Spontaneous motility in preterm, small-for-gestational age infants. II. Qualitative aspects

General movements assessment: A bibliometric analysis

This bibliometric analysis provides an in-depth exploration of the scholarly landscape in the field of Prechtl General Movement Assessment (GMA) research, spanning the period from 1961 to 2023. It offers valuable insights into the evolutionary trajectory and global impact of GMA. The study employs a longitudinal approach, meticulously tracking trends in scholarly output, international collaborations, and authorship patterns. Notably, our findings reveal a significant increase in GMA-related publications, highlighting the growing prominence of this field. The dominance of Australia and Austria in scholarly contributions underscores their pivotal roles. International collaborations are prominent, with active participation from European nations and the Americas. However, it is essential to acknowledge certain limitations, including potential data source biases and a reliance on English-language publications. This analysis serves as a valuable resource for stakeholders in the field, emphasizing the need for ongoing evaluation and collaborative efforts to enhance GMA applications and further our understanding of its clinical implications.

Spontaneous movements as prognostic tool of neurodevelopmental outcomes in preterm infants: a narrative review

An estimated 15 million infants are born prematurely each year. Although the survival rate of preterm infants has increased with advances in perinatal and neonatal care, many still experience various complications. Since improving the neurodevelopmental outcomes of preterm births is a crucial topic, accurate evaluations should be performed to detect infants at high risk of cerebral palsy. General movements are spontaneous movements involving the whole body as the expression of neural activity and can be an excellent biomarker of neural dysfunction caused by brain impairment in preterm infants. The predictive value of general movements with respect to cerebral palsy increases with continuous observation. Automated approaches to examining general movements based on machine learning can help overcome the limited utilization of assessment tools owing to their qualitative or semiquantitative nature and high dependence on assessor skills and experience. This review covers each of these topics by summarizing normal and abnormal general movements as well as recent advances in automatic approaches based on infantile spontaneous movements.

The Early Motor Repertoire in Preterm Infancy and Cognition in Young Adulthood: Preliminary Findings

OBJECTIVE

Preterm birth poses a risk to cognition during childhood. The resulting cognitive problems may persist into young adulthood. The early motor repertoire in infancy is predictive of neurocognitive development in childhood. Our present aim was to investigate whether it also predicts neurocognitive status in young adulthood.

METHOD

We conducted an explorative observational follow-up study in 37 young adults born at a gestational age of less than 35 weeks and/or with a birth weight below 1200 g. Between 1992 and 1997, these individuals were videotaped up until 3 months' corrected age to assess the quality of their early motor repertoire according to Prechtl. The assessment includes general movements, fidgety movements (FMs), and a motor optimality score (MOS). In young adulthood, the following cognitive domains were assessed: memory, speed of information processing, language, attention, and executive function.

RESULTS

Participants in whom FMs were absent in infancy obtained lower scores on memory, speed of information processing, and attention than those with normal FMs. Participants with aberrant FMs, that is, absent or abnormal, obtained poorer scores on memory, speed of information processing speed, attention, and executive function compared to peers who had normal FMs. A higher MOS was associated with better executive function.

CONCLUSIONS

The quality of the early motor repertoire is associated with performance in various cognitive domains in young adulthood. This knowledge may be applied to enable the timely recognition of preterm-born individuals at risk of cognitive dysfunctions.

A markerless pipeline to analyze spontaneous movements of preterm infants

BACKGROUND AND OBJECTIVE

The analysis of spontaneous movements of preterm infants is important because anomalous motion patterns can be a sign of neurological disorders caused by lesions in the developing brain. A diagnosis in the first weeks of child's life is crucial to plan timely and appropriate rehabilitative interventions. An accurate visual assessment of infants' spontaneous movements requires highly specialized personnel, not always available, and it is operator dependent. Motion capture systems, markers and wearable sensors are commonly used for human motion analysis, but they can be cumbersome, limiting their use in the study of infants' movements.

METHODS

In this paper we propose a computer-aided pipeline to characterize and classify infants' motion from 2D video recordings. The final goal is detecting anomalous motion patterns. The implemented pipeline is based on computer vision and machine learning algorithms and includes a specific step to increase the interpretability of the results. Specifically, it can be summarized by the following steps: (i) body keypoints detection: we rely on a deep learning-based semantic features detector to localize the positions of meaningful landmark points on infants' bodies; (ii) parameters extraction: starting from the trajectories of the detected landmark points, we extract quantitative parameters describing infants motion patterns; (iii) classification: we implement different classifiers (Support Vector Machines, Random Forest, fully connected Neural Network, Long Short Term Memory) that, starting from the motion parameters, classify between normal or abnormal motion patterns.

