How to use: the neonatal neurological examination

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

Background

The 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. 

Aim

This 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.

Methods

An 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.

Results

One 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.

Conclusions

There 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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03616-4.

"The Value of Clinical Examination in Preterm Newborns after Neonatal Sepsis: A Cross-sectional Observational Study."

BACKGROUND

Neonatal sepsis is an important risk factor for lesions in the brain of preterm newborns (PTNB) and the most effective strategies to minimize its deleterious effects are early detection and intervention.

AIM

To investigate the presence of neurological abnormalities in PTNBs after neonatal sepsis.

METHODS

This was a prospective cross-sectional study with 100 PTNBs selected at random, 50 of the study group (sepsis) and 50 of the control group (non-sepsis). The neurological evaluation protocol adopted was the Hammersmith Neonatal Neurological Examination (HNNE).

RESULTS

The PTNBs of the sepsis group had total HNNE scores lower than expected for normality in 86% of the cases, and the non-sepsis group in 26% (p < .001). Higher prevalence levels of altered scores in tone category (p < .001), tone patterns (p = .026), reflexes (p = .002), movements (p < .001), abnormal signs (p < .001) and behavior (p < .001).

CONCLUSION

The neurological dysfunctions after neonatal sepsis could be identified by clinical neonatal neurological evaluation.

Relationships between early postnatal cranial ultrasonography linear measures and neurobehaviour at term-equivalent age in infants born <30 weeks' gestational age

BACKGROUND

The relationship between early postnatal brain development and neurobehaviour at term-equivalent age (TEA) remains uncertain.

AIM

We aimed to explore relationships between early postnatal cranial ultrasonography (cUS) linear measures of brain size and brain growth with neurobehaviour at TEA in infants born <30 weeks' gestational age (GA).

STUDY DESIGN

Prospective observational cohort study.

SUBJECTS

137 infants born <30 weeks' GA without major brain injury on neonatal cUS.

OUTCOME MEASURES

Neurobehaviour at TEA assessed using the General Movements Assessment (GMA) and Hammersmith Neonatal Neurological Examination (HNNE).

RESULTS

The GMA was administered in 115/137 (84%) infants; 80 (70%) presented with abnormal general movements (GMs) (79 poor repertoire, 1 cramped synchronised). The HNNE was assessed in 106/137 (77%) infants; 52 (49%) had a suboptimal total score. With respect to brain size, larger measures of the corpus callosum length (CCL) and right anterior horn width (AHW) at 1-month were related to lower risk of abnormal GMs, and larger measures of the biparietal diameter at 1-week and 2-months were related to lower risk of a suboptimal HNNE. As for brain growth, increases of the CCL and transcerebellar diameter between birth and 1-month, and left and right AHWs between 1- and 2-months, were related to lower risk of abnormal GMs.

CONCLUSION

Early postnatal brain size and brain growth were related to neurobehaviour at TEA in infants born <30 weeks' GA. This study provides preliminary evidence for the prognostic utility of early postnatal cUS linear measures as potential markers of neurodevelopment in later childhood.

Newborn Neurobehavior Is Related to Later Neurodevelopment and Social Cognition Skills in Extremely Preterm-Born Children: A Prospective Longitudinal Cohort Study

Objective: The aim of this study was to evaluate the ability of the neonatal neurobehavioral characteristics to act as an indicator for later neurodevelopment and neurocognitive performance.

Methods: Sixty-six infants born extremely preterm (<28 gestational weeks) were followed until 6.5 years. Neurobehavior at term age was assessed by the behavior subscale of the Hammersmith Neonatal Neurological Examination (HNNE) using dichotomic rating, optimal, and non-optimal. The Griffiths Mental Developmental Scales (GMDS) at 2 years, and the Wechsler Intelligence Scales at 6.5 years, and a Neuropsychological Assessment at 6.5 years were used to assess neurodevelopment and neurocognitive performance including social cognition skills.

Results: An optimal auditory orientation at term age was associated with better developmental quotients (DQ) in Personal–Social, and Hearing–Language GMDS subscale at 2 years (p < 0.05). An optimal visual alertness was associated with better Total (p < 0.01), Locomotor (p < 0.001), and Eye–Hand Coordination (p < 0.01) DQs at 2 years, and with sensorimotor function (p < 0.001) and social perception (p < 0.01) tests at 6.5 years.

Conclusion: The neurobehavioral characteristics of newborns might serve as a precursor of social cognition skills and the HNNE behavior subscale offers a tool to identify infants at risk for later deficits in neurodevelopment and social cognition.

