sample size, local caregiving practices, or statistical adjustments that controlled for confounding variables.

Although comorbidities such as malnutrition and coronary heart disease increase COVID-19 mortality risk in children [19], our study found no association between these comorbidities and growth or development. This could be due to the low prevalence of those comorbidities (ie, malnutrition and coronary heart disease), milder disease, or differences in comorbidity definitions.

Severe malnutrition is widely linked to developmental delays, with some studies reporting delays in more than >60% of affected children. However, our severity variable was not significant, possibly due to inconsistent classification, low disease severity among children, or the influence of statistical controls diminishing its apparent effect.

Respiratory and neurological impacts of COVID-19, as reported by Bögli et al [20], did not emerge as significant in our cohort—possibly due to the predominance of mild presentation.

Coronary heart disease is known to impair motor development due to chronic hypoxia [21], and febrile seizures in children with epilepsy can lead to neurological damage [22]. These conditions, while important, were infrequent in our population.

Finally, while Ludvigsson [1] argued it was too early to determine if children under 3 years of age are more vulnerable to COVID-19, newborns remain at higher risk due to immature immune systems and lack of maternal antibodies [23].

Limitations

Discharged patient records were no longer accessible via the electronic health records, and medical records officers were only available until 9 PM daily, leading to delayed data retrieval.

Conclusions

Age was significantly correlated with child growth. Significant correlations were also found between comorbidities and length of stay and child development. To improve child health outcomes post–COVID-19, comprehensive discharge planning should be provided to families to ensure continuous stimulation, and community health care services should be optimized to offer follow-up care and monitoring for children posthospitalization.