The aim of the current study was to assess the development of infants with CHD using VABS focusing on four main domains: communication, daily life skills, socialization, and motor skills.

We compared the results of VABS and the different risk factors that may affect their developmental status such as prematurity, history of NICU admission, anemia, underweight, stunted growth, cyanotic CHD, and abnormal EEG.

Previous studies conducted by Khalil et al. demonstrated that there is a high risk of neurodevelopmental delay in form of convulsions, feeding difficulties, cranial nerve, motor abnormalities, and\or lethargy in infants with CHD [13].

As regards results of VABS, almost all infants (99%) included in the current study demonstrated developmental delay in its all domains: communication, daily life, socialization, and motor skills (Table 1).

This is in agreement with Mebius et al., who found that there is a risk of neurodevelopmental delay in infants with CHD due to many factors as injury to multiple cerebral regions and alternation of cerebral blood flow that lead to impairment of oxygen and nutrient supply to the brain [14]. Also, Marino et al. found that they had developmental and behavioral abnormalities as impairment of cognitive, social, and communication skills. Also, they have impairment in academic performance, language, perception, visual, and motor development as a result of multiple risk factors including the circulatory disorders related to the CHD, medical treatment, and surgical interventions performed [2].

The current study goes in concordance with Butler et al., who demonstrated that infants with CHD had detective interaction with their environment as they have abnormalities in attention [15].

Prematurity was revealed to be a significant risk factor for developmental delay in infants with CHD especially in receptive behavior (p-value 0.021), total motor skills (p-value 0.035), and average equivalent age with (p-value 0.035). This is in line with Woythaler et al., who followed 950 preterm infants and detected that preterm infants had significant developmental delay in different fields such as expressive language at 24 months and may increase to be severe at school age. It is due to many reasons such as events occurred at prenatal period affecting the growing brain that may have a risk of injury compared with full-term infants [16].

It is concordant with Mebius et al., who demonstrated that preterm infants are at risk for acquiring brain injury. Their brains have immature vasculature, vulnerable white matter, and affected autoregulation. This brain injury is associated with developmental delay [14].

Also, Jarjour found that there is a high prevalence of adverse developmental outcomes in the majority of very preterm infants. These included almost all developmental aspects. Early recognition of the neurolo-developmental disability is important in counseling of the families. Also, this helps in referring these infants to early suitable intervention programs and appropriate medical care [17].

Thus, we attributed our results not only due to prematurity but also due to circulatory changes in infants with CHD that could impair cerebral blood flow and lead to decrease of oxygen and nutrient supply to the brain.

History of NICU admission among our infants (38%) was a significant risk factor of developmental delay regarding receptive behavior (p-value 0.001), total communication (p-value 0.010), personal behavior (p-value 0.001), play and leisure time (p-value 0.047), total socialization field (p-value 0.033), total motor skills (p-value 0.039), and average equivalent age (p-value 0.001).

This corresponds to Philpott-Robinson et al., who noted NICU admission had risk of exposure to sounds of alarms that affect functions of the tactile system. Also, painful procedures and exposures to bright lights affect motor and cognitive development negatively [18].

Also, Fallah et al. found that infants admitted to the NICU showed degrees of developmental delay at the ages of 6 and 12 months, especially in the gross motor and personal-social developmental domains [19].

It was detected in 23% of the infants, and it was a significant risk factor for developmental delay in play and leisure time subdomain (p-value 0.02).

Similarly, Ozmen et al. detected a significant relation between anemia and developmental delay [20].

Stunted infants (8%) were a significant risk factor of developmental delay in interpersonal relationship and total socialization field with p-value 0.036 and 0.019, respectively.

Ravishankar et al. detected that stunting in 37% of their patients correlated with decreased size of the brain. This results from changes in concentration of growth factor, structural proteins, and neurotransmitter production. So, these infants have affected developmental functions and school performance [21].

Also, in current study, underweight infants (14%) showed a statistically significant developmental delay in expressive behavior and gross motor skills with p-value 0.021 and 0.04, respectively.

This is in agreement with Lata et al., who found that 57% of infants with CHD were underweight attributing that to malnutrition and inadequate caloric intake [4]. In addition, Luo et al. detected that in his study group, 1.2% were underweight, 1.6% were wasted, 20% of the infants had delayed cognitive development, while 32.3% had delayed in psychomotor development, thus highlighting the significant relation between infant nutrition and their development. Micronutrient deficiency plays an important role in developmental delay [22].

Infants with cyanotic CHD (22%) in the current study had more statistically significant developmental delayed than infants with acyanotic heart disease regarding receptive behavior (p-value 0.029), personal behavior (p-value 0.002), interpersonal relationship (p-value 0.02), total of socialization field (p-value 0.025), fine motor skills (p-value 0.021), total motor skills (p-value 0.022), and average equivalent age with p-value 0.022). Our results are in agreement with Lata et al., who noted that children who had cyanotic CHD were at high risk of developmental delay as they had chronic hypoxaemia [4].

Infants with abnormal EEG records (23%) had a significant developmental delay compared with infants with normal EEG records in receptive behavior (p-value 0.005), total daily life skills (p-value 0.002), and in average equivalent age (p-value 0.018).

Mulkey et al. study detected 60% of infants with CHD had abnormal EEG patterns. It may give data about the infants’ neurological status that may affect their developmental [23].

Also, Limperopoulos et al. conducted a study on infants with CHD, suggesting that EEG abnormalities may increase the risk of persistent neurologic deficits [24].

There was no statistically difference between the presence of one risk factor over the other as regard the degree of developmental delay. This could be explained as 99 out of 100 infants had some degree of developmental delay. So, we could not reach which risk factor was the most significant. Yet, these risk factors should be considered during the assessment of infants with CHD.