Neurodevelopmental Examination Research Articles

Early Outcome Determination of Low-Birth-Weight Infants Using the Neurodevelopmental Risk Examination

A neonatal neurodevelopmental assessment, the Neurodevelopmental Risk Examination (NRE), was developed, through adaptation of the scoring of the Allen/Capute neonatal neurodevelopmental examination, for screening the development of low-birth-weight (LBW) infants in the newborn period. A pilot study was conducted of the NRE and its ability to predict motor and cognitive outcome in LBW infants. The NRE was performed on 92 LBW infants (mean birth weight 1,192 g; mean gestational age 29 weeks) at or near term and included assessments of sensory/behavioral response, axial tone, extremity tone, deep tendon reflexes, and primitive reflexes. Developmental outcome was assessed at a mean age of 13.7 months by neuromotor examination and by the mental scale of the Bayley Scales of Infant Development. The NRE total risk score, reflecting overall neurodevelopmental status, correlated well with motor and cognitive outcomes (r = .50, P = .0001; and r = -.38, P = .0001, respectively). When infants were clustered into risk groups based upon NRE score (69 infants were deemed low-risk, 20 moderate-risk, and three high-risk), a strong relationship to outcome was maintained (motor outcome: chi 2 = 43.6, P < .0001; cognitive outcome: analysis of variance (ANOVA) F = 6.78, df(2.89), P = .002). All subcategories of the examination, except primitive reflexes, were associated with outcome. Therefore, by using a simple method of scoring and interpretation, the NRE can validly predict motor and cognitive outcome in LBW infants.

Neurodevelopment in Pediatric HIV Infection

Pediatric neuro-AIDS may be the first clinical manifestation of HIV infection in children born to HIV infected mothers. As part of the neurodevelopmental examination of children, the Clinical Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS) was investigated as a tool for pediatricians to use to monitor the development of children at risk for HIV infection. The CAT/CLAMS was found to detect neurodevelopmental differences between HIV-infected and uninfected children at 12 and 18 months of age. Good correlations were found between the CAT/CLAMS and concurrently administered Bayley Scales of Infant Development. These findings suggest that the CAT/CLAMS should be considered as a part of the neurodevelopmental examination of children at risk for pediatric neuro-AIDS.

Neurodevelopmental Testing of Children Born to Human Immunodeficiency Virus Type 1 Seropositive and Seronegative Mothers: A Prospective Cohort Study in Kigali, Rwanda

The results of developmental testing of 218 children born to human immunodeficiency virus (HIV)-seropositive mothers and infected or uninfected themselves were compared with those of 218 children born to HIV-seronegative mothers in an ongoing cohort study in Kigali, Rwanda. When the children were 6, 12, 18, and 24 months of age, a specific neurodevelopmental examination was performed blindly by study physicians assessing gross motor development, fine motor development, language acquisition, and social contacts. Only one acute severe HIV-related encephalopathy was identified among the 50 infected children. The proportion of abnormal neurologic examinations in HIV-infected children varied from 15% to 40% according to age and was always higher than in HIV-uninfected children born to HIV-seropositive and seronegative mothers (< or = 5% or less of abnormal examinations at each time period). After excluding those children with clinical acquired immunodeficiency syndrome (AIDS) from the analysis, the proportion of abnormal examinations in infected children was 12.5% at 6 months, 16% at 12 months, 20% at 18 months, and 9% at 24 months of age and was still more frequent than in HIV-uninfected children. The developmental delay was principally due to significantly lower gross motor scores. HIV-1-infected children are more frequently developmentally delayed than uninfected children during the first 2 years of life in this African population. This developmental delay is related to the AIDS stage of pediatric HIV infection.

The High-Risk Infant

A large number of infants are born each year with biologic or environmental risk factors that put them at increased risk for developmental disability, although most do not go on to have major disabilities. Some risk factors, for example, intraparenchymal hemorrhage, periventricular cysts, encephalomalacia, and abnormal neurodevelopmental examination, carry a much higher risk of developmental disability than others. There is much overlap among risk factors, and infants with multiple risk factors generally have a greater risk of disability than infants with just a single risk factor. All high-risk infants should receive careful pediatric follow-up that includes developmental screening, but efficient use of so far quite limited resources argues for selection of the highest risk infants for comprehensive developmental follow-up or early intervention programs. A system of tracking and monitoring high-risk infants during infancy and childhood would allow for early identification of developmental delay and appropriate referral for community resources.