RESULTS

We tested the proposed pipeline on a dataset, recorded at the 40th gestational week, of 142 infants, 59 with evidence of neuromotor disorders according to a medical assessment carried out a posteriori. Our procedure successfully discriminates normal and anomalous motion patterns with a maximum accuracy of 85.7%.

CONCLUSIONS

In conclusion, our pipeline has the potential to be adopted as a tool to support the early detection of abnormal motion patterns in preterm infants.

The trajectory of general movements from birth until 12 - 14 weeks corrected age in very low birthweight and extremely low-birthweight infants born preterm

Background. General movement assessment (GMA) is an assessment tool with high predictive validity for neurodevelopmental outcomes in preterm infants. Information available describing the trajectory of general movements (GMs) in high-risk preterm-born infants and the use thereof in low- and middle-income countries is limited. Objective. To describe the trajectories of GMs from birth until 12 - 14 weeks’ corrected age, and determine the association of known perinatal risk factors on GM trajectories in very low-birthweight and extremely low-birthweight preterm infants. Methods. This was a longitudinal, prospective cohort study with 119 preterm infants born at <33 weeks’ gestation and with a birthweight <1 500 g. GMs were recorded at four key age periods: 1 - 2 weeks after birth to 33 weeks post menstrual age (PMA); 34 - 37 weeks PMA; term equivalent age (TEA); and 12 - 14 weeks corrected age. Detailed perinatal data were collected. Results. A total of 300 GMAs were conducted, 157 during the preterm age, 55 during TEA and 88 at 12 - 14 weeks corrected age. At <33 weeks PMA, 96% of GMs were abnormal and 4% normal. At 34 - 37 weeks PMA, 89% of GMs were abnormal and 11% normal. All GMs recorded at term equivalent age were abnormal. At 12 - 14 weeks corrected age, 7% of GMs were abnormal and 93% normal. Conclusion. GMs were predominantly abnormal prior to term with a significant decrease in abnormality at 12 - 14 weeks corrected age. Lower birthweight and lower PMA were associated with increased odds for abnormal GMs. In a resource-constrained environment, observing GMs at 12 - 14 weeks corrected age (during the fidgety period) is a time- and cost-effective method to determine the risk for adverse neurodevelopment.

Recording activity in proximal muscle networks with surface EMG in assessing infant motor development

OBJECTIVE

To develop methods for recording and analysing infant's proximal muscle activations.

METHODS

Surface electromyography (sEMG) of truncal muscles was recorded in three months old infants (N = 18) during spontaneous movement and controlled postural changes. The infants were also divided into two groups according to motor performance. We developed an efficient method for removing dynamic cardiac artefacts to allow i) accurate estimation of individual muscle activations, as well as ii) quantitative characterization of muscle networks.

RESULTS

The automated removal of cardiac artefacts allowed quantitation of truncal muscle activity, which showed predictable effects during postural changes, and there were differences between high and low performing infants.The muscle networks showed consistent change in network density during spontaneous movements between supine and prone position. Moreover, activity correlations in individual pairs of back muscles linked to infant́s motor performance.

CONCLUSIONS

The hereby developed sEMG analysis methodology is feasible and may disclose differences between high and low performing infants. Analysis of the muscle networks may provide novel insight to central control of motility.

SIGNIFICANCE

Quantitative analysis of infant's muscle activity and muscle networks holds promise for an objective neurodevelopmental assessment of motor system.

Novel AI driven approach to classify infant motor functions

The past decade has evinced a boom of computer-based approaches to aid movement assessment in early infancy. Increasing interests have been dedicated to develop AI driven approaches to complement the classic Prechtl general movements assessment (GMA). This study proposes a novel machine learning algorithm to detect an age-specific movement pattern, the fidgety movements (FMs), in a prospectively collected sample of typically developing infants. Participants were recorded using a passive, single camera RGB video stream. The dataset of 2800 five-second snippets was annotated by two well-trained and experienced GMA assessors, with excellent inter- and intra-rater reliabilities. Using OpenPose, the infant full pose was recovered from the video stream in the form of a 25-points skeleton. This skeleton was used as input vector for a shallow multilayer neural network (SMNN). An ablation study was performed to justify the network's architecture and hyperparameters. We show for the first time that the SMNN is sufficient to discriminate fidgety from non-fidgety movements in a sample of age-specific typical movements with a classification accuracy of 88%. The computer-based solutions will complement original GMA to consistently perform accurate and efficient screening and diagnosis that may become universally accessible in daily clinical practice in the future.

PREDICTIVE VALUE OF THE GENERAL MOVEMENTS ASSESSMENT IN PRETERM INFANTS: A META-ANALYSIS

Objective:

To discuss the predictive value of the General Movements Assessment for the diagnosis of neurodevelopment disorders in preterm newborns.

