Early prediction of neurodevelopmental outcomes at 12 years in children born extremely preterm

Relationship between early infant motor repertoire and neurodevelopment on the hammersmith infant neurological examination in a developmentally vulnerable First Nations cohort

AIM

To implement a culturally-adapted screening program aimed to determine the ability of infant motor repertoire to predict early neurodevelopment on the Hammersmith Infant Neurological Examination (HINE) and improve Australian First Nations families' engagement with neonatal screening.

METHODS

A prospective cohort of 156 infants (55 % male, mean (standard deviation [SD]) gestational age 33.8 (4.6) weeks) with early life risk factors for adverse neurodevelopmental outcomes (ad-NDO) participated in a culturally-adapted screening program. Infant motor repertoire was assessed using Motor Optimality Score-revised (MOS-R), captured over two videos, 11-13+6 weeks (V1; <14 weeks) and 14-18 weeks (V2; ≥14 weeks) corrected age (CA). At 4-9 months CA neurodevelopment was assessed on the HINE and classified according to age-specific cut-off and optimality scores as; developmentally 'on track' or high chance of either adverse neurodevelopmental outcome (ad-NDO) or cerebral palsy (CP).

RESULTS

Families were highly engaged, 139/148 (94 %) eligible infants completing MOS-R, 136/150 (91 %), HINE and 123 (83 %) both. Lower MOS-R at V2 was associated with reduced HINE scores (β = 1.73, 95 % confidence interval [CI] = 1.03-2.42) and high chance of CP (OR = 2.63, 95%CI = 1.21-5.69) or ad-NDO (OR = 1.38, 95%CI = 1.10-1.74). The MOS-R sub-category 'observed movement patterns' best predicted HINE, infants who score '4' had mean HINE 19.4 points higher than score '1' (95%CI = 12.0-26.9). Receiver-operator curve analyses determined a MOS-R cut-off of <23 was best for identifying mild to severely reduced HINE scores, with diagnostic accuracy 0.69 (sensitivity 0.86, 95%CI 0.76-0.94 and specificity 0.40, 95 % CI 0.25-0.57). A trajectory of improvement on MOS-R (≥2 point increase in MOS-R from 1st to 2nd video) significantly increased odds of scoring optimally on HINE (OR = 5.91, 95%CI 1.16-29.89) and may be a key biomarker of 'on track' development.

INTERPRETATION

Implementation of a culturally-adapted program using evidence-based assessments demonstrates high retention. Infant motor repertoire is associated with HINE scores and the early neurodevelopmental status of developmentally vulnerable First Nations infants.

Early Intervention Guided by the General Movements Examination at Term Corrected Age-Short Term Outcomes

BACKGROUND AND AIM

The early identification of the former premature neonates at risk of neurologic sequelae could lead to early intervention and a better prognosis. This pilot study aimed to investigate whether the General Movement patterns observed at term-equivalent age in former premature infants could serve as predictors for guiding early intervention and improving prognosis.

MATERIALS AND METHODS

In a population of 44 premature neonates (mean gestational age 33.59 weeks (+2.43 weeks)) examined at term-equivalent age, 10 neonates with a cramped-synchronized General Movements motor pattern were identified. These neonates were included in an early intervention program consisting of physiotherapy executed both by the therapist and by the parents at home. They were again examined at a corrected age of 12 weeks. The presence or absence of fidgety movements and the MOS-R (motor optimality score revised) was noted. The examinations were performed by certified specialists.

RESULTS

Normal fidgety movements and a MOS-R of 20-24 were presented in 9/10 of the former premature infants, with normal foot to foot contact present in 7/10, and normal hand to hand contact present in 5/10. The atypical patterns noted were side to side movements of the head in 5/10, a non-centered head in 9/10, asymmetric tonic neck reflex in 9/10 and jerky movements in 10/10. One patient presented with no fidgety movements and a MOS-R score of 9.

CONCLUSION

Early intervention in our group of patients allowed for an improvement in the neurologic status, demonstrated by the presence of fidgety movements. We suggest that early intervention should be indicated in all premature infants that present with a cramped-synchronized GM pattern during examination at term-equivalent age. However, due to the small sample size, the absence of statistical analysis and a control group, and the limited follow-up period, the conclusions must be approached with caution.