Children of drug-dependent mothers--personal experiences and review of the literature

The increasing incidence of drug abuse in central Europe leads to a growing number of children with intrauterine drug exposure. During pregnancy various risks affect these children. Postnatally severe symptoms of withdrawal are observed frequently. The psychosocial development is endangered. Between 1986 and 1990 30 drug dependent women attended the obstetric department of the University Hospital Basel during pregnancy. The data of 21 children born to mothers drug dependent at birth were evaluated. 11 children were born in 1990. 12 mothers received Methadon, 10 were polydrug abusers. Positive serology was found for hepatitis in 18, for HIV-infection in 9 women. 6 babies were premature, 8 were small for gestational age. 20 newborns presented withdrawal symptoms which required a mean hospitalization time of 45 days. Tonic and/or clonic seizures were observed in 6 neonates. In 9 other children some symptoms were suspicious of seizures. EEG recordings were pathological in 10 of 12 infants. For the control of withdrawal symptoms 16 children received pharmacological treatment for a mean duration of 61 days. Neurodevelopmental examinations were performed in 14 children at an average age of 22 months. Neurological findings were pathological in 2 children. 3 had mild, 2 had severe mental retardation, 5 presented with behavioural disturbances. Our data are compared with those of the literature. Therapeutic proposals for children of drug dependent mothers are presented. The impact of methadon programs on the exposed children is discussed.

56 RELATION BETWEEN CEREBRAL HAEMODYNAMICS AND OUTCOME IN BIRTH ASPHYXIATED NEWBORN INFANTS STUDIED BY NEAR INFRARED SPECTROSCOPY (NIRS)

The purpose of this study was to measure cerebral blood flow (CBF), cerebral blood volume (CBV) and its response to changes in arterial carbon dioxide tension (CBVR) by NIRS in 21 term newborn infants who had suffered birth asphyxia. All had clinical and biochemical (base deficit ≥ 15 mmol/l) evidence of asphyxia and were studied during ihc first 24 hours. Eight of the 21 infants died and neurodevelopmental examination in survivors at one year of age showed that 7 had major neurological impairments; the remaining 6 infants were normal or had minor impairments. Results (mean ± SEM) were as follows: Values for CBF and CBV were significantly higher than previously defined normal values and for CBVR lower. The extern of the abnormalities was related to the severity of adverse outcome (ANOVA p<0.05).

Jitteriness Beyond the Neonatal Period: A Benign Pattern of Movement in Infancy

Jitteriness is a frequent, well-recognized phenomenon in neonates. Its occurrence in early infancy, beyond the neonatal period, is much less documented. Thirty-eight full-term infants who were jittery after 6 weeks of age were followed until the jitteriness disappeared and then reevaluated at the age of 3 years. The jittery movements had already been observed during the neonatal period in 16 babies but not before 6 weeks of age in 22. In 34 infants (89%), 1- and 5-minute Apgar scores were 9 or 10. At the initial examination, a mildly increased muscle tone was found in 12 infants, and hyperactive deep-tendon reflexes were found in 19. The jitteriness resolved at a mean age of 7.2 +/- 3.4 months. At 3 years, 92% of the infants had a normal neurodevelopmental examination, while in the rest only minor, transient disturbances were found. This study indicates that jitteriness as a sole presentation in infants beyond the neonatal period is a benign phenomenon, associated with an excellent prognosis. Its etiology is unknown but seems most likely to be related to a maturational process within the central nervous system.

Measures of attention deficit. Part II: Clinical perspectives and test interpretation.

After a detailed behavioral and developmental history has been supplemented by the use of formal questionnaires, the diagnosis of an attentional disorder can be further clarified by the judicious selection of psychoeducational and pediatric physical and neurodevelopmental examinations. The most common difficulty in the interpretation of psychoeducational test subscores and profiles is the significant overlap between the patterns generated by attentional deficits and those associated with memory-based learning disabilities. Certain other medical and behavioral conditions need to receive careful consideration prior to finalizing the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). A thorough but focused general examination coupled with the pediatric neurodevelopmental examination can contribute to this differentiation.

