Neonatal Neurological Examination Research Articles

Neonatal and Infant Neurological Examination: Value and Applicability in Recent Medical Setting in Vietnam.

Neonatal and Infant Neurological Examination: Value and Applicability in Recent Medical Setting in Vietnam.

Early neurological signs in infants identified through neonatal screening for SMA: do they predict outcome?

Neonatal screening for SMA has allowed the identification of infants who may present with early clinical signs. Our aim was to establish whether the presence and the severity of early clinical signs have an effect on the development of motor milestones. Infants identified through newborn screening were prospectively assessed using a structured neonatal neurological examination and an additional module developed for the assessment of floppy infants. As part of the follow-up, all infants were assessed using the HINE-2 to establish developmental milestones. Only infants with at least 24 months of follow-up were included. Normal early neurological examination (n = 11) was associated with independent walking before the age of 18 months while infants with early clinical signs of SMA (n = 4) did not achieve ambulation (duration follow-up 33.2 months). Paucisymptomatic patients (n = 3) achieved ambulation, one before the age of 18 months and the other 2 between 22 and 24 months. Conclusion: Our findings suggest that early clinical signs may contribute to predict motor milestones development.What is Known:• There is increasing evidence of heterogeneity among the SMA newborns identified via NBS.• The proposed nosology describes a clinically silent disease, an intermediate category (‘paucisymptomatic’) and ‘symptomatic SMA’.What is New:• The presence of minimal clinical signs at birth does not prevent the possibility to achieve independent walking but this may occur with some delay.• The combination of genotype at SMN locus and clinical evaluation may better predict the possibility to achieve milestones.

Effects of increased physical therapy staffing in the neonatal intensive care unit on oral feeding maturation and neurodevelopment of extremely low birth weight infants

BackgroundIt remains a matter of debate as to what extent early intervention may facilitate long-term functional outcomes of preterm infants in the neonatal intensive care unit (NICU). We aimed to examine the effect of increasing physical therapy (PT) staff dedicated to the NICU on temporal changes (initiation, duration) of PT interventions and functional outcomes (acquisition of full oral feeding and Hammersmith Neonatal Neurological Examination). MethodsExtremely low birth weight infants, retrospectively collected from an academic medical center, were allocated to two subgroups, either a baseline period (N = 48) without NICU-dedicated PT staff (non-dedicated group) or a quality improvement period (N = 42) with additional dedicated staff (dedicated group). ResultsCompared to those in the non-dedicated group, NICU infants in the dedicated group started PT earlier and had increased PT treatment for additional 14 min per day when achieving full oral feeding. The infants in the dedicated group significantly achieved full oral feeding earlier than the non-dedicated group. As for Hammersmith Neonatal Neurological Examination, there were significant differences in two items (total and tone) between the groups. ConclusionsAdditional NICU-dedicated PT staff facilitated earlier intervention and increased PT treatment in terms of daily duration. Moreover, the dedication shortened the completion of full oral feeding and improved neurological development, presumably resulting in better developmental outcome.

Agreement between Hammersmith Neonatal Neurological Examination (HNNE) and Test of Infant Motor Performance (TIMP) in neurodevelopmental assessment of preterm infants

