Hammersmith Infant Neurological Examination and long-term cognitive outcome in children born very preterm

Association between working memory performance and parent and teacher ratings of working memory in 11-year-old children born preterm

Working memory (WM) difficulties are often observed in children born preterm. We examined whether performance-based measures of WM components are associated with parent- and teacher-rated WM difficulties in the everyday life of children born very preterm and/or at very low birth weight (VPT/VLBW) at 11 years (n = 165). The WM components as defined in the original Baddeley's model - phonological loop (PL), visuospatial sketchpad (VS), and central executive (CE) - were assessed with tasks from the Working Memory Test Battery for Children (WMTB-C) and the Wechsler Intelligence Scale for Children - Fourth edition (WISC-IV). Parents and teachers completed the WM subscale of the Behavioral Rating Inventory for Executive Functions (BRIEF). Measures of WM components were modestly associated with BRIEF scores, explaining 18.9% of the variance in parent-rated and 14.0% of teacher-rated WM difficulties. CE was the component most consistently associated with parent- and teacher-rated everyday WM. To conclude, our results suggest that tasks that utilize CE functions may best reflect WM outside of controlled test settings in the follow-up of VPT/VLBW children. However, performance and rating-scale measures provide unique information and are both needed to comprehensively assess WM skills.

Neurological assessment tool for screening infants during the first year after birth: The Brief-Hammersmith Infant Neurological Examination

AIM

To develop a short version of the original Hammersmith Infant Neurological Examination (HINE) to be used as a screening tool (Brief-HINE) and to establish if the short examination maintains good accuracy and predictive power for detecting infants with cerebral palsy (CP).

METHOD

Eleven items were selected from the original HINE ('visual response'; 'trunk posture'; 'movement quantity'; 'movement quality'; 'scarf sign'; 'hip adductor angles'; 'popliteal angle'; 'pull to sit'; 'lateral tilting'; 'forward parachute reaction'; 'tendon reflexes') identifying those items previously found to be more predictive of CP in both low- and high-risk infants. In order to establish the sensitivity of the new module, the selected items were applied to existing data, previously obtained using the full HINE at 3, 6, 9, and 12 months, in 228 infants with typical development at 2 years and in 82 infants who developed CP.

RESULTS

Brief-HINE scores showed good sensitivity and specificity, at each age of assessment, for detecting infants with CP. At 3 months, a score of less than 22 was associated with CP with a sensitivity of 0.88 and a specificity of 0.92; at 6, 9, and 12 months, the cut-off scores were less than 25 (sensitivity 0.93; specificity 0.87), less than 27 (sensitivity 0.95; specificity 0.81), and less than 27 (sensitivity 1; specificity 0.86) respectively. The presence of more than one warning sign, or items that are not optimal for the age of assessment, imply the need for a full examination reassessment.

INTERPRETATION

These findings support the validity of the Brief-HINE as a routine screening method and the possibility of its use in clinical practice.

Long-term outcomes of congenital cytomegalovirus infection in children early identified by extended hearing-targeted screening

OBJECTIVES

Congenital Cytomegalovirus (cCMV) has been associated with hearing, vision, and neurodevelopmental long-term sequelae. Despite the social burden associated with the disease, a universally accepted consensus on screening, diagnostic, therapeutic and follow-up approaches has not been reached. The present observational retrospective study aims at describing long-term sequelae and radiological abnormalities associated with cCMV in children early identified by extended hearing-targeted screening and evaluated by audiological follow-up in a single III Level Audiological Referral Center for at least 2 years.

METHODS

Audiological neonatal and follow-up data were available for all subjects. Data collection included clinical neonatal and virological assessment at birth. Ophthalmological, neurodevelopmental and neuroradiological follow-up abnormalities compatible with cCMV sequelae were collected by clinical reports. Spearman's rank correlation coefficient (rho-ρ) was used to evaluate possible correlations among the considered parameters.

