The objective of this study was to extend the understanding of neurodevelopment in normocephalic Zika virus (ZIKV)-exposed children by longitudinally tracking neurodevelopmental outcomes and anthropometrics from birth to 48 months of age in a cohort of ZIKV-exposed children and a parallel group of unexposed controls born during a period of active ZIKV transmission in Grenada, West Indies. In the present study, the neurodevelopmental outcomes and rates of microcephaly between ZIKV-exposed children and unexposed controls at 1, 3, and 4 years were compared, and whether environmental and perinatal factors that increase and decrease neurodevelopmental delay (NDD) risk differ between the ZIKV-exposed and unexposed groups was examined. This ambispective, population-based cohort study followed 388 children born to 384 mothers during a period of active ZIKV transmission in Grenada, West Indies. The children were followed from birth to 4 years of age. Mother-child dyads were enrolled between April 2016 and March 2017 at public health centres throughout Grenada.