ObjectivesTo determine the agreement between HNNE and TIMP at TCA for preterm infants born <32+0 weeks' gestation, and to evaluate their correlation to PDMS-2 at 12-month corrected age (CA). MethodsInfants born between November 2013 to June 2022 who had both HNNE and TIMP performed at TCA of 37+0–41+6 weeks gestation, and motor outcome assessed using the PDMS-2 at 12-month old were enrolled. The HNNE and 12-month PDMS-2 findings were categorized as optimal vs sub-optimal. TIMP was categorized as typical vs atypical. Cohen's kappa was used to determine the agreement between HNNE and TIMP. Sensitivity analysis and Receiver Operating Characteristic (ROC) curves were used to evaluate the predictive values of HNNE and TIMP on motor outcome at CA of 12-months. ResultsHNNE and TIMP done on 125 infants at TCA do not show reliable agreement. HNNE demonstrated slight and fair agreement with the 12-month Total Motor Quotient (TMQ) and Fine Motor Quotient (FMQ) of the PDMS-2 respectively. TIMP at TCA demonstrated fair agreement with all sub-domains of motor function on PDMS-2 at 12-months. In comparison with TIMP, HNNE at TCA is more sensitive at predicting suboptimal total, gross and fine motor outcomes at 12-month CA with sensitivity of 68.4 %, 51.9 %, and 83.3 % vs 44.4 %, 31.8 % and 53.3 % respectively. Atypical TIMP at TCA is more specific for suboptimal total, gross and fine motor outcomes at 12-month CA with specificity of 90.3 %, 89 % and 90.5 % respectively.Neurobehavioral assessments at TCA using HNNE and TIMP were predictive of suboptimal fine motor quotient at CA of 12-months with AUC of 0.760 (p = 0.011) and 0.718 (p = 0.032) respectively. The difference in AUC between the 2 instruments of 0.042 was not statistically significant (p = 0.741). ConclusionsWhile the HNNE and TIMP done at TCA did not demonstrate significant agreement, suboptimal HNNE and atypical TIMP at TCA were predictive of suboptimal FMQ on PDMS-2 at 12-month CA.

Comparison of neurological assessment and general movements of infants at risk at different time points

Background: Brain development is a constant interaction between genetic, biological, and environmental factors. Its maturation process is extremely sensitive, and if it does not occur in sync, brain damage can occur in the immature brain, triggering a set of permanent movement and posture disorders. Thus, early diagnosis of developmental changes is essential for intervention to begin as soon as possible, optimizing results, improving functional skills, and reducing the damage to the future life of these babies, and serve as a basis for the actions of professional teams dedicated to stimulation and monitoring of child development. Objectives: To compare the neurological assessment and general movements of infants at risk at 40, 52, and 64 weeks of gestational age (GA). Methods: Infants at risk born in a reference maternal and child hospital were assessed for their neuromotor behavior using the "Hammersmith Neonatal Neurological Examination (HNNE)", "Hammersmith Infant Neurological Examination (HINE)" and "General Movements Assessment (GMA)" scales at 40, 52, and 64 weeks gestational age. Data will be correlated and analyzed descriptively. Results: 33 infants at risk were assessed at 40, 52 and 64 weeks, i.e., up to six months of corrected age. Male gender (75.8%), a cesarean delivery (51.5%), and white race (60.6%) predominated. The Median Apgar score was nine, mean of five prenatal visits, and a mean GA of 35.8 weeks. Prematurity and congenital syphilis were the main diagnoses found. 30.3% of the patients underwent neuroimaging exams, especially brain ultrasounds, with normal results. There was a predominance of "altered evaluation" in HNNE and HINE at the three evaluative moments for term babies, especially for babies with congenital syphilis, and "adequate" for premature babies. In the GMA evaluation and regarding the presence of fidgety, there was a higher frequency of the "suboptimal" classification and most presented fidgety. In the longitudinal comparison between the three moments assessed using the HNNE/HINE scales, it was found that there was a significant difference between the first and the third evaluative moment (p = 0.029), where babies improved their classification. There were positive associations of results between the HNNE/HINE scales with scores in different variables. Conclusion: Infants at risk had altered scores on neurological assessments, indicating developmental delay. Children at risk or with delayed neurological development may present restrictions in activities and participation with compromised quality of life and even school learning. Therefore, it is extremely important to include standardized scales during neonatal screening in the routine of the Neonatal Intermediate Care Unit (NICU), as they are highly reliable and low-cost, so that early identification of neurological changes can be enabled, and thus intervene early, enhancing development.

The Key Aspects of Neonatal and Infant Neurological Examination: The Ballard Score, the Infant's Head with Hydrocephalus and Assessment in a Clinical Setting.

The physical examination of the newborn is essential in diagnosing neurological or neurosurgical conditions in the newborn. This article focuses on three clinical assessments of newborns and infants that are especially important if neurological problems are suspected: The Ballard score, the examination of the head in a baby with (suspected) hydrocephalus, and the neurological and developmental evaluation of an infant in an ambulatory setting. A textual description and a link to a video describe each assessment.