Data source:

We conducted a systematic literature review using the following databases: Scientific Electronic Library Online (SciELO), National Library of Medicine, National Institutes of Health (PubMed), and Excerpta Medica Database (EMBASE). The articles were filtered by language, year of publication, population of interest, use of Prechtl’s Method on the Qualitative Assessment of General Movements, and presence of variables related to the predictive value. The Quality Assessment of Diagnostic Accuracy Studies 2 was used to assess the methodology of the included studies. Sensitivity, specificity, Diagnostic Odds Ratio, positive and negative likelihood ratio, and parameter of accuracy were calculated.

Data synthesis:

Six of 342 articles were included. The evaluation of Writhing Movements is a good indicator for recognizing cerebral palsy, as it has high values for the sensitivity and accuracy parameters. The evaluation of Fidgety Movements has the strongest predictive validity for cerebral palsy, as it has high values in all measures of diagnostic accuracy. The quality assessment shows high risk of bias for patient selection and flow and timing of the evaluation. Therefore, the scale has potential to detect individuals with neurodevelopment disorders. However, the studies presented limitations regarding the selection of subjects and the assessment of neurological outcomes.

Conclusions:

Despite the high predictive values of the tool to identify neurological disorders, research on the subject is required due to the heterogeneity of the current studies.

Prediction of long-term neurodevelopmental outcome in preterm infants using trajectories of general movement assessments

OBJECTIVE

To assess the predictive value of trajectories and individual assessment of quality of general movements (AQGM) for identification of neurodevelopmental impairment (NDI) at 18-24 months corrected age (CA) in infants <30 weeks gestational age and/or birth weight <1500 g.

METHODS

In this retrospective cohort study, AQGM at 6 weeks and 3 months CA were scored and categorized as normal (N) or abnormal (A). AQGM measures were compared with degree of NDI and Bayley Scales of Infant Development, Third Edition (BSID-III) composite motor and cognitive scores. 'Persistently abnormal' AQGM included both mildly abnormal (MA) and definitely abnormal (DA) assessments. A "modified AQGM" where MA assessments were considered normal variant/transient injury was used to conduct post-hoc analysis.

RESULTS

Across 244 cases, persistently abnormal AQGM trajectory predicted the level of NDI (OR 2.5, 95% CI 1.2, 5.1) compared to AQGM trajectory that normalized. However, using the "modified AQGM", persistently DA trajectories were associated with significantly lower BSID-III composite motor and cognitive scores (p < 0.001 and p = 0.039, respectively).

CONCLUSION

Categorizing MA assessments as transient injury increased the predictive value of AQGM trajectories and significantly predicted lower cognitive and motor scores at 18-24 months CA.

Neuroimaging perspectives on fetal motor behavior

We are entering a new era of understanding human development with the ability to perform studies at the earliest time points possible. There is a substantial body of evidence to support the concept that early motor behaviour originates from supraspinal motor centres, reflects neurological integrity, and that altered patterns of behaviour precede clinical manifestation of disease. Cine Magnetic Resonance Imaging (cineMRI) has established its value as a novel method to visualise motor behaviour in the human fetus, building on the wealth of knowledge gleaned from ultrasound based studies. This paper presents a state of the art review incorporating findings from human and preclinical models, the insights from which, we propose, can proceed a reconceptualisation of fetal motor behaviour using advanced imaging techniques. Foremost is the need to better understand the role of the intrauterine environment, and its inherent unique set of stimuli that activate sensorimotor pathways and shape early brain development. Finally, an improved model of early motor development, combined with multimodal imaging, will provide a novel source of in utero biomarkers predictive of neurodevelopmental disorders.

Challenges in the development and growth of small for gestational age newborns

Being born with low birth weight (less than 2.500 gr) is considered a public health problem, with an overall world rate of about 14%. Low birth weight may result from a premature birth (< 37 weeks of gestation), from several causes of intra-uterine growth restriction or from a combination of both. Areas covered: We described how, if weight and/or length at birth are not adequate for gestational age, the newborn is considered 'small for gestational age' and may present several growth, hormonal and developmental peculiarities, possibly due to the growth restriction developed during pregnancy. Expert commentary: We provide a description of the possible mid-term consequences of being born small for gestational age and how to follow and provide care for these babies from a multidisciplinary point of view.

Inter-observer agreement of the General Movements Assessment with infants following surgery

BACKGROUND

The General Movements Assessment (GMA) is a validated and reliable method of identifying infants at risk of adverse neurodevelopmental outcomes, however there is minimal data available on the use of the GMA with infants following surgery.

AIMS

The aim of this study was to investigate the inter-observer agreement for the GMA with this infant population.

STUDY DESIGN

Reliability and agreement study.

SUBJECTS

This was a prospective cohort study of 190 infants (male n=112) born at term (mean 38weeks, SD 2weeks).