Neurobehaviour of very preterm infants at term equivalent age is related to early childhood outcomes

AIM

To describe neurodevelopmental outcomes during early childhood among infants born very preterm and define the relationships between neurobehaviour of very preterm infants and neurodevelopmental outcomes at 4 years.

METHODS

Forty-eight infants born ≤32 weeks gestation had neurobehaviour assessed at term equivalent age using the NICU Network Neurobehavioral Scale (NNNS). Outcomes at 4 years were assessed with the Ages and Stages Questionnaire (ASQ-3), the Sensory Profile-Short Form (SF) and the Behavior Rating Inventory of Executive Function-Preschool version (BRIEF-P).

RESULTS

At 4 years, 23 (48%) children had at least one below average score on the ASQ-3, 15 (31%) had a below average total score on the Sensory Profile-SF, and 3 (6%) had an abnormal total score on the BRIEF-P. Children with lower fine motor scores at 4 years had poorer orientation (P = 0.03) and self-regulation (P =0.03), hypertonia (P = 0.01), and more sub-optimal reflexes (P = 0.02) as neonates. Children with lower gross motor scores at 4 years of age had more sub-optimal reflexes (P = 0.03) and lethargy (P = 0.046) as neonates. Children with tactile sensitivity at 4 years of age had poorer orientation (P = 0.01) and tolerance of handling (P = 0.03) as neonates. Children with decreased responsiveness at 4 years of age had low arousal (P = 0.02) as neonates, and those with poor auditory filtering at age 4 years had hypotonia (P = 0.03) as neonates.

CONCLUSION

Early neurobehaviour is related to neurodevelopmental outcome in early childhood.

Neurodevelopmental Outcome in Extremely Low Birth Weight Infants at 2-3 Years of Age

Background and objectives: The aims of this study were to examine the relationship between neurological outcomes at 3- and 6-months corrected age with the neurodevelopmental outcome at 3 years of age; to identify the perinatal/neonatal risk factors for poor neurodevelopmental outcomes at 3 years of age. Materials and methods: In our single-centre longitudinal cohort study, of the 73 consecutive infants admitted to our Neonatal Intensive Care Unit (NICU), 49 infants (80%) received both Hammersmith Infant Neurological Examination (HINE) at 3- and 6-months corrected age and Bayley-III neurodevelopmental assessment at 2-3 years chronological age. At 3 months follow up, 8.2% had suboptimal scores (below 10th percentile) on the HINE. At 6 months follow up, 4.1% had suboptimal scores (below 10th percentile) on the HINE. The means(±SD) for Bayley-III cognitive, language, and motor subscales were (96.3 ± 9.8), (99.9 ± 11.9), (93.2 ± 9.9). Results: At 3 months corrected age, higher total HINE scores and subscores for function of cranial nerves, posture, tone, were associated with better cognitive scores while poorer scores for function of cranial nerves, posture, movements, tone, and total HINE score were associated with lower motor scores. Infants with a HINE subscore of function of cranial nerves in the suboptimal range have three times higher odds of having a motor delay. Infants with a HINE subscore of function of cranial nerves in the suboptimal range have more than two times higher odds of having a language delay. At 6 months corrected age, poorer scores for function of cranial nerves, movements, tone, reflexes, and total HINE score were associated with worse Bayley-III motor scores whilst infants who have a total HINE score and a subscore of reflexes in the suboptimal range have four and seven times, respectively, higher odds of having a motor delay. Conclusions: Early identification of infants at risk for adverse long-term outcomes is essential in introducing early intervention therapies for optimizing neurodevelopmental outcomes.

Infants born to women with substance use: Exploring early neurobehavior with the Dubowitz neurological examination

BACKGROUND

There is a special concern regarding substance using pregnant women due to the possible adverse effects on the infant. While the immediate effects of prenatal substance exposure are well known, the long-term data on the infants' neurodevelopment is inconclusive.

AIMS

The purpose of this study was to assess early neurobehavior of infants of mothers with substance use using the Dubowitz examination and to follow their neuromotor development until one year of age.

STUDY DESIGN AND SUBJECTS

Ninety-five pregnant women with a recent history of substance use were recruited and followed up at the maternity outpatient clinic. Follow-up data was collected from hospital records and maternal interviews. The Dubowitz neurological examination was performed to the 54 clinically healthy term infants. The results were converted into optimality scores and compared to normative values from clinically healthy term infants derived from a separate normative population. The infant's neuromotor development was followed up to one year of age.