Warning Signs on Short Hammersmith Neonatal Neurological Examination and Correlation With Hammersmith Infant Neurological Examination Global Score in Preterm Infants: A Prospective Cohort Study

Warning Signs on Short Hammersmith Neonatal Neurological Examination and Correlation With Hammersmith Infant Neurological Examination Global Score in Preterm Infants: A Prospective Cohort Study

Diagnostic accuracy of the Hammersmith Neonatal Neurological Examination in predicting motor outcome at 12 months for infants born very preterm.

To evaluate the predictive validity of the Hammersmith Neonatal Neurological Examination (HNNE) performed early (at 32 weeks postmenstrual age) and at term-equivalent age (TEA) for 12-month motor outcomes in infants born very preterm. This was a diagnostic study using data from a prospective birth cohort. A total of 104 infants born preterm at less than 31 weeks gestational age (males n=61; mean=28 weeks 1 day [SD 1 week 6 days], range 23 weeks 1 day-30 weeks 6 days) underwent HNNE early and at TEA, which were scored by comparison with term data. Motor outcomes at 12 months corrected age were determined using the Bayley Scales of Infant and Toddler Development, Third Edition (scores ≤85). Cut-off points were determined using receiver operating characteristic curves. Sixteen (15%) infants born preterm had motor impairment at 12 months corrected age. The HNNE total score cut-off points with the best combination of sensitivity and specificity at early and TEA assessments were 15.2 or lower (sensitivity 77%, 95% confidence interval [CI]=46%-95%; specificity 74%, 95% CI=63%-83%) and 23.5 or lower (sensitivity 67%, 95% CI=38%-88%; specificity 66%, 95% CI=54%-76%) respectively. The most predictive subscale at the early assessment was reflexes (sensitivity 86%, 95% CI=57%-98%; specificity 62%, 95% CI=51%-72%; cut-off point ≤3); at TEA, it was spontaneous movements (sensitivity 73%, 95% CI=45%-92%; specificity 60%, 95% CI=48%-70%; cut-off point ≤2). The HNNE provides moderate predictive accuracy for motor outcome at 12 months corrected age in infants born very preterm. Although modest at both time points, early assessment had stronger predictive ability for motor outcomes than TEA when scored using term data, highlighting the value of performing the HNNE earlier in the neonatal period. Performing HNNE earlier may assist risk stratification when planning follow-up services.

Cultural adaptation and reliability assessment of the Hammersmith neonatal neurological examination for Brazilian newborns at risk of cerebral palsy

Reliable instruments that lead to early diagnosis for CP are extremely important so that these children are referred for early stimulation, benefiting their development. To perform a cross-cultural adaptation and reliability assessment of a Brazilian version of the Hammersmith Neonatal Neurological Examination (HNNE), expanded and summarized. A methodological, cross-sectional, nonexperimental quantitative analysis was conducted in two phases as follows: cultural adaptation of the HNNE, expanded and summarized, and reliability assessment of the Brazilian version of the HNNE. Phase one was developed in five stages (initial translation, synthesis of the translation, a committee of experts, backtranslation, and submission to the author), with the semantic questions, content, and face validity being evaluated. Phase two included 143 newborns and we analyzed the internal consistency, stability, and equivalence (intra- and interexaminer) of the instrument. Internal consistency was calculated using Cronbach's alpha, and intra- and interexaminer reliability and reproducibility assessed through test-retest were calculated using the intraclass correlation coefficient RESULTS: Although internal consistency, assessed using Cronbach's alpha, showed unsatisfactory results, the results of inter-and intraexaminer equivalence showed a high agreement between the evaluations in all domains. The test-retest also showed excellent agreement between the domains. The Brazilian HNNE expanded and summarized versions can be considered to be adapted and reliable for the neurological assessment of Brazilian newborns to identify changes in neurological development and early referral to the stimulation or early rehabilitation units and as a promising option to be used in the context of primary care in Brazil.