OUTCOME MEASURES

A GMA was conducted in the Neonatal Intensive Care Unit (NICU) following either cardiac surgery (n=92), non-cardiac surgery (n=93) or both types of surgery (n=5), and then again at three months of age. All videos were independently assessed by three advanced trained clinicians. Agreement and reliability statistics were calculated between each pair.

RESULTS

We found moderate to substantial levels of agreement in the writhing period (66-77%, AC₁=0.53-0.69). For fidgety general movements, agreement was classified as almost perfect, ranging from 86 to 89% (AC₁=0.84-0.88).

CONCLUSIONS

The GMA has high levels of inter-observer agreement when used with infants who have undergone surgery in the neonatal period, making it a valid, complementary assessment tool. Research is now underway to determine the ability of the GMA to predict neurodevelopmental outcomes in this population.

Relationship between general movements in neonates who were growth restricted in utero and prenatal Doppler flow patterns

OBJECTIVE

To investigate whether Doppler pulsatility indices (PIs) of the fetal circulation in cases of fetal growth restriction (FGR) are associated with the general movements (GMs) of the neonate after birth.

METHODS

This was a prospective observational cohort study including pregnancies with FGR diagnosed between June 2012 and September 2014. A diagnosis of FGR was based on an abdominal circumference or estimated fetal weight < 10^th percentile (in conjuction with abnormal Doppler) or declining fetal growth of at least 30 percentiles with respect to previous size measurements. Doppler parameters of the umbilical artery (UA), fetal middle cerebral artery (MCA) and ductus venosus (DV) were measured maximally 1 week prior to delivery. Cerebroplacental ratio (CPR) was calculated as MCA-PI divided by UA-PI. We assessed the quality of neonatal GMs 7 days after birth, around the due date if cases were born preterm, and at 3 months post-term. We performed a detailed analysis of the motor repertoire by calculating a motor optimality score (MOS).

RESULTS

Forty-eight FGR cases were included with a median gestational age at delivery of 35 (range, 26-40) weeks. UA-PI, MCA-PI and CPR correlated strongly (ρ, -0.374 to 0.472; P < 0.01) with the MOS on day 7 after birth, but DV-PI did not. Doppler PI measurements did not correlate with MOS at 3 months post-term.

CONCLUSION

Fetal arterial Doppler measurements are associated with the quality of neonatal GMs 1 week after birth, but this association is no longer evident at 3 months post-term. Brain sparing in particular is associated strongly with GMs of an abnormal quality. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Aminophylline-associated irritable behaviour in preterm neonates

AIM

This study investigated the effect of aminophylline on behaviour and autonomic function in the preterm period.

METHOD

Subjects were preterm infants cared for in the Oita University hospital from August 2012 to October 2014. The group that was administered aminophylline (Am+) and the group that received no aminophylline (Am-) included 11 cases that exhibited a mean gestational age of 28weeks 5days and a mean birth weight of 1109g and 8 cases that exhibited a mean gestational age of 30weeks 5days and a mean birth weight of 1223g, respectively. Intravenous aminophylline was administered continuously at a dose of 4-6mg/kg/day followed by oral therapy when the infant suffered repetitive apnoea. Two-hour video recordings were obtained every 2weeks, and electrocardiograms were performed simultaneously. Onset-offset and tremulous movements in general movement (GM) optimality list were used as indices of behaviour. Autonomic functions were investigated via heart-rate and heart-rate variability measurements using frequency domain spectral analysis and the MemCalc method. We compared indices in 4 periods: 30-31, 32-33, 34-35 and 36-37weeks gestation.

RESULTS

The Am+ group exhibited significantly low optimality of tremulous movements at 32-33weeks gestation. The autonomic parameters did not differ significantly between the Am+ and Am- groups. There was no significant correlation between GMs optimality score and serum theophylline concentration.

CONCLUSION

Aminophylline administration was associated with transient irritable behaviour without autonomic changes in the preterm period.

The general movement optimality score: a detailed assessment of general movements during preterm and term age

AIM

To explore the appropriateness of applying a detailed assessment of general movements and characterize the relationship between global and detailed assessment.

METHOD

The analysis was based on 783 video recordings of 233 infants (154 males, 79 females) who had been videoed from 27 to 45 weeks postmenstrual age. Apart from assessing the global general movement categories (normal, poor repertoire, cramped-synchronized, or chaotic general movements), we scored the amplitude, speed, spatial range, proximal and distal rotations, onset and offset, tremulous and cramped components of the upper and lower extremities. Applying the optimality concept, the maximum general movement optimality score of 42 indicates the optimal performance.