Childhood dysgraphia. Part 2. A study of hand function.

Sixty-six children were studied who had presented to the paediatric neurology service over a 2-year period, because they were failing to make the expected progress in mainstream school. Their parents were interviewed with a structured questionnaire and the children had a full neurodevelopmental examination which included a detailed assessment of hand function. Thirty-nine per cent of the children had a specific dysgraphia and there was a male predominance. The different populations of affected children had distinguishing characteristics. A family history of written language skill difficulties was elicited for most of the children with a developmental spelling dysgraphia, but it was uncommon in the children with an acquired spelling dysgraphia or motor dysgraphia. Slow speech development occurred frequently in developmental and acquired spelling dysgraphic children. Mixed handedness was significantly commoner in dysgraphic children who had acquired problems (P less than 0.05), whereas handedness in the developmental groups was within the expected normal distribution. Aspects of hand function such as power of hand grip did not distinguish the dysgraphic children. However, children with a spelling or motor dysgraphia had speeds of motor performance on successive finger movements and rapid hand pats outwith the normal range. These simple tests are a useful way of examining pertinent handskill difficulties in dysgraphic children.

Neonatal Neurodevelopmental Examination as a Predictor of Neuromotor Outcome in Premature Infants

There was a marked correlation (P less than .000001) between neonatal neurodevelopmental examination results and neuromotor outcome at 1 year of age or older in 210 high-risk premature infants (mean birth weight 1,107 g, mean gestational age 28.4 weeks). This neonatal examination consisted of assessment of posture, extremity and axial tone, deep tendon reflexes, pathologic reflexes, primitive reflexes, symmetry, oromotor function, cranial nerve function, auditory and visual responses, and behavior. Premature infants whose neonatal neurodevelopmental examination results were abnormal had significantly higher incidences of both cerebral palsy (38% v 6%, P less than .000001) and minor neuromotor dysfunction (27% v 13%, p less than .05) than did premature infants whose examination results were normal. This correlation continued to be highly significant even with the analysis of subgroups (infants born at or before 27 weeks' gestation, infants with chronic lung disease discharged with oxygen supplementation, infants with periventricular hemorrhage) and when a variety of individual perinatal, demographic, and social variables were used as controls. Normal or nearly normal neonatal neurodevelopmental examination results can be used to reassure parents of high-risk premature infants. Although abnormal neonatal neurodevelopmental examination results cannot be used to diagnose handicap in premature infants, they can be used to select a group of high-risk infants who should be carefully monitored during infancy and childhood.

PREDICTION OF EARLY SCHOOL‐AGE PROBLEMS BY A PRESCHOOL NEURODEVELOPMENTAL EXAMINATION OF CHILDREN AT RISK NEONATALLY

A group of 350 children who had had neonatal developmental risk-factors were assessed at the age of five years with a neurodevelopmental examination. At nine years they were assessed again for neuropaediatric, motor, psycholinguistic, cognitive and school-achievement problems. (Children with major handicaps were excluded). Poor performance at age five was significantly associated with failure in the nine-year examinations and with school problems. Sensitivity of the five-year neurodevelopmental examination in predicting problems at nine years was 0.30 to 0.50, and its predictive value for an abnormal performance was 0.30 to 0.60. Predictively, the neurodevelopmental examination was accurate in defining children without later problems, but less satisfactory in defining those who did develop problems. Multiple linear regression analyses between the neurodevelopmental examination and the scores at nine years revealed low explanatory power. A shortened neurodevelopmental examination, based on the best predictors, seemed to be as efficient as the full examination.

Vaginally born low-risk preterm infants: fetal acidosis and outcome at 6 years of age.

In a population of vaginally born low-risk preterm infants fetal acidosis (scalp pH less than 7.20) was found in 50% (6 out of 12) of infants of 29-33 weeks' gestational age (Group I) and in 9% (2 of 22) infants of 34-36 weeks' gestational age (Group II). At 6-7 years of age the children underwent a neurodevelopmental examination including a Griffith test. Five out of 6 Group I infants with fetal acidosis and 10 out of 20 Group II infants without fetal acidosis had minor or moderate neurodevelopmental problems. On the Griffith test Group II infants scored below Group I with more coordination and fine motor problems on the tested subscales. Fetal acidosis was more common in very preterm infants but cannot be used per se as a reliable indicator of long-term outcome.