Transcranial Doppler in hypoxic-ischemic encephalopathy babies as a prognostic marker in the short-term outcome

Background: Birth asphyxia is a lack of blood flow or gas exchange to or from the fetus in the period immediately before, during, or after the birth process. Birth asphyxia can result in profound systemic and neurologic sequelae due to decreased blood flow and/or oxygen to the developing fetus or infant. Birth asphyxia is one of the most common causes of neonatal mortality and morbidity globally. Aims and Objectives: The aims of this study were to assess the importance of cranial Doppler as investigation tool for the early prognostic marker of babies with hypoxic-ischemic encephalopathy (HIE) in short term. Materials and Methods: This prospective study was carried out in a tertiary care teaching hospital. The present study includes 50 newborns, out of which 30 newborns admitted with birth asphyxia were considered as a case, while 20 healthy term newborns were taken as control. Transcranial Doppler of middle cerebral artery (MCA) was done on day 1 of life. They were followed up at discharge for neuromotor outcome by Hammersmith Neonatal neurological examination (HNNE). The outcome was correlated with, Doppler findings of MCA. P&lt;0.05 was taken significant. Results: Abnormality detected by transcranial Doppler within 24 h of life in neonates with birth asphyxia was significantly associated with poor neuromotor outcome when compared to healthy term neonates. HNNE score in HIE babies was lesser than healthy term neonates on discharge. Conclusion: Cranial Doppler within 24 h of birth in term HIE babies has very high sensitivity in predicting short-term outcome in babies with HIE, such as Low HNNE score.

Early Electroencephalogram as Predictor of Neuromotor Outcome in a Term Newborn with Hypoxic Ischaemia Encephalopathy- A Prospective Cohort Study

Introduction: Birth asphyxia is the leading cause of neonatal morbidity and mortality globally. Early prediction of neuromotor problems in babies with Hypoxic Ischaemic Encephalopathy (HIE) allows parental counseling regarding treatment continuation, better utilisation of limited resources and prompt referral for early intervention services to so that the best possible outcomes can be achieved. Aim: To investigate the role of early Electroencephalogram (EEG) background activity in prediction of cerebral palsy, epilepsy and developmental delay in term newborn with HIE and also to check the association of EEG background activity with Hammersmith Neonatal Neurological Examination (HNNE), Hammersmith Infant Neurological Examination (HINE) score and various short-term and long-term outcome. Materials and Methods: This prospective clinical study was conducted in Neonatal Intensive Care Unit (NICU) of Department of Paediatrics, Shyam Shah Medical college and associated Gandhi Memorial Hospital, Rewa (MP) during April 2019 to June 2020. Total 81 term neonates with HIE underwent conventional EEG within six hours of birth using International 10-20 system, (modified for neonate) for electrode placement. At the time of discharge HNNE was performed. On follow-up (6 to 12 months), cerebral palsy was evaluated using HINE and modified Ashworth score, Developmental delay by Development Assessment Scale for Indian Infant (DASII) scale and for epilepsy by clinical history and EEG background activity. Association between EEG background activity, HNNE, HINE score and various short-term and long-term outcome was calculated using Chi-square test and Fisher’s-exact test. Results: In present study, out of 81 cases, 58 (71.6%) cases were male and 23 (28.4%) cases were female with mean Gestational Age (GA) of 39 weeks. A total of 57 neonates were discharged successfully after stay of mean duration 13.8 days in NICU. All neonates with normal/mildly abnormal EEG background activity had 100% survival rates whereas only 68.2% (15) and 37% (10) could be discharged from moderately abnormal and severely abnormal EEG background activity group. Out of discharged patients none with severely abnormal background had optimal HNNE whereas 75% (24) of mildly abnormal EEG had optimal HNNE score. Mean HNNE and HINE score was significantly lower in newborns with severely abnormal EEG (mean score 20.8) as compared to normal EEG group (mean score 30.3). Severely abnormal EEG at birth had significant association with cerebral palsy (p-value&lt;0.0001), epilepsy (p-value= 0.003) and developmental delay (p-value&lt;0.001) as compared to moderately and mildly abnormal EEG background activity in newborns with HIE. Conclusion: EEG within six hours of birth in term neonate with HIE has very high sensitivity and Negative Predictive Value (NPV) in predicting short-term outcome as death, poor neurological outcome and long-terms outcome as cerebral palsy, epilepsy and developmental delay.