RESULTS

General movement optimality scores (GMOS) differentiated between normal general movements (median 39 [25-75th centile 37-41]), poor repertoire general movements (median 25 [22-29]), and cramped-synchronized general movements (median 12 [10-14]; p<0.01). The optimality score for chaotic general movements (mainly occurring at late preterm age) was similar to those for cramped-synchronized general movements (median 14 [12-17]). Short-lasting tremulous movements occurred from very preterm age (<32wks) to post-term age across all general movement categories, including normal general movements. The detailed score at post-term age was slightly lower compared to the scores at preterm and term age for both normal (p=0.02) and poor repertoire general movements (p<0.01).

INTERPRETATION

Further research might demonstrate that the GMOS provides a solid base for the prediction of improvement versus deterioration within an individual general movement trajectory.

Trajectories of general movements from birth to term-equivalent age in infants born <30 weeks' gestation

BACKGROUND

General movements (GMs) is an assessment with good predictive validity for neurodevelopmental outcomes in preterm infants. However, there is limited information describing the early GMs of very preterm infants, particularly prior to term.

AIMS

To describe the early GMs trajectory of very preterm infants (born <30weeks' gestation) from birth to term-equivalent age, and to assess the influence of known perinatal risk factors on GMs.

STUDY DESIGN

Prospective cohort study.

SUBJECTS

149 very preterm infants born <30weeks' gestation.

OUTCOME MEASURES

GMs were recorded weekly from birth until 32weeks' postmenstrual age, and then fortnightly until 38weeks' postmenstrual age. GMs were also assessed at term-equivalent age. Detailed perinatal data were collected.

RESULTS

Of 669 GMs assessed, 551 were preterm and 118 were at term-equivalent age. Prior to term, 15% (n=82) of GMs were normal and 85% (n=469) were abnormal, with the proportion of abnormal GMs decreasing with increasing postmenstrual age (p for trend <0.001). By term-equivalent 30% (n=35) of GMs were normal. On univariable analysis, lower gestational age (p<0.001), postnatal infection (p<0.001) and bronchopulmonary dysplasia (p=0.001) were associated with abnormal GMs. Postnatal infection was the only independent perinatal association with abnormal GMs on multivariable analysis. All four infants with grade III/IV intraventricular haemorrhage (IVH) had persistently abnormal GMs.

CONCLUSIONS

GMs were predominantly abnormal in very preterm infants, with a higher proportion of normal GMs at term-equivalent age than prior to term. Abnormal GMs were associated with postnatal infection and IVH.

Characterization and intervention for upper extremity exploration & reaching behaviors in infancy

This article aims to: 1) highlight general exploration, reaching, and object exploration behaviors as key activities of daily living in infancy, 2) describe how knowledge of early warning signs for these behaviors may improve early assessment, and 3) discuss interventions that may advance performance of these behaviors. Early intervention should focus on improving performance of these behaviors because: a) these early, interrelated upper extremity behaviors serve an integral role in global learning and development in infancy, b) among at-risk populations, differences have been observed in the quantity and quality of performance of these behaviors and, in many cases, these differences are associated with related perceptual-motor and cognitive delays. This article highlights how early assessment and intervention can target these key early behaviors in populations at risk for upper extremity disabilities, such as those born preterm, with Down syndrome, brachial plexus palsy, or arthrogryposis multiplex congentia.

[Motor behavior of human fetuses during the second trimester of gestation: a longitudinal ultrasound study]

INTRODUCTION

The aim of this research is to contribute to knowledge of the normal spontaneous motor behavior of the human fetus during the second trimester of pregnancy. This study focuses on five patterns of spontaneous fetal movement: startle (S), axo-rhizomelic rhythmia (ARR), axial stretching (AS), general movement (GM), and diaphragmatic contraction (DC).

METHODS

A cohort of 13 subjects was followed up using 2D obstetrical ultrasound images at 12, 16, 20, and 24 weeks of gestation. As inclusion criteria, neonatal neurological examination and general movements after eutocic delivery at term were normal in all of the subjects, and their neuromotor and cognitive development until the end of pre-school age were also normal.

RESULTS

All these five motor patterns are present at the beginning of the 2(nd) gestational trimester, but their quantitative and qualitative traits are diverse according to gestational ages. The phasic, isolated or rhythmically repeated movements, S and ARR, are prominent at 12 and 16 weeks of gestation, and then their presence gradually diminishes. By contrast, tonic and complex AS and GM movements increase their presence and quality at 20 and 24 weeks. RAR constitute a particular periodic motor pattern not described in previous literature. Moreover, the incidence of DC is progressive throughout the trimester, in clusters of 2-6 arrhythmic and irregular beats. Fetal heart rate increases during fetal motor active periods.

CONCLUSIONS

All five normal behavioral patterns observed in the ultrasounds reflect the progressive tuning of motor generators in human nervous system during mid-pregnancy.

Placental pathology and neurological morbidity in preterm infants during the first two weeks after birth

BACKGROUND

The placenta plays a crucial role during pregnancy and dysfunction causes long-term neurological problems. Identifying placenta-related risks for neurological problems shortly after birth may provide clues for early interventions aiming to improve neurological outcome.