Developmental coordination disorder in preterm children: A systematic review and meta-analysis

This study aimed to review the prevalence of developmental coordination disorder (DCD) in individuals born preterm and systematically explore this prevalence according to gestational age and different assessment cut-offs and compare it to full-term peers. The eligibility criteria were observational and experimental studies reporting the prevalence of DCD in preterm individuals. A systematic search was performed in databases from inception until March 2022. Two independent reviewers performed the selection. Study quality assessment was performed using the checklists from Joanna Briggs Institute (JBI). Data analysis was performed on Excel and Review Manager Software 5.4. Among the 1774 studies identified, 32 matched the eligibility criteria. The pooled estimate rate of the DCD rate in preterm was 21% (95% confidence interval [CI] 17.8-24.3). The estimate rates were higher as gestational age decreased, and preterm children are two times more likely to have DCD than their full-term peers risk ratio (RR) 2.2 (95% CI 1.77-2.79). The limitation was high heterogeneity between studies; the assessment tools, cut-off points and age at assessment were diverse. This study provided evidence that preterm children are at higher risk for DCD than full-term children, and the risks increased as gestational age decreased.

Using the center of pressure movement analysis in evaluating spontaneous movements in infants: a comparative study with general movements assessment

BACKGROUND

Researchers have attempted to automate the spontaneous movement assessment and have sought quantitative and objective methods over the past decade. The purpose of the study was to present a quantitative assessment method of spontaneous movement using center-of-pressure (COP) movement analysis.

METHODS

A total of 101 infants were included in the study. The infants were placed in the supine position on the force plate with the cranial-caudal orientation. In this position, the recording of video and COP movement data were made simultaneously for 3 min. Video recordings were used to observe global and detailed general movement assessment (GMA), and COP time series data were used to obtain quantitative movement parameters.

RESULTS

According to the global GMA, 13 infants displayed absent fidgety movements (FMs) and 88 infants displayed normal FMs. The binary logistic regression model indicated significant association between global GMA and COP movement parameters (chi-square = 20.817, p < 0.001). The sensitivity, specificity, and overall accuracy of this model were 85% (95% CI: 55-98), 83% (95% CI: 73-90), and 83% (95% CI: 74-90), respectively. The multiple linear regression model showed a significant association between detailed GMA (motor optimality score-revised/MOS-R) and COP movement parameters (F = 10.349, p < 0.001). The MOS-R total score was predicted with a standard error of approximately 1.8 points (6%).

CONCLUSIONS

The present study demonstrated the possible avenues for using COP movement analysis to objectively detect the absent FMs and MOS-R total score in clinical settings. Although the method presented in this study requires further validation, it may complement observational GMA and be clinically useful for infant screening purposes, particularly in clinical settings where access to expertise in observational GMA is not available.

Use of the Motor Optimality Score-Revised (MOS-R) to predict neurodevelopmental outcomes in infants with congenital anomalies

AIMS

To describe the Motor Optimality Score-Revised (MOS-R) in infants with congenital anomalies requiring major surgery in the neonatal period; and to determine the predictive validity of the MOS-R, including specific movement and postural patterns, for neurodevelopmental outcomes at 3 years of age.

METHOD

A retrospective cohort study of 201 infants born with congenital anomalies requiring surgery in the neonatal period (mean gestational age 38.2 weeks, SD 2.2). MOS-R completed using the pre-recorded General Movements Assessment (GMA) videos taken at 12 to 14 weeks post-term age (mean 12.45, SD 1.54). Developmental outcomes were assessed at 3 years of age (38.13 months, SD 1.76) using the Bayley Scales of Infant and Toddler Development (3rd ed).

RESULT

The mean score for the MOS-R was 21.85 (SD 5.16), with scores ranging from 6 to 28. Fifty-six infants (27.9 %) scored within the optimal range (25-28) with only 12 % demonstrating a normal movement character. A MOS-R total score of <21 was identified as the best performing cut-off to predict a mild, moderate or severe delay or CP diagnosis with sensitivity 0.39 (95 % CI: 0.25, 0.54) and specificity 0.86 (95 % CI: 0.80, 0.91), and an area under the ROC curve of 0.63. Outcome at 3 years was significantly associated with the MOS-R total (p < 0.01) and the subscales for observed movement patterns (p < 0.01) and age adequate repertoire (p = 0.02).

CONCLUSION

The MOS-R may be an effective tool to use in addition to existing assessments to identify infants who are at risk of adverse developmental outcomes. Our study found that a MOS-R of <21 identified infants who would benefit from referral to early intervention.

Motor repertoire in 3- to 5- month-old infants with prenatal exposure to syphilis and toxoplasmosis

AIM

To characterize the motor repertoire of 3- to 5-month-old infants who were prenatally exposed to the infectious agents of syphilis and toxoplasmosis.