Neurodevelopmental Readiness for Adolescence

The Pediatric Examination of Educational Readiness at Middle Childhood (PEERAMID) is a neurodevelopmental examination for 9- to 14-year-old children. The examination was designed largely for use by developmental-behavioral pediatricians as a way of assessing certain critical developmental functions, including attention, memory, language, and motor coordination in children with school problems. Preliminary field testing of the PEERAMID was carried out in one community, and subsequently a revised version was standardized on randomly selected subjects from three communities near Boston, Massachusetts, and on groups of children from those towns said to be having significant problems at school. Additionally, the examination was used for the evaluation of 106 consecutive patients referred to the School Function Program at The Children's Hospital in Boston. Statistically significant performance differences discriminated between children with normal academic performance and those with school problems in the community as well as in the referral setting. It was discovered that children with school problems tended to have clusters of dysfunction, whereas normally achieving youngsters more often harbored no developmental dysfunctions or perhaps one or two areas of difficulty. It is believed that the PEERAMID can be a useful instrument in serving as part of a pediatric contribution to a multidisciplinary assessment in children in this age group.

FOLLOW UP STUDY OF MACRO CEPHALIC DEVELOPMENTALLY DELAYED PRESCHOOLERS

Of nine developmentally delayed preschool children with macrccephaly identified at an inner city developmental evaluation clinic, eight were still macrccephalic on follow up. Evaluations consisted of parental and child interviews, assessment of academic progress, and physical and neurodevelopmental examinations. Follow up examinations revealed an unexpected finding of acceleration of growth in height for the group as a whole. Academic placement of children initially diagnosed as having borderline intelligence was at grade level with performance above expectations in reading and spelling and below in arithmetic on the Wide Range Achievement Test (WRAT) and on the Test of Early Language Development (TELD). These children were without major behavior problems. Children who initially tested as mildly retarded were in special classes receiving added therapies, tested below grade and age expectations on the WRAT and TELD, and had significant emotional difficulties. Those who initially tested as moderately or severely retarded were in special classes, had no academic gains and were noted to have significant behavior problems. Our data suggests that: (1) Macrocephaly tends to persist; (2) These children surprisingly display an accelerated rate of growth in height; (3) Initial intelligence testing was prognostically discriminating; (4) Emotional and behavior problems were common in this cohort of children.

A neurodevelopmental screening examination for five‐year‐old children

A neurodevelopmental screening examination for five‐year‐old children is described. The examination takes only 15‐20 minutes and tests a wide range of neurodevelopmental abilities. The children receive points for items which they are not able to perform. The sum of the points given is a measure of the child's neurodevelopmental impairment. A group of 52 control children had a mean score of 10.2 points, and the 326 children from child health centres had a mean score of 8.9 points. A group of 647 children who belonged neonatally to a high risk group was also examined. In 609 of these children no clear neurological disease was evident and they received mean score of 18.1 points while the mean score for 38 children with clear handicaps was 73.0. The results show that children who were at risk neonatally had more neurodevelopmental disabilities than children without any neonatal risk factors. Children who received high scores should be referred for more detailed neurological and neuropsychological examinations.

Neurodevelopmental screening for five‐year‐old children at child health centres

In 1987, child health centres in the city of Espoo, Finland, started an intensified check‐up on five‐year‐old children. Emphasis was laid on detecting slight neurodevelopmental handicaps. The examination consisted of tests for vision and hearing, a neurodevelopmental examination and a questionnaire to the parents about their child's development. The check‐up was attended by 2027 children. The neurodevelopmental examination comprised the testing of vision, motor performance, perception and behaviour. Each child was scored 1‐8 points for tasks in which he failed. The mean score was 9.6±7.3. A score of 24‐29 was given to 55 (3.1%) and a score ≥ 30 to 34 (1.9%) children. The majority of the children with high scores were boys. Among the children with high scores were several not previously diagnosed as having MBD, slight mental retardation, vision and hearing impairment or emotional problems. The results accorded with the preschool performance two years later.