Comparison of the neurobehavioural profile of early-preterm infants against term and late-preterm infants using the Hammersmith neonatal neurological examination.

To compare the neurobehavioural profile of early-preterm infants (<32 weeks gestation) at term-corrected age (39+0 -41+6 weeks) versus late-preterm and full-term infants at similar term gestational ages. Early-preterm infants were assessed neurologically at term-corrected age using the Hammersmith neonatal neurological examination. The raw scores of the 34 Hammersmith neonatal neurological examination items were converted to optimality scores. Pairwise comparison of neurobehavioural patterns between early-preterm infants at term-corrected age versus late-preterm and full-term infants at similar gestational ages were made using independent sample t tests. Differences in optimality scores between the three groups were evaluated using one-way analysis of variance. Sixty-eight early-preterm infants assessed at term-corrected age were compared against 75 late-preterm infants and 133 full-term infants. Mean total optimality scores (±standard deviation) of early-preterm, late-preterm and full-term infants at term-corrected age were 27.68 (±3.97), 29.09 (±2.45) and 31.58 (±1.39), respectively (P < 0.001). The mean optimality score of early-preterm infants was significantly lower when compared pairwise with late-preterm infants and full-term infants with mean difference of -1.42 (P=0.013) and -3.91 (P < 0.001), respectively. The neurobehavioural profile of early-preterm infants lags significantly behind those of late-preterm and full-term infants at term-corrected age. This study also provides reference raw and optimality scores for all items in the Hammersmith neonatal neurological examination for early-preterm infants in a predominantly Asian population.

Attitudes towards the neurological examination in an unwell neonate: a mixed methods approach

BackgroundThe neurological examination of an unwell neonate can aid management, such as deciding if hypothermia treatment is warranted in hypoxic ischaemic encephalopathy or directing investigations in hypotonic neonates. Current standardised examinations are not designed for unwell or ventilated neonates, and it is unclear how confident paediatricians feel about the examination or what aspects they perform. AimThis study aimed to review the confidence of UK paediatricians on the neurological examination in unwell neonates, describe their attitudes towards it, and determine what could improve practice.MethodsAn explanatory sequential mixed methods approach (QUAN → QUAL) with equal weighting between stages. A survey on attitudes to the neonatal neurological examination was sent to all UK neonatal units and members of the British Paediatric Neurology Association. Volunteers were sought for semi-structured interviews. Thematic analysis was used to interpret qualitative data, which was triangulated with quantitative questionnaire data.ResultsOne hundred ninety-three surveys were returned, 31.0% from neonatologists, 9.3% paediatric neurologist. The median range for confidence was 4 (IQR3-5). Twenty-three interviews occurred. Thematic analysis revealed three themes: “Current culture on neonatal units”, “ Practicalities of the neurological examination in unwell neonates”, and “Changing the culture”. Most interviewees did not feel confident performing or interpreting the neurological examination in unwell neonates. Many units had a culture of seeing it as low priority, did not see its relevance in the acute management of unwell neonates. A few interviewees worked in units with a positive culture towards the neurological examination who used adapted standardised examinations and provided training. 72% of questionnaire responders wanted a new standardised neurological examination designed for the unwell neonate, which should be short, utilise pictures like the Hammersmith Neonatal Neurological Examination, contain an assessment of consciousness, be developmentally appropriate and achievable in unwell, ventilated neonates, be accompanied by a schematic to aid interpretation, and for greater training and assessments of competence.ConclusionsThere are barriers preventing paediatricians being able to perform a neurological examination in unwell neonates, and a culture of neurophobia is common. A new standardised examination is needed, alongside aids to interpretation, training, and assessment.