RESULTS

Only 7% of the infants born to women with recent or current substance use reached optimal scores (<30.5) in the Dubowitz neurological examination compared to 95% reported in normative population. Sixty-three percent of the newborns needed follow-up based on physiotherapeutic assessment of neurobehavior. By 12 months of age, the neuromotor status of 88% (n = 30) of these infants was found normal.

CONCLUSIONS

A high percentage of infants of mothers who were referred prenatally to hospital due to substance use showed suboptimal neurological findings during their first days of life.

Interrater reliability of the Saint-Anne Dargassies Scale in assessing the neurological patterns of healthy preterm newborns

Abstract Objectives: to assess the interrater reliability of the Saint-Anne Dargassies Scale in assessing neurological patterns of healthy preterm newborns. Methods: twenty preterm newborns met the inclusion criteria for participation in this prospective study. The neurologic examination was performed using the Saint-Anne Dargassies Scale, showing normal serial cranial ultrasound examination. In order to test the reliability, the study was structured as follows: group I (rater 1/physiotherapist; rater 2/neonatologist); group II (rater 3/physiotherapist; rater 4/child neurologist) and the gold standard (expert and professor in pediatric neurology). Results: high interrater agreement was observed between groups I - II compared with the gold standard in assessing postural pattern (p<0.01). Regarding the assessment ofprimitive reflexes, greater agreement was observed in the evaluation of palmar grasp reflex and Moro reflex (p< 0.01) for group I compared with the gold standard. An analysis of tone demonstrated heterogeneous agreement, without compromising the reliability of the scale. The probability of equality between measurements of head circumference in the two groups, compared with the gold standard, was observed. Conclusions: the Saint-Anne Dargassies Scale demonstrated high reliability and homogeneity with significant power of reproducibility and may be capable to identify preterm newborns suspected of having neurological deficits.

Survey of neurodevelopmental allied health teams in Australian and New Zealand neonatal nurseries: Staff profile and standardised neurobehavioural/neurological assessment

AIMS

The primary aim of this study was to establish how many neonatal nurseries in Australia and New Zealand had a neurodevelopmental allied health team, to ascertain the disciplines involved, their qualifications and experience. The secondary aim was to evaluate which standardised neurobehavioural/neurological assessments were currently being implemented, and the existing practice in relation to their use.

METHODS

A descriptive cross-sectional survey, sampling 179 eligible public and private hospital neonatal intensive care units (NICUs) and special care nurseries (SCNs) throughout Australia and New Zealand, was purpose-developed and administered electronically from the 5th April to 23rd July 2013.

RESULTS

A total of 117 units (65%) overall, and 26 of 26 (100%) NICUs responded to the survey. NICUs had more neurodevelopmental allied health staff than SCNs, with physiotherapists and speech pathologists the most common disciplines. Physiotherapists were more likely to administer standardised neurobehavioural/neurological assessments in NICUs, while medical staff were more likely to do so in SCNs. A wide variety of standardised neurobehavioural/neurological assessment tools were used, with Prechtl's General Movements Assessment the most common in the NICUs (50%) and the Hammersmith Neonatal Neurological Examination the most common in the special care units (25%). Standardised neurobehavioural assessments were not administered in 22% of SCNs.

CONCLUSIONS

Although neurodevelopmental allied health teams and standardised neurobehavioural/neurological assessments are valued by many, there was little consistency across Australian and New Zealand neonatal nurseries.

Neurobehaviour at term-equivalent age and neurodevelopmental outcomes at 2 years in infants born moderate-to-late preterm

AIM

To examine the association between newborn neurobehavioural assessments and neurodevelopmental outcomes at 2 years in infants born moderate-to-late preterm (MLPT).

METHOD

Two-hundred and one infants born MLPT (born 32-36⁺⁶ wks' gestation) were assessed with the Hammersmith Neonatal Neurological Examination (HNNE) and NICU Network Neurobehavioral Scale (NNNS), with suboptimal performance defined as scores lower than the 10th centile. Development was assessed at 2 years corrected age with the Bayley Scales of Infant and Toddler Development 3rd Edition, with delay defined as scores less than 1 standard deviation (SD) below the mean. The relationships between neurobehaviour at term and Bayley-III cognitive, language, and motor scales at 2 years were examined using linear regression.

RESULTS

Increased odds for cognitive delay were associated with suboptimal HNNE total scores (odds ratio [OR] 2.66; 95% confidence interval [CI] 1.14-6.23, p=0.020) and suboptimal NNNS excitability (OR 3.01; 95% CI 1.33-6.82, p=0.008) and lethargy (OR 4.05; 95% CI 1.75-9.31, p=0.001) scores. Suboptimal lethargy scores on the NNNS were associated with increased odds of language (OR 5.64; 95% CI 1.33-23.85, p=0.019) and motor delay (OR: 6.86; 95% CI 1.64-28.71, p=0.08).