METHODS

Exploratory observational study that evaluated 15 exposed infants (34.4 ± 3.5 weeks gestation) recruited from a referral center. Age assessment ranged 12-20 (median 12) weeks post-term. General Movement Assessment, including the Motor Optimality Score-Revised (MOS-R), was used to assess the global quality of fidgety movements (FMs) and to quantify and detail coexisting motor patterns. Clinical variables were also collected. Later motor outcomes were obtained from medical reports when possible.

RESULTS

MOS-R ranged 10-26 (median 24). There was a higher proportion of infants with normal (80.0 %) than aberrant FMs, but the proportion of infants with reduced MOS-R (80.0 %) was higher compared to optimal MOS-R. One infant with aberrant FMs was later diagnosed with cerebral palsy. Only 13.3 % of the infants showed smooth and fluent movement character. All observed tongue movements were abnormal.

CONCLUSION

Infants had predominantly normal FMs, but with reduced MOS-R and abnormalities in the coexisting motor repertoire.

Reliability of the Motor Optimality Score-Revised: A study of infants at elevated likelihood for adverse neurological outcomes

AIM

To assess the inter-assessor reliability of the Motor Optimality Score-Revised (MOS-R) when used in infants at elevated likelihood for adverse neurological outcome.

METHODS

MOS-R were assessed in three groups of infants by two assessors/cohort. Infants were recruited from longitudinal projects in Sweden (infants born extremely preterm), India (infants born in low-resource communities) and the USA (infants prenatally exposed to SARS-CoV-2). Intraclass correlation coefficients (ICC) and kappa (κw) were applied. ICC of MOS-R subcategories and total scores were presented for cohorts together and separately and for age-spans: 9-12, 13-16 and 17-25-weeks post-term age.

RESULTS

252 infants were included (born extremely preterm n = 97, born in low-resource communities n = 97, prenatally SARS-CoV-2 exposed n = 58). Reliability of the total MOS-R was almost perfect (ICC: 0.98-0.99) for all cohorts, together and separately. Similar result was found for age-spans (ICC: 0.98-0.99). Substantial to perfect reliability was shown for the MOS-R subcategories (κw: 0.67-1.00), with postural patterns showing the lowest value 0.67.

CONCLUSION

The MOS-R can be used in high-risk populations with substantial to perfect reliability, both in regards of total/subcategory scores as well as in different age groups. However, the subcategory postural patterns as well as the clinical applicability of the MOS-R needs further study.

Smartphone application links severity of retinopathy of prematurity to early motor behavior in a cohort of high-risk preterm infants

PURPOSE

To evaluate the General Movement Assessment (GMA) with the Motor Optimality Score-Revised (MOS-R) as a neurodevelopmental marker in infants with retinopathy of prematurity (ROP).

METHODS

Infants screened prospectively for ROP were evaluated at 3 months' post-term age using a smartphone application to complete the GMA and MOS-R. Results were analyzed by ROP severity.

RESULTS

Of 105 enrolled infants, 83 completed the study. Of these, 54 (65%) had any ROP, 32 (39%) had severe ROP, and 13 (16%) had type 1 ROP. The proportion with aberrant GMA was significantly higher in infants with severe ROP (14/32 [44%]) compared with infants who had milder ROP (8/51 [16%]; P = 0.006). Of those with severe ROP, there was no significant difference comparing infants with type 1 ROP treated with bevacizumab (7/13 [54%]) to infants with type 2 ROP without treatment (7/19 [37%]; P = 0.47). Although the presence of any ROP, stage of ROP, and severe ROP each predicted lower MOS-R scores on univariate analyses, only severe bronchopulmonary dysplasia and markers of brain injury remained significant in the multivariate analysis.

CONCLUSIONS

The GMA was a convenient, short-term method of data collection with low attrition. Although severe ROP initially appeared linked to poor early motor scores, this association is likely confounded by neurological and respiratory complications, which frequently accompany severe ROP.

Neuromotor repertoires in infants exposed to maternal COVID-19 during pregnancy: a cohort study

OBJECTIVE

To evaluate neuromotor repertoires and developmental milestones in infants exposed to antenatal COVID-19.

DESIGN

Longitudinal cohort study.

SETTING

Hospital-based study in Los Angeles, USA and Rio de Janeiro, Brazil between March 2020 and December 2021.

PARTICIPANTS

Infants born to mothers with COVID-19 during pregnancy and prepandemic control infants from the Graz University Database.