Neurological examination at 32-weeks postmenstrual age predicts 12-month cognitive outcomes in very preterm-born infants

BackgroundTo determine the diagnostic accuracy of Hammersmith Neonatal Neurological Examination (HNNE) at 30–32 weeks postmenstrual age (PMA, ‘Early’) and term equivalent age (TEA) in infants born <31 weeks PMA to predict cognitive outcomes at 12 months corrected age (CA).MethodsProspective cohort study of 119 infants (73 males; median 28.4 weeks gestational age at birth) who underwent Early and TEA HNNE. At 12 months CA, 104 participants completed Bayley Scales of Infant and Toddler Development, 3rd Edition, (Bayley-III). Optimum cut-off points for each HNNE subscale were determined to establish diagnostic accuracy for predicting adverse cognitive outcomes on the Bayley-III Cognitive Composite Scale (≤85).ResultsThe best diagnostic accuracy for HNNE total score at 30–32 weeks PMA predicting cognitive impairment occurred at cut-off ≤16.7 (sensitivity (Se) = 71%, specificity (Sp) = 51%). The Abnormal Signs subscale demonstrated the best balance of sensitivity/specificity combination (Se = 71%, Sp = 71%; cut-off ≤1.5). For HNNE at TEA, the total score at cut-off ≤24.5 had Se = 71% and Sp = 47% for predicting cognitive impairment. The Tone Patterns subscale demonstrated the strongest diagnostic accuracy at TEA (Se = 71%, Sp = 63%; cut-off ≤3).ConclusionsEarly and TEA HNNE demonstrated moderate diagnostic accuracy for cognitive outcomes at 12-months CA in infants born <31 weeks gestational age.Clinical Trial Registration: Australian New Zealand Clinical Trials Registry; Trial Registration Number: ACTRN12613000280707; web address of trial: http://www.ANZCTR.org.au/ACTRN12613000280707.aspx.ImpactEarly Hammersmith Neonatal Neurological Examination (HNNE) assessment at 30–32 weeks postmenstrual age has moderate diagnostic accuracy for cognitive outcomes at 12 months corrected age in infants born <31 weeks gestation.Early HNNE at 30–32 weeks has stronger predictive validity than HNNE at term equivalent age.Early HNNE may provide an early marker for risk-stratification to optimise the planning of post-discharge support and follow-up services for infants born preterm.

Assessing the Utility of Neonatal Screening Assessments in Early Diagnosis of Cerebral Palsy in Preterm Infants.

Background: Early diagnosis of cerebral palsy (CP) in high-risk infants is possible at 3–4 months’ corrected age (CA) using standardised assessments. Aim: To assess the utility of neonatal screening assessments—writhing general movements (GMs) and the Hammersmith Neonatal Neurological Examination (HNNE)—to predict CP/high-risk status at 3–4 months’ CA in extremely preterm infants. Methods: Retrospective cohort study of high-risk preterm infants (born < 29 weeks’ gestation and/or birth weight < 1000 g) attending an Early Neurodevelopment Clinic. Data from neonatal assessments were compared with CP/high-risk diagnosis at 3–4 months’ CA, fidgety GMs, and Hammersmith Infant Neurological Examinations (HINE) using logistic regression, linear regression, and Spearman rank correlation. Results: Two hundred and two preterm infants (median gestation age at birth 27.3 (IQR 25.4–28.3) weeks, mean birth weight 870.3 (SD 248.4) grams) were included. A total of 26 (12.8%) infants received early CP/high-risk diagnoses at 3–4 months’ CA. A lower gestational age (GA) (OR = 0.78; p = 0.029, 95% CI [0.26, 0.97]) and abnormal writhing GMs (OR 1.56; p = 0.019, 95% CI [1.07, 2.27]) were predictive of CP/high-risk diagnosis. Although after adjustment for sex, GA, birth weight, and growth restriction, GA (aOR = 0.67; p = 0.068, 95% CI [0.44, 1.03]) and writhing GMs (aOR = 1.44; p = 0.087, 95% CI [0.95, 2.20]) were not significant, a strong trend still persisted. The HNNE scores significantly correlated with both the HINE evaluation (rs = 0.43, p < 0.001, 95% CI [0.31, 0.56]) and fidgety GMs (rs = −0.10, p = 0.012, 95% CI [−0.32, −0.04]). Linear regression confirmed the HNNE was highly predictive of the HINE (correlation coefficient 0.82; p < 0.001, 95% CI [0.48, 1.15]). Writhing GMs did not significantly correlate with either fidgety GMs (p = 0.723, 95% CI [−0.12, 0.17]) or the HINE (p = 0.173, 95% CI [−0.24, 0.04]). Conclusions: Abnormal writhing GMs in the neonatal period were non-significantly associated with early CP/high-risk diagnoses in extremely preterm infants in a multivariate analysis. Additionally, the HNNE significantly correlated with both fidgety GMs and the HINE.