OBJECTIVE

To determine the association between placental pathology and neurological morbidity in preterm infants during the first two weeks after birth.

STUDY DESIGN

Placentas of 52 singleton, preterm infants (GA: 25-31weeks, BW: 560-2250 grammes) were examined for histopathology. The infants' neurological condition shortly after birth was determined by assessing the quality of their general movements (GMs): normal, abnormal, or hypokinetic, on days 5, 8, and 15. A motor optimality score (MOS) was also assigned.

RESULTS

Examination of the placentas revealed maternal vascular underperfusion (n=29), ascending intrauterine infection (AIUI) (n=19), villitis of unknown aetiology (n=6), chronic deciduitis (n=11), foetal thrombotic vasculopathy (FTV) (n=9), and elevated nucleated red blood cells (NRBCs) as a marker for foetal hypoxia (n=7). None of the placental lesions were significantly associated with the quality of GMs or MOS.

CONCLUSIONS

This study indicated that placental lesions were not associated with infants' neurological condition as measured by the quality of their general movements during the first two weeks after birth.

General movements in healthy full term infants during the first week after birth

BACKGROUND

The quality of general movements (GMs) is a widely used criterion to assess neurological dysfunction in young infants. It is unknown, however, whether the birth process influences the motor repertoire of healthy full term infants during the first week after birth.

AIMS

To assess the quality of GMs and to determine the motor optimality score (OS) in healthy full term infants during the first week after birth and to evaluate the influence of the mode of delivery on GM quality.

STUDY DESIGN

Thirty-three healthy full term infants born either vaginally or after caesarean section (CS) under spinal anaesthesia were video recorded in the first week after birth in order to assess GM quality and to determine OS with Prechtl's method.

RESULTS

Abnormal GMs were observed mainly on the early recordings: 86% on the day of birth (day 0), 94% on day 1, and 68% on day 2. On days 5 to 7 (day 5-7) all GMs were normal (P<.001). The OSs increased significantly from median 12 on day 0 to 18 on day 5-7 (P<.001). Monotonously slow movements were frequently seen during the first days but not on day 5-7 (P<.001). GM quality and OS did not differ between infants born by vaginal delivery or after CS under spinal anaesthesia.

CONCLUSIONS

Healthy full term infants often showed abnormal GM quality and lower OSs during the first week after birth, irrespective of the mode of delivery. GM quality normalised during subsequent days and was normal on day 5-7.

Neurodevelopment after fetal growth restriction

Fetal growth restriction (FGR) can emerge as a complication of placental dysfunction and increases the risk for neurodevelopmental delay. Marked elevations of umbilical artery (UA) Doppler resistance that set the stage for cardiovascular and biophysical deterioration with subsequent preterm birth characterize early-onset FGR. Minimal, or absent UA Doppler abnormalities and isolated cerebral Doppler changes with subtle deterioration and a high risk for unanticipated term stillbirth are characteristic for late-onset FGR. Nutritional deficiency manifested in lagging head growth is the most powerful predictor of developmental delay in all forms of FGR. Extremes of blood flow resistance and cardiovascular deterioration, prematurity and intracranial hemorrhage increase the risks for psychomotor delay and cerebral palsy. In late-onset FGR, regional cerebral vascular redistribution correlates with abnormal behavioral domains. Irrespective of the phenotype of FGR, prenatal tests that provide precise and independent stratification of risks for adverse neurodevelopment have yet to be determined.

Fetal and infant spontaneous general movements as predictors of developmental disabilities

The challenge of identifying infants who are at risk for developmental delay and possible adverse neurodevelopmental outcome demands methods of evaluation that will lead to early intervention to minimize developmental disability and to maximize the infant's potential. A qualitative assessment of spontaneous general movements (GMs) in the preterm, term, and young infant at risk is a valid and reliable tool for evaluation (Prechtl [1990] Early Hum. Dev. 23:151-158). The aim of this review is to describe the theoretical and clinical bases for the assessment of GMs and its relationship to developmental delay and brain dysfunction. Thirty-seven studies related to the predictive validity of GMs were included in this review. Results suggested that consistent cramped synchronized GMs are highly predictive of later development of cerebral palsy. The fidgety movement quality that appears at the age of 2 to 3 months was found to be a most sensitive predictor of neurodevelopmental outcome in different populations of infants.

Uncoordinated sucking patterns in preterm infants are associated with abnormal general movements

OBJECTIVE

To examine the association between sucking patterns and the quality of fidgety movements in preterm infants.