INTERVENTIONS

General movement assessment (GMA) videos between 3 and 5 months post-term age were collected and clinical assessments/developmental milestones evaluated at 6-8 months of age. Cases were matched by gestational age, gender and post-term age to prepandemic neurotypical unexposed controls from the database.

MAIN OUTCOME MEASURES

Motor Optimality Scores Revised (MOS-R) at 3-5 months. Presence of developmental delay (DD) at 6-8 months.

RESULTS

239 infants were enrolled; 124 cases (83 in the USA/41 in Brazil) and 115 controls. GMA was assessed in 115 cases and 115 controls; 25% were preterm. Median MOS-R in cases was 23 (IQR 21-24, range 9-28) vs 25 (IQR 24-26, range 20-28) in controls, p<0.001. Sixteen infants (14%) had MOS-R scores <20 vs zero controls, p<0.001. At 6-8 months, 13 of 109 case infants (12%) failed to attain developmental milestones; all 115 control infants had normal development. The timing of maternal infection in pregnancy (first, second or third trimester) or COVID-19 disease severity (NIH categories asymptomatic, mild/moderate or severe/critical) was not associated with suboptimal MOS-R or DD. Maternal fever in pregnancy was associated with DD (OR 3.7; 95% CI 1.12 to 12.60) but not suboptimal MOS-R (OR 0.25; 95% CI 0.04 to 0.96).

CONCLUSIONS

Compared with prepandemic controls, infants exposed to antenatal COVID-19 more frequently had suboptimal neuromotor development.

Identification of risk factors in pre-term infants with abnormal general movements

INTRODUCTION

This study aimed to investigate the relationship between prenatal, perinatal, and postnatal risk factors for neurodevelopmental impairment (NDI) with the outcomes of General Movement (GM) Assessment (GMA) in pre-term infants at 3-5 months of age. We sought to identify the risk factors associated with the predictors of psychomotor development in pre-term newborns, such as normal fidgety movements (FMs), absent FMs, or abnormal FMs, assessed during the fidgety period of motor development.

METHODS

The SYNAGIS program (prophylactic of Respiratory Syncytial Virus Infection) was used to identify risk factors for the development of neuromotor deficits in 164 pre-term infants who were at high risk of developing these deficits. Based on the GMA, all participants were divided into three groups of infants who presented: (1) normal FMs; (2) absent FMs; and (3) abnormal FMs.

RESULTS

The results of the current study suggest that abnormal GMs not only indicate commonly known factors like birth asphyxia (BA), respiratory distress syndrome (RDS), periventricular leukomalacia (PVL), intraventricular hemorrhage (IVH) grades 3-4, but also predict the development of motor impairments. In the present study, several specific risk factors including bronchopulmonary dysplasia (BPD), infertility treatments, maternal acute viral/bacterial infections during pregnancy, and elevated bilirubin levels were identified as attributes of an atypical fidgety movement pattern.

CONCLUSIONS

Additional clinical data, such as risk factors for NDI associated with early predictors of psychomotor development in pre-term newborns, i.e., absent or abnormal FMs, may be helpful in predicting neurological outcomes in pre-term infants with developmental concerns in the 1st month of life.

A Neurologist's Guide to Neonatal Neurodevelopmental Assessments and Preterm Brain Injury

Despite advances in medical care and improved survival of extremely preterm infants, rates of neurodevelopmental impairment remain high. Outcomes are significantly improved with early intervention, but infants must be appropriately identified to facilitate services. Neuroimaging provides important information regarding neurodevelopmental outcomes but prognosticating and communicating risk remains challenging. Standardized neonatal neurodevelopmental assessments provide supplemental information to aid in the identification of high-risk infants and counseling for their families.

Early Spontaneous Movements and Postural Patterns in Infants With Extremely Low Birth Weight

BACKGROUND

Extremely-low-birth-weight (ELBW) infants are at high risk of morbidity, mortality, and long-term neurodevelopmental disorders. Evaluating infants' early spontaneous movements and postural patterns could facilitate the early detection of neurological dysfunction. This study aimed to analyze the results of global-and detailed-General Movements Assessment (GMA) in ELBW infants at a corrected age of three to five months and to compare with normal-birth-weight (NBW) infants.

METHODS

Fifty-two ELBW infants (median birth weight = 915.5 g) and 50 NBW infants were included. All infants were assessed according to GMA using Motor Optimality Score for 3- to 5-Month-Old Infants-Revised score sheet (MOS-R). In addition, later diagnoses of ELBW infants with atypical development were presented.