RESULTS

61 newborns were identified by extended hearing-targeted cCMV screening and diagnosed mostly (83.6 %) by PCR viral DNA extraction in urine collected within the 15° day of life. Seventeen babies were born preterm, with a mean gestational age of 33.5 weeks. Sixteen patients (26.2 %) were admitted to an Intensive or sub-Intensive Neonatal Care Unit. At birth, 35 newborns were symptomatic (57.3 %), and 19 of them received antiviral treatment by valganciclovir or ganciclovir. Overall, 20 children (32.7 %) were diagnosed with sensorineural hearing loss (SNHL), among them 17 (85 %) were refer at the newborn hearing screening while 3 (15 %) were Pass. 5/20 children (25 %) presented isolated SNHL, while in 15/20 (75 %) children SNHL was associated to other long-term sequelae. In 5 patients (25 %) a progression of the hearing threshold was observed, with a mean age of progression of 26 months of age. Risk factors for progression were a worse final hearing threshold (Spearman's ρ = 0.434; p = 0.0001) and a worse hearing threshold at birth (Spearman's ρ = 0.298; p = 0.020). Thirteen children were fitted with hearing aids, 8 of whom subsequently underwent cochlear implantation. Concerning long term impairments, 10/61 children (17 %) presented a variety of ophthalmological sequelae, while 16/40 cCMV patients (40 %) were diagnosed with neurodevelopmental abnormalities. Language delays were significantly associated with a worse hearing threshold (ρ = 0.582; p = 0.0001) and with other neurocognitive abnormalities (ρ = 0.677, p = 0.0001). 30 children underwent radiological brain evaluation by Magnetic Resonance Imaging, and 63.3 % of them presented abnormalities compatible with cCMV. Mean viral load at birth did not show significant associations with long-term sequelae.

CONCLUSIONS

The study highlights the diverse and significant long-term sequelae of cCMV infection detected through early screening. With a significant proportion of cCMV children developing sensorineural hearing loss, ophthalmological and neurodevelopmental issues, the results emphasize the importance of continuous, multidisciplinary follow-up. Early identification and tailored interventions are crucial for improving the long-term health and quality of life of children affected by cCMV.

Intelligence Assessment of Children & Youth Benefiting from Psychological-Educational Support System in Poland

This article presents a unique dataset comprising 419,135 intelligence assessment results. The study utilised the Polish adaptation of the Stanford-Binet Intelligence Scale 5 during individual diagnostic sessions conducted under natural conditions. The research included children aged 3;0-18;11 of both genders who had been referred to support institutions (psychological-educational counselling centres, post-hospital clinics, hospital departments) by preschools or schools, or voluntarily requested by parents with their consent. The data collection spanned the entire country of Poland from 2018 to 2023. In addition to comprehensive intelligence assessment results, the dataset contains valuable demographic information, enabling in-depth analyses. The dataset's uniqueness lies in its impressive sample size, encompassing over four hundred thousand observations as well as the utilisation of time-consuming and thorough intelligence assessment procedures in settings that mimic the real world. Moreover, the context of the study is noteworthy, as the participants are individuals benefiting from the publicly - available Polish psychological support system.

Associations between the aetiology of preterm birth and mortality and neurodevelopment up to 11 years

AIM

To investigate how the aetiology of very preterm birth/very low birth weight is associated with mortality and later neurodevelopmental outcomes.

METHODS

Very preterm/very low-birth weight singletons were categorised based on the aetiology of preterm birth: spontaneous preterm birth (n = 47, 28.1%), preterm premature rupture of membranes (n = 56, 33.5%) or placental vascular pathology (n = 64, 38.3%). Mortality, cerebral palsy, severe cognitive impairment by 11 years of age (<2SD) and mean full-scale intelligence quotient at 11 years were studied in association with birth aetiology.

RESULTS

There was no difference in mortality or rate of cerebral palsy according to birth aetiologies. The rate of severe cognitive impairment was lower (4.9% vs. 15.3%) in the preterm premature rupture of the membrane group in comparison to the placental vascular pathology group (OR 0.2, 95% CI 0.03-0.9, adjusted for gestational age). At 11 years, there was no statistically significant difference in the mean full-scale intelligence quotient.

CONCLUSION

Placental vascular pathology, as the aetiology of very preterm birth/very low birth weight, is associated with a higher rate of severe cognitive impairments in comparison to preterm premature rupture of membranes, although there was no difference in the mean full-scale intelligence quotient at 11 years. The aetiology of very preterm birth/very low birth weight was not associated with mortality or the rate of cerebral palsy.

Identifying and Evaluating Young Children with Developmental Central Hypotonia: An Overview of Systematic Reviews and Tools

Children with developmental central hypotonia have reduced muscle tone secondary to non-progressive damage to the brain or brainstem. Children may have transient delays, mild or global functional impairments, and the lack of a clear understanding of this diagnosis makes evaluating appropriate interventions challenging. This overview aimed to systematically describe the best available evidence for tools to identify and evaluate children with developmental central hypotonia aged 2 months to 6 years. A systematic review of systematic reviews or syntheses was conducted with electronic searches in PubMed, Medline, CINAHL, Scopus, Cochrane Database of Systematic Reviews, Google Scholar, and PEDro and supplemented with hand-searching. Methodological quality and risk-of-bias were evaluated, and included reviews and tools were compared and contrasted. Three systematic reviews, an evidence-based clinical assessment algorithm, three measurement protocols, and two additional measurement tools were identified. For children aged 2 months to 2 years, the Hammersmith Infant Neurological Examination has the strongest measurement properties and contains a subset of items that may be useful for quantifying the severity of hypotonia. For children aged 2-6 years, a clinical algorithm and individual tools provide guidance. Further research is required to develop and validate all evaluative tools for children with developmental central hypotonia.

Consensus-Based Evaluation of Outcome Measures in Pediatric Stroke Care: A Toolkit

Following a pediatric stroke, outcome measures selected for monitoring functional recovery and development vary widely. We sought to develop a toolkit of outcome measures that are currently available to clinicians, possess strong psychometric properties, and are feasible for use within clinical settings. A multidisciplinary group of clinicians and scientists from the International Pediatric Stroke Organization comprehensively reviewed the quality of measures in multiple domains described in pediatric stroke populations including global performance, motor and cognitive function, language, quality of life, and behavior and adaptive functioning. The quality of each measure was evaluated using guidelines focused on responsiveness and sensitivity, reliability, validity, feasibility, and predictive utility. A total of 48 outcome measures were included and were rated by experts based on the available evidence within the literature supporting the strengths of their psychometric properties and practical use. Only three measures were found to be validated for use in pediatric stroke: the Pediatric Stroke Outcome Measure, the Pediatric Stroke Recurrence and Recovery Questionnaire, and the Pediatric Stroke Quality of Life Measure. However, multiple additional measures were deemed to have good psychometric properties and acceptable utility for assessing pediatric stroke outcomes. Strengths and weaknesses of commonly used measures including feasibility are highlighted to guide evidence-based and practicable outcome measure selection. Improving the coherence of outcome assessment will facilitate comparison of studies and enhance research and clinical care in children with stroke. Further work is urgently needed to close the gap and validate measures across all clinically significant domains in the pediatric stroke population.

The psychometric properties of Turkish version of the Modified Paediatric Mini Mental Scale

BACKGROUND

Children with neurological diseases suffer from neurocognitive problems due to both the disease and the treatment processes. Therefore, it is necessary that a battery can be used to determine and track the cognitive function of these children. The aim of this study is to establish the Turkish version of the Modified Paediatric Mini Mental Scale (MPMMS), ensure its cultural adaptation, and test the validity and reliability of the Turkish version of the MPMMS.

METHODS

Sixty-five children with the neurological condition were enrolled in this methodological study. The subjects' age, height, weight, and body mass index were recorded. The MPMMS and the social function subscale of the Paediatric Evaluation of Disability Inventory (PEDI) were used to assess the participants' cognitive function. The construct validity of the questionnaire was determined by the correlation between the MPMMS and the social function subscale of the PEDI. Cronbach's alpha was calculated to determine internal consistency. To determine test-retest reliability, 32 children were assessed 7-14 days after the initial assessment, and the intraclass correlation coefficient (ICC) was calculated.

RESULTS

The mean age of the participants was 9.26 ± 3.87 years. A very strong significant correlation was found between the MPMMS and social function subscale of the PEDI (r = 0.935, p = 0.000). The internal consistency of the MPMMS was excellent (Cronbach's alpha = 0.932).

CONCLUSIONS

The Turkish version of the MPMMS has excellent validity and reliability and can be used by professionals in various health care settings to determine children's cognitive abilities.

Accuracy of the Hammersmith infant neurological examination for the early detection of neurological changes in infants exposed to Zika virus: A case-cohort study

The Hammersmith infant neurological examination (HINE) is a highly predictive tool for the easy and low-cost detection of cerebral palsy. Between 2015 and 2016, the rapid spread of the Zika virus (ZIKV) in Brazil was responsible for an increase in microcephaly cases. This study aimed to verify the accuracy of the HINE for the early detection of neurological problems in Brazilian babies exposed to ZIKV.This was a cross sectional case-control study of children exposed to ZIKV. This study was part of the Jundiaí ZIKV Cohort. Of a total sample of 782 children, 98 were evaluated (26 in the exposed group and 63 in the control group). We included late preterm infants and term infants who were exposed to the ZIKV and were participants in the ZIKV Cohort study. Student's t-test and stepwise multivariate logistic regression were used to compare groups.Of the 26 items evaluated in the five scored categories of the HINE (cranial nerve function, posture, movements, tone, reflexes, and reactions), only the difference in ankle dorsiflexion between the exposed and the control groups was statistically significant. However, some items showed a significant trend in relation to the control group.Our results demonstrated the importance of early neurological assessment of infants exposed to ZIKV, even in those without a microcephaly diagnosis.

Intelligent wearable allows out-of-the-lab tracking of developing motor abilities in infants

Background

Early neurodevelopmental care needs better, effective and objective solutions for assessing infants' motor abilities. Novel wearable technology opens possibilities for characterizing spontaneous movement behavior. This work seeks to construct and validate a generalizable, scalable, and effective method to measure infants' spontaneous motor abilities across all motor milestones from lying supine to fluent walking.

Methods

A multi-sensor infant wearable was constructed, and 59 infants (age 5-19 months) were recorded during their spontaneous play. A novel gross motor description scheme was used for human visual classification of postures and movements at a second-level time resolution. A deep learning -based classifier was then trained to mimic human annotations, and aggregated recording-level outputs were used to provide posture- and movement-specific developmental trajectories, which enabled more holistic assessments of motor maturity.

Results

Recordings were technically successful in all infants, and the algorithmic analysis showed human-equivalent-level accuracy in quantifying the observed postures and movements. The aggregated recordings were used to train an algorithm for predicting a novel neurodevelopmental measure, Baba Infant Motor Score (BIMS). This index estimates maturity of infants' motor abilities, and it correlates very strongly (Pearson's r = 0.89, p < 1e-20) to the chronological age of the infant.

Conclusions

The results show that out-of-hospital assessment of infants' motor ability is possible using a multi-sensor wearable. The algorithmic analysis provides metrics of motility that are transparent, objective, intuitively interpretable, and they link strongly to infants' age. Such a solution could be automated and scaled to a global extent, holding promise for functional benchmarking in individualized patient care or early intervention trials.

Motor Performance in Association with Perceived Loneliness and Social Competence in 11-Year-Old Children Born Very Preterm

Background: Very preterm birth may affect motor performance and social competence up to adulthood. Our objective was to describe perceived loneliness and social competence in children born very preterm in relation to motor impairment. Methods: 165 children born very preterm (birth weight ≤ 1500 g and/or gestational age < 32 weeks) were assessed at 11 years of age. Cerebral palsy (CP) was diagnosed by 2 years of age. At 11 years of age, motor outcome was assessed using the Movement Assessment Battery for Children—Second edition (Movement ABC-2). Loneliness was evaluated by using the Peer Network and Dyadic Loneliness scale and social competence by using the Multisource Assessment of Children’s Social Competence Scale. Results: In total, 6 (4%) children had CP, 18 (11%) had Developmental Coordination Disorder (DCD) (Movement ABC-2 ≤ 5th percentiles), and 141 (85%) had typical motor development. There was no correlation between percentiles for total scores of the Movement ABC-2 and perceived loneliness or social competence when the children with motor impairment (CP or DCD) were excluded. Children with DCD reported less perceived loneliness, but more problems with social competence compared to children with CP. Conclusions: It is important to recognize children born very preterm with DCD to provide interventions and support services to prevent social exclusion.

Reference Material for Hammersmith Infant Neurologic Examination Scores Based on Healthy, Term Infants Age 3-7 Months

OBJECTIVE

To provide a valid, continuous reference interval, including a 10th percentile cut-off, for Hammersmith Infant Neurological Examination (HINE) scores based on 3- to 7-month-old term infants with weight appropriate for gestational age.

STUDY DESIGN

In a prospective study, we examined 168 Norwegian infants at one timepoint with HINE at 3-7 months of age. In 134 of these infants Ages and Stages Questionnaire was completed by their parents at 2 years of age to ensure typical motor development. We calculated a reference interval for HINE scores with the 10th percentile as cut-off for age-dependent optimal scores.

RESULTS

The best fitting mean model for HINE total score was 78.1358 + 9659.231∗1/age in weeks²-5104.174∗natural logarithm(age in weeks)/age in weeks², which explained 49.8% of the variance. The HINE total score 10th percentile cut-off corresponded to 52.1 points at age 12 weeks, 55.6 points at 16 weeks, 59.0 points at 20 weeks, 61.8 points at 24 weeks, and 63.8 points at 28 weeks. We found an excellent intraclass correlation coefficient of 0.953 (0.931-0.968) between 2 examiners. The infants had a typical motor development at 2 years follow-up.

CONCLUSION

We have presented a valid, continuous reference interval and a 10th percentile cut-off for HINE scores for infants age 3-7 months.

Early neuromotor performance and later cognition in children born preterm

This commentary is on the original articles by Romeo et al. and Uusitalo et al. on pages 939–946 and 947–953 of this issue.