EARLY PREDICTORS OF NEURODEVELOPMENTAL OUTCOME OF VERY LOW‐BIRTHWEIGHT INFANTS AT THREE YEARS

Seventy-nine premature infants weighting less than 1501 g at birth but appropriate for gestational age underwent a neurodevelopmental examination at one, three, six, nine and 12 months post-term, and a standard neurological examination and the Stanford-Binet Intelligence Scale at three to four years of age. Children were classified as normal, suspect or abnormal on the three-year neurological examination, on the IQ test, and on composite neurodevelopmental outcome at age three years. Results showed that items from both the nine- and 12-month neurodevelopmental examinations correctly classified about 80 per cent of the children as to composite outcome at three years. In addition, the 12-month examination enabled correct prediction for 89 per cent of the children as to neurological outcome and for 82 per cent as to IQ. Neurodevelopmental examination of high-risk infants in the last quarter of the first year of life (post-term) should assist pediatricians in predicting which children will be normal and which will require early intervention.

Ventriculoperitoneal shunts in low birth weight infants with intracranial hemorrhage: neurodevelopmental outcome.

Fifty preterm infants (mean birth weight, 1266 +/- 303 g; mean gestational age, 30 +/- 2 weeks) who required a ventriculoperitoneal (VP) shunt for posthemorrhagic hydrocephalus (92% with Grade III or IV hemorrhage) were followed for neurodevelopmental problems. VP shunts were placed at a median age of 29 days (range, 18 to 87 days) after serial lumbar punctures failed to control progressive and symptomatic ventriculomegaly. A total of 34 infants (68%) required one shunt revision or more, and the overall infection rate per patient was 50%. Seven infants died, 2 from shunt infections. The infants were evaluated with audiological, ophthalmological, and neurodevelopmental examinations. Of the survivors, 11 (28%) have severe visual loss and 10 (24%) have hearing impairment. Of the infants, 21 (49%) have severe motor handicaps and 19 (38%) have seizure disorders. Developmental and motor scores were obtained using the Bayley or Knobloch-Gesell scales. Seven infants (18%) have normal developmental outcomes; 26 (60%) have multiple handicaps. Grade IV hemorrhage or the occurrence of seizures was a predictor of poor neurodevelopmental outcome. We conclude that progressive posthemorrhagic hydrocephalus in low birth weight infants is associated with multiple handicaps despite early VP shunt placement.

The Diagnostic Value of the Neurodevelopmental Examination

The neurodevelopmental examination is a pediatric approach to developmental diagnosis that relies on evaluation of multiple streams of development. The value of the neurodevelopmental examination for the early diagnosis of cerebral palsy and mental retardation was studied by a retrospective analysis of prospectively (longitudinally) collected data. Both conditions were found to be accurately diagnosed in the first year of life. For cerebral palsy, sensitivity was 0.81 and specificity 1.00; for mental retardation, sensitivity was 0.56 and specificity 0.96. The trained pediatrician can make early diagnoses of developmental disabilities.

DEVELOPMENTAL ABNORMALITIES IN CHILDREN WITH ACQUIRED IMMUNODEFICIENCY SYNDROM (AIDS)

An AIDS-like disease in infants was first described in 1982, with 2 types of clinical pictures reported: a full-blown syndrome and a prodromal stage. Some adults with AIDS have a progressive encephalopathy and suble cognitive changes. A study was initiated to determine whether 6 AIDS children, ages 10 mos. to 6 yrs. exhibited developmental abnormalities. Four children were hospitalized and 2 were examined in the OPD. Five had the full syndrome and 1 the prodrome. Parents used IV drugs in 5 cases, and in 2 cases mothers died of AIDS. Two children were siblings. Neurodevelopmental and psychological examinations were given using Bayley Scales for children < 30 months and the Stanford-Binet for older children. The 4 inpatients had microcephaly and failure-to-thrive; 3 had spasticity, 1 had seizures, and 1 regressed. All 4 scored < 50 on the Bayley. The 2 outpatients, each over 5 yrs., had IQs of 67 and 71, and scored well below normal on language tests. Therefore, all subjects were retarded. Whether this is due to AIDS itself or other factors is uncertain. A larger number of AIDS children and a comparison group of offspring of drug-addicted mothers without AIDS are being studied to clarify the etiology of the developmental abnormalities.