RESULTS

Fidgety movements were observed in 36 (69.2%) of ELBW infants and all NBW infants. MOS-R scores were lower in the ELBW group (median = 24) compared with the NBW group (median = 26). The ELBW infants scored lower than NBW infants in all MOS-R subcategories. Twenty-three (44.2%) of ELBW infants were diagnosed as atypical in the later period, although all control infants had normal development.

CONCLUSIONS

The study indicated that ELBW might increase the risk of atypical development in infants. The MOS-R could help us to find the risk of atypical development in infants with ELBW.

Early Motor Repertoire of Very Preterm Infants and Relationships with 2-Year Neurodevelopment

The Motor Optimality Score, revised (MOS-R) is an extension of the Prechtl General Movements Assessment. This study aims to determine the relationship between MOS-R and 2-year neurodevelopmental outcomes in a cohort of 169 infants born very preterm (<31 weeks’ gestational age), and to examine the predictive validity of the MOS-R at 3−4 months’ corrected age (CA) above perinatal variables associated with poor outcomes, including Prechtl fidgety movements. Development at 2 years’ CA was assessed using Bayley Scales of Infant and Toddler Development, Third edition (Bayley-III) (motor/cognitive impairment: Bayley-III ≤ 85) and Neurological, Sensory, Motor, Developmental Assessment (NSMDA) (neurosensory motor impairment: NSMDA ≥ 12). Cerebral palsy (CP) was classified at 2 years as definite or clinical. The MOS-R was related to 2-year outcomes: Bayley-III motor (BMOS-R = 1.24 95% confidence interval (0.78, 1.70)), cognitive (BMOS-R = 0.91 (0.48, 1.35)), NSMDA scores (BMOS-R = −0.34 (−0.42, −0.25)), definite CP (odds ratio [OR] 0.67 (0.53, 0.86)), clinical CP (OR 0.74 (0.66, 0.83)) for each 1-point increase in MOS-R. MOS-R ≤ 23 predicted motor (sensitivity 78% (60−91%); specificity 63% (54−72%)) and neurosensory motor impairment (sensitivity 86% (64−97%); specificity 59% (51−68%)). The MOS-R is strongly related to CP and motor and cognitive delay at 2 years and is a good predictor of motor and neurosensory motor impairment.

The Impact of Increased Maternal sFlt-1/PlGF Ratio on Motor Outcome of Preterm Infants

BACKGROUND

The sFlt-1 (soluble fms-like tyrosine kinase-1)/PlGF (placental growth factor) ratio serves as a clinical biomarker to predict the hypertensive, placenta-derived pregnancy disorder pre-eclampsia which is often associated with placental dysfunction and fetal growth restriction. Additionally elevated levels also indicate an increased risk for prematurity. However, its predictive value for subsequent neonatal neurological outcome has not been studied.

OBJECTIVE

This study aimed to evaluate the correlation of maternal sFlt-1/PlGF ratio with early motor outcome of preterm infants. Design/Methods: 88 preterm infants (gestational age ≤ 34 + 0) born between February 2017 and August 2020 at the Department of Obstetrics and Gynecology, University Hospital Essen in Germany, were included, when the following variables were available: maternal sFlt-1/PlGF levels at parturition and general movement assessment of the infant at the corrected age of 3 to 5 months. The infants were stratified into high and low ratio groups according to maternal sFlt-1/PlGF cut-off values of 85. To investigate the early motor repertoire and quality of spontaneous movements of the infant, the Motor Optimality Score (MOS-R) based on antigravity movements and posture patterns, was applied. In the given age, special attention was paid to the presence of fidgety movements. Linear regressions were run to test differences in infants motor repertoire according to the maternal sFlt-1/PIGF ratio.

RESULTS

Linear regression analysis showed that the sFlt-1/PlGF ratio does not predict the MOS-R score (β=≤0.001; p=0.282). However, children with birth weight below the 10th percentile scored significantly lower (mean 20.7 vs 22.7; p=0.035). These children were 91% in the group with an increased ratio, which in turn is a known predictor of low birth weight (β= -0.315; p <0.001). In the group with a high sFlt-1/PLGF ratio above 85 the mothers of female infants had a lower average sFlt-1/PlGF ratio compared to a male infant (median: 438 in female vs. 603 in male infant, p=0.145).

CONCLUSIONS

In our cohort, especially low birth weight, which correlated with an elevated sFlt-1/PlGF ratio, had a negative effect on the outcome in the MOS-R. A direct correlation between an increased ratio and a worse motor outcome was not demonstrated.