Children with critical congenital heart disease showed a clearer weakness in motor development than in cognition as they moved from toddlerhood into school age, according to a longitudinal cohort study. Motor performance was lower than normative expectations at later assessments, while cognitive scores were broadly near the norms. The pattern describes associations in a small follow-up group, not proof that the heart condition, surgery or any other factor caused the outcomes.
Motor scores were the clearest concern
The source group comprised 37 children with aortic arch obstruction who needed neonatal heart repair using cardiopulmonary bypass. The cohort came from a randomized trial of perioperative cerebral injury after specific perfusion techniques. For the follow-up analysis, 31 surviving children without genetic syndromes were included; three children who had died and three with a genetic syndrome were excluded. Assessments were reported for 29 children at age 2, 27 at age 5 and 25 at age 8.
The motor results showed a mean composite score of 102.9 at age 2, with no children at or below 1.5 standard deviations below the norm. By age 5, 10 children, or 44%, were in that low-score category for the total motor measure. At age 8, three children, or 13%, were in the category for the total motor composite. At age 5, manual dexterity and ball skills each placed nine children, or 39%, in the same category.
Those figures cannot be read as a single score falling from age 2 to age 8. The researchers used different age-specific motor instruments at the three assessments, and the score scales changed. That makes the age-to-age pattern harder to compare directly, even though the reported group-level motor performance was lower than expected at the later assessments.
Cognitive scores were closer to expectations
Cognitive results were more stable in broad terms. At age 2, the mean composite was 103.5, with no children at or below 1.5 standard deviations below the norm. At age 5, processing speed averaged 84.8 and eight children, or 35%, were in that low-score category. Total IQ was 94.1, with an interquartile range from 83.5 to 107.0, and two children, or 10%, were in the category. At age 8, processing speed averaged 99.2, with one child, or 5%, in the category, while total IQ averaged 96.5 and three children, or 14%, were in it. The researchers note that threshold definitions and endpoint counts were not fully consistent across the narrative and tables, so these figures should not be treated as a clean measure of change over time.
The researchers used age-specific developmental tests, converted outcomes to standardized z-scores and examined relationships among motor, cognitive and executive-function results with Spearman correlations. They also applied a Bonferroni-Holm correction after the correlations. Because the tests changed with age, the results are best read as patterns at each stage rather than as a single continuous score.
The clearest longitudinal link was within the cognitive measures. The results reported a large positive association between cognition at age 2 and total IQ at age 8, with a correlation of 0.71 and a p-value below 0.001. The reported association between total IQ at ages 5 and 8 was 0.82, also with a p-value below 0.001. In plain terms, children with higher scores earlier tended to have higher scores later in this group. That is a statistical association, not evidence that an early test causes a later IQ score.
Attention results did not settle the bigger question
Executive-function testing at age 8 was limited to a small subset. On an auditory-attention task, five of 12 children, or 42%, scored at or below the 25th percentile. On a shifting-response-set task, four of 11, or 36%, were at or below that percentile. On an inhibition-switching measure, one of 12, or 8%, was in the same range. The small, task-specific denominators mean these results describe the tested subset, not all children in the cohort.
Despite the lower motor results and the continuity within cognition, the exploratory analysis found no statistically significant correlations between motor and cognitive development or between either domain and executive function. That does not show that the abilities are unrelated. The study had a small sample, and the executive-function battery covered only a limited set of measures.
Exploratory patterns need a larger test
Researchers also used a pattern-finding method called k-means clustering to group children with similar motor or cognitive trajectories. The motor analysis produced a higher-performing cluster containing 45% of participants, around 0.7 standard deviations above the total motor score, and a lower cluster containing 55%, around 0.6 standard deviations below it. The cognitive analysis produced a higher cluster containing 37% of participants, around 1 standard deviation above the total cognition score, or approximately an IQ of 115, and a lower cluster containing 63%, at approximately an IQ of 91. Lower birth weight was associated with the lower-cognition cluster, with a reported Mann-Whitney test statistic of 36.0 and p-value of 0.004.
The cluster patterns are exploratory, not diagnoses or forecasts. The analysis excluded participants missing outcomes at more than one timepoint and imputed remaining missing values with a copy-mean method; cluster selection used 20 iterations. The small cohort and changing instruments also limit how confidently the trajectories can be generalized. The authors call for larger studies to test whether the apparent links among motor, cognition and executive function hold in broader groups.
Taken together, the authors interpret the findings as moderately lower motor performance but generally comparable cognition relative to normative means, with continuity in cognitive scores across ages. The lack of cross-domain correlation may reflect the small sample and limited executive-function testing. The study supports continued attention to development after neonatal cardiac surgery, but its associations do not establish causation or provide individual forecasts.
Paper data and sources
Original title: From toddler to school age: longitudinal motor and cognitive outcomes in children with critical congenital heart disease
Authors: Oppelaar E, Sprong M, van Schooneveld M et al.
Journal/Repository: Frontiers in pediatrics
Status: Peer-reviewed
First online: 2026-10-08
DOI: Not available
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