Neurobehavior in very preterm infants with low medical risk and full-term infants.

To describe differences in neurobehavior among very preterm infants with low medical risk at term equivalent age and full-term infants. One-hundred eighty-six (136 infants born ≤32 weeks gestation with low medical risk at term equivalent age and 50 full-term infants within 4 days of birth) had standardized neurobehavioral assessments. Low medical risk was defined by ventilation &lt;10 days and absence of significant brain injury, necrotizing enterocolitis, patent ductus arteriosus, and retinopathy of prematurity. Very preterm infants with low medical risk at term equivalent age demonstrated more sub-optimal reflexes (p &lt; 0.001; ß = 1.53) and more stress (p &lt; 0.001; ß = 0.08) on the NICU Network Neurobehavioral Scale compared to their full-term counterparts. Very preterm infants with low medical risk also performed worse on the Hammersmith Neonatal Neurological Examination (p = 0.005; ß = -3.4). Very preterm infants at term equivalent age continue to demonstrate less optimal neurobehavior compared to full-term infants.

Neurological assessment of newborns with spinal muscular atrophy identified through neonatal screening

The possibility to identify patients with spinal muscular atrophy through neonatal screenings has highlighted the need for clinical assessments that may systematically evaluate the possible presence of early neurological signs. The aim of this study was to use the Hammersmith Neonatal Neurological Examination (HNNE) and a module specifically designed for floppy infants to assess the possible variability of neurological findings in infants identified through neonatal screening. The infants included in this study were identified as part of a pilot study exploring neonatal screening in two Italian regions. A neurological examination was performed using the HNNE and an additional module developed for the assessment of floppy infants. Seventeen infants were identified through the screening. One patient had 1 SMN2 copy, 9 had 2 copies, 3 had 3, and 4 had more than 3 copies. Nine of the 17 infants (53%) had completely normal results on both scales, 3 had minimal signs, and the other 5 had more obvious clinical signs. The number of SMN2 copies was related to the presence of abnormal neurological signs (p = 0.036) but two SMN2 copies were associated with variable clinical signs as they were found in some infants with respectively normal examination or obvious severe early signs.Conclusions: Our results suggest that the combination of both scales increases the possibility to detect neonatal neurological signs and to define different early patterns of involvement also identifying paucisymptomatic patients.What is Known:• The use of new therapeutic options in presymptomatic SMA patients leads to a dramatic reduction of the onset and severity of the diesease.• The already existing tools commonly used in Type I SMA (HINE and CHOP-intend) may not be suitable to identify minor neurological signs in the neonatal period.What is New:• Combining the HNNE and the floppy infant module, we were able to identify early neurological signs in SMA infants identified through newborn screening and may help to predict the individual therapeutic outcome of these patients.• Iinfants with 2 SMN2 copies identified through the screening had a more variable neonatal examination compared to those with three or more copies, in agreement with similar findings in older infants.

Assessing floppy infants: a new module

Our aim was to develop a new module for assessing the floppy infant, to describe the application of the module in a cohort of low-risk newborns and piloting the module in a cohort of floppy infants. The module was applied to a cohort of 143 low-risk newborns and piloted in in a cohort of 24 floppy infants. The new add-on module includes a neurological section and provides a section for recording information obtained by physical examination and antenatal history. For each item, column 1 reports abnormal findings, column 3 normal findings, and column 2 intermediate signs to be followed. Consistent with previous studies, in low-risk infants, none had definitely abnormal or mildly abnormal signs, with the exception of tendon reflexes that were not easily elicitable in 17.14% of term-born infants.Conclusion: Our study suggest that the module can be easily used in a clinical setting as an add-on to the regular neonatal neurological examination in newborns identified as hypotonic on routine examination. Larger cohorts are needed to establish the accuracy of the prognostic value of the module in the differential diagnosis of floppy infant.What is Known:• Hypotonia is one of the key signs in newborns with neuromuscular disorders and can be associated with a wide range of other conditions (central nervous system involvement, genetic and metabolic diseases).• Weakness or/and contractures can identify infants with a neuromuscular disorder and help in the differential diagnosis of floppy infants.What is New:• To date, this is the first attempt to develop and apply a specific neurological module for the assessment of the floppy infant.• The module can be used in a routine clinical setting as an add-on to the regular neurological examination and has potential to differentiate the floppy infants from the low-risk infants.

Early Diagnosis of Cerebral Palsy in Low- and Middle-Income Countries.

Cerebral palsy describes a group of permanent disorders of movement, motor function and posture that occur due to non-progressive insults to the developing brain. Most of the information concerning the early diagnosis of cerebral palsy originates from studies conducted in high-income countries. In this scoping review, we aimed to explore the tools used in low- and middle-income countries for the early diagnosis of cerebral palsy. A systematic search was conducted using OVID Medline and PubMed databases. “Early diagnosis” was defined as diagnosis prior to 12 months of age, and low- and middle-income countries were classified according to the World Bank classification system. We identified nine studies on the early diagnosis of cerebral palsy from low- and middle-income countries. The tools featured (n = number of studies) were: General Movement Assessment (6), neonatal magnetic resonance imaging (3), Hammersmith Neonatal Neurological Examination (2), Hammersmith Infant Neurological Examination (1) and cranial ultrasound (1). We found a paucity of published literature on the early diagnosis of cerebral palsy from low- and middle-income countries. Further research is needed to determine the tools that are accurate and feasible for use in low-resource settings, particularly since cerebral palsy is more prevalent in these areas.

Effectiveness of Bedside Clinical Screening Tools in Predicting Short-Term Neurodevelopmental Delay Among Very-Low-Birth-Weight Pre-terms: A Prospective Observational Study.

Background: Pre-term births are associated with increased risk of various morbidities, especially neurological. Early detection and early intervention to prevent these morbidities will have immediate and long-term benefits to the individuals and society at large. However, the screening and assessment tools, including both clinical and radiological, are not uniformly available in resource-poor settings. The present study was carried out to evaluate the validity of the clinical screening tools for detecting neurodevelopmental delay among very-low-birth-weight (VLBW) pre-term babies.Methods: This prospective observational study was undertaken in the child development unit of a tertiary care hospital from July 2015 to October 2017. All pre-term VLBW neonates admitted in level III Neonatal Intensive Care within the first 24 hours of life were included in the study. They were subjected to Hammersmith Neonatal Neurological Examination (HNNE) and magnetic resonance imaging (MRI) of brain at term-equivalent age. Subsequently, the same group was followed up with Amiel-Tison (AT) angles, Child Development Centre (CDC) grading for sitting developed at Trivandrum, Kerala, India, and Denver Development Screening Test (DDST-II gross motor) at eight months corrected age, and their outcomes were analyzed.Results: 17.9% of the ex-preterm were abnormal as per HNNE evaluation at term-corrected age. At short-term follow-up screening, 13.8% were found to be abnormal based on AT angles, while 35.2% were found to be abnormal as per CDC grading and 30.4% were found to have risk for delay as per DDST-II (gross motor). A high level of sensitivity (93.6%) and positive predictive value (91.2%) was observed for HNNE at term equivalent with MRI brain assessment considered as gold standard. Among the follow-up screening tools, CDC grading for sitting, AT angles, and DDST-II had high sensitivity (>85%).Conclusion: The combination of HNNE along with radiological assessment at term-corrected age can be considered as appropriate for predicting long-term neurodevelopmental outcome in VLBW pre-term infants. During follow-up, simple tools like CDC grading for motor milestones, AT angles, and DDST-II may be utilized if facilities for standard assessment are not available as in resource-poor settings.