STUDY DESIGN

We studied the sucking patterns and fidgety movements of 44 preterm infants (gestational age <35 weeks) longitudinally from 34 weeks' postmenstrual age up to 14 weeks postterm. We used the Neonatal Oral-Motor Assessment Scale during feeding and scored the sucking patterns as normal or abnormal. Abnormal sucking patterns were categorized into arrhythmic sucking and uncoordinated sucking. At 14 weeks postterm, we scored the quality of fidgety movements from videotapes as normal, abnormal, or absent.

RESULTS

The postmenstrual age at which sucking patterns became normal (median, 48 weeks; range, 34 to >50 weeks) was correlated with the quality of fidgety movements (Spearman ρ = -0.33; P = .035). The percentage per infant of normal and uncoordinated sucking patterns was also correlated with the quality of fidgety movements (ρ = 0.31; P = .048 and ρ = -0.33; P = .032, respectively). Infants with uncoordinated sucking patterns had a higher rate of abnormal fidgety movements (OR, 7.5; 95% CI, 1.4-40; P = .019).

CONCLUSION

The development of sucking patterns in preterm infants was related to the quality of fidgety movements. Uncoordinated sucking patterns were associated with abnormal fidgety movements, indicating that uncoordinated sucking, swallowing, and breathing may represent neurologic dysfunction.

Poor repertoire General Movements predict some aspects of development outcome at 2 years in very preterm infants

BACKGROUND

Observation of the quality of endogenously generated "General Movements" has been proved to be a reliable and sensitive tool in the assessment of fragile neonates. The absence of fidgety movements at 2-4 months post-term is highly predictive of Cerebral Palsy. On the contrary, the presence of a poor repertoire pattern during the writhing period is not reliable in predicting motor or neurobehavioral disorders at any stage of development.

AIM

To examine if the presence of a PR pattern at 1 month post-term was associated with lower neurodevelopmental quotients at 2 years.

STUDY DESIGN

General Movements evaluation at 1 and 3 months and the Griffiths Scales of Mental Development at 2 years were administered to a sample of very preterm infants. Infants were divided into two groups: poor repertoire pattern group and normal pattern group. Student's t Test and Chi squared test and ANOVA were used to compare neonatal variables and results between the two groups.

SUBJECTS

79 very preterm infants (birthweight≤1500 g or gestational age≤32 weeks), born January 2003 to December 2006 who had a follow-up at 2 years.

OUTCOME MEASURE

Griffiths developmental quotient at 2 years.

RESULTS

The Poor Repertoire group had lower Gestational Age, lower Birth Weight, lower Apgar scores at birth and lower Developmental Quotient at 2 years. Eye and Hand Coordination (subscale D) was the domain mostly responsible for such a difference. Quality of fidgety movements (normal or abnormal fidgety) at 3 months did not show any correlation with outcome measures at 2 years.

CONCLUSION

The presence of a PR pattern at 1 month post-term seems to predict lower neurodevelopmental scores at 2 years especially in the domain of eye and hand coordination. Longer follow-up is necessary in order to ascertain if such difference will continue to persist at older ages.

The motor repertoire of extremely low-birthweight infants at term in relation to their neurological outcome

AIM

The aim of this study was to assess the motor repertoire of extremely low-birthweight infants at term-equivalent age (TEA), in relation to their neurological outcome.

METHOD

Using Prechtl's method, we assessed both the quality of general movements and a detailed motor optimality score in 13 extremely low-birthweight infants (four males; nine females; mean gestational age 27.9wks, SD 2.9wks; mean birthweight 798g, SD 129g) at TEA, and related them to general movements at the age of 3 months after term and neurological outcome at the age of 2 years 6 months.

RESULTS

At TEA, 10 of the 13 infants had abnormal general movements. All infants showed abnormal leg lifting with extended legs; nine showed stiff movements, three showed cramped movements, and two showed cramped synchronized general movements. At 3 months, three infants still had abnormal general movements. Concurrent movements were abnormal in nine infants owing to monotony and jerkiness. Abnormal posture was seen in seven infants. None developed cerebral palsy; one infant showed cognitive and motor delay. Neurological outcome was not related to general movement quality and optimality score at TEA.

INTERPRETATION

Abnormal general movements at TEA are common in extremely low-birthweight infants. General movements often appear stiff and cramped with extended legs. At the age of 3 months after term, general movements are mostly normal, but concurrent movements are not. Nevertheless, these abnormalities do not imply an impaired neurological outcome such as cerebral palsy.

Predictive validity of Prechtl's Method on the Qualitative Assessment of General Movements: a systematic review of the evidence

AIM

The aim of this systematic review was to examine the evidence for the predictive validity of Prechtl's Method on the Qualitative Assessment of General Movements (GMsA) with respect to neurodevelopmental outcomes.