INTERPRETATION

Suboptimal performance on specific aspects of newborn neurobehavioural assessments is associated with neurodevelopmental delay at 2 years in children born MLPT.

Reliability of Neurobehavioral Assessments from Birth to Term Equivalent Age in Preterm and Term Born Infants

Neurobehavioral assessments provide insight into the functional integrity of the developing brain and help guide early intervention for preterm (<37 weeks' gestation) infants. In the context of shorter hospital stays, clinicians often need to assess preterm infants prior to term equivalent age. Few neurobehavioral assessments used in the preterm period have established interrater reliability.

AIM

To evaluate the interrater reliability of the Hammersmith Neonatal Neurological Examination (HNNE) and the NICU Network Neurobehavioral Scale (NNNS), when used both preterm and at term (>36 weeks).

METHODS

Thirty-five preterm infants and 11 term controls were recruited. Five assessors double-scored the HNNE and NNNS administered either preterm or at term. A one-way random effects, absolute, single-measures interclass correlation coefficient (ICC) was calculated to determine interrater reliability.

RESULTS

Interrater reliability for the HNNE was excellent (ICC > 0.74) for optimality scores, and good (ICC 0.60-0.74) to excellent for subtotal scores, except for 'Tone Patterns' (ICC 0.54). On the NNNS, interrater reliability was predominantly excellent for all items. Interrater agreement was generally excellent at both time points.

CONCLUSIONS

Overall, the HNNE and NNNS neurobehavioral assessments demonstrated mostly excellent interrater reliability when used prior to term and at term.

Neurobehaviour and neurological development in the first month after birth for infants born between 32-42 weeks' gestation

AIMS

The objective of this study was to generate reference values for infants born moderate preterm (MPT), late preterm (LPT) and full term (FT) for three newborn neurobehavioural/neurological examinations in the first weeks after birth.

STUDY DESIGN

Prospective cohort study to examine the expected range of values for MPT (born 32(+0) to 33(+6)), LPT (34(+0) to 36(+6)) and FT (born 37 to 42weeks' gestation) infants' performance on the Hammersmith Neonatal Neurological Examination (HNNE), the Neonatal Intensive Care Unit Network Neurobehavioural Scale (NNNS) and Prechtl's General Movements Assessment (GMA) in the first weeks after birth. Further, to determine the effects of sex, gestational age at birth, and postmenstrual age at assessment on the 3 different assessments within the gestational age groups.

SUBJECTS

80 MPT, 129 LPT and 201 FT infants were recruited shortly after birth from a tertiary hospital.

RESULTS

The means, standard deviations and 5th, 10th, 25th, 50th, 75th, 90th and 95th centiles are presented for the HNNE and NNNS for each of the three gestational age groups. Overall, FT infants performed better than MPT and LPT infants. The rate of normal GMA within the first few weeks after birth was 25% for MPT, 32% for LPT, and 90% for FT infants. The effects of sex, gestational age at birth, and postmenstrual age at assessment varied between test and gestational age groups.

CONCLUSIONS

This study provides normative data for the HNNE, NNNS, and GMA administered within the first weeks after birth in a sample of MPT, LPT and healthy FT infants.

General Movements Assessment of infants in the neonatal intensive care unit following surgery

AIM

There is an identified gap in the literature regarding the use of the General Movements (GMs) Assessment to identify risk in infants post-surgery. This paper aims to examine the GMs for infants who have undergone surgery to identify common risk profiles in the writhing age.

METHODS

This was a prospective cohort study of 170 infants (99 male, 58%) admitted to a neonatal surgical unit from 2012 until June 2014. Infants were born at a mean age of 38 weeks (standard deviation (SD) 2.3), and writhing GMs were conducted at term (40 weeks, SD 2.6) following either cardiac (n = 84, 49%) or non-cardiac surgery (n = 86, 51%). GMs were categorised by three trained assessors.

RESULTS

Normal writhing was recorded in 64 infants (38%). The most common profile was poor repertoire (n = 80, 47%), with 14 (8%) cramped synchronised. There was no difference in scores between infants who had undergone cardiac versus non-cardiac surgery (P = 0.45).

CONCLUSION

This is the first report on the GMs assessment in an infant surgical population. Infants who have undergone surgery most commonly display poor repertoire writhing movements. Research is needed to determine the ability of the GMs to predict neurodevelopmental outcomes in this population.