METHOD

Six electronic databases (PsychINFO, Embase, Health and Psychosocial Instruments, PubMed, and AMED) were searched using the following keywords to identify all studies that examined the predictive validity of the GMsA: 'general movements', 'assessment', 'movement', 'child development', 'infant', and 'predictive value of test'. Only English- and French-language studies were included, whereas studies that focused on spontaneous mobility in preterm infants, but not necessarily the GMsA, or which did not report on the predictive value of the GMsA were excluded. A total of 39 studies were included in the final analysis.

RESULTS

Studies were separated according to the age at follow-up: 12 to 23 months, 2 to 3, 4 to 11, and 12 to 18 years. All used a longitudinal cohort study design; however, the outcome measures differed greatly amongst the studies. Values for sensitivity, specificity, positive predictive value, and negative predictive value varied amongst studies. The overall trend indicated that the presence of abnormalities in the quality of fidgety movements at 12 weeks adjusted age is more predictive of adverse outcomes than abnormal writhing movements.

INTERPRETATION

The GMsA demonstrates potential as a cost-effective, non-intrusive means of infant examination. However, current studies include important sources of bias. Future methodologically rigorous studies with functional outcomes are suggested.

Comparative analysis of perinatal and postnatal factors, and general movement in extremely preterm infants

STUDY AIM

To describe general movement in extremely premature infants and examine correlations with risk factors for antenatal, perinatal, and postnatal morbidity.

STUDY TYPE

Prospective, single-center study. Nineteen patients were followed up.

METHODOLOGY

The infants' general movement was analyzed using video recordings. Qualitative and quantitative assessments were performed during the writhing movement (WM) period and fidgety movement (FM) period. The quality of the general movements (GMs) and the scores achieved were then correlated with antenatal, perinatal, and postnatal factors.

RESULTS

Infants' motor activity fluctuated during the WM period, especially in extremely premature infants where poor repertoire is often observed. No correlations were found between WMs and obstetric factors. Gestational age correlated with WMs' quality (p=0.023). WMs correlated with factors of postnatal morbidity such as chronic lung disease (CLD) (p=0.034) and nosocomial infections (p=0.05). At 3 months corrected age, the spontaneous movement quality are correlated with neurological explorations such as US brain (p=0.032), MRI (p=0.039), EEG (p=0.036), and neurological follow-up assessments (p=0.015).

CONCLUSION

Prudence must be used when performing the analysis of general movement in extremely preterm infants. WMs may be influenced by perinatal morbidity, and possibly by the severe brain immaturity of these infants. WMs correlate with CLD and nosocomial infections. Analysis of general movement in infants of 3 months corrected age is a valuable means to detect neurological disorders.

Inter- and intra-observer agreement of Prechtl's method on the qualitative assessment of general movements in preterm, term and young infants

BACKGROUND

Prechtl's method on the qualitative assessment of general movements (GMs) has been shown to be a good predictor of neurological outcome. There is substantial evidence that this method has good inter- and intra-observer agreement.

AIMS

We wanted to find out whether this high agreement is reproducible in the clinical setting.

STUDY DESIGN

Reliability study (inter- and intra-observer agreement).

SUBJECTS

Twenty video-sequences of children at the age of preterm and writhing movements (31-41 weeks postmenstrual age) and 10 video-sequences of children at the fidgety movements age (49-54 weeks postmenstrual age) were rated by five physiotherapists.

OUTCOME MEASURES

Intra- and inter-observer agreements were analyzed with percentage agreement and with nominal kappa statistic with bootstrapped bias corrected 95% confidence intervals.

RESULTS

We found fair to substantial inter-observer reliability for the six response categories (time-point 1(t1): median kappa 0.44, range 0.27 to 0.59, time-point 2 (t2): median kappa 0.55, range 0.41 to 0.77) and fair to almost perfect for the normal/abnormal ratings (t1: median kappa 0.53, range 0.29 to 0.61, t2: median kappa 0.63, range 0.29 to 0.85). There was statistically significant improvement from t1 to t2 for the six response categories. The intra-observer reliability for the 9-week interval was moderate to almost perfect (median kappa 0.68, range 0.41 to 0.86).

CONCLUSIONS

We were not able to exactly reproduce the generally very good results. In our clinical setting now videos are evaluated by at least two trained therapists and the results are discussed, if necessary, to reach a consensus.

Neurodevelopment following fetal growth restriction and its relationship with antepartum parameters of placental dysfunction

Placental dysfunction leading to fetal growth restriction (FGR) is an important risk factor for neurodevelopmental delay. Recent observations clarify that FGR evolves prenatally from a preclinical phase of abnormal nutrient and endocrine milieu to a clinical phase that differs in characteristics in preterm and term pregnancies. Relating childhood neurodevelopment to these prenatal characteristics offers potential advantages in identifying mechanisms and timing of critical insults. Based on available studies, lagging head circumference, overall degree of FGR, gestational age, and umbilical artery (UA), aortic and cerebral Doppler parameters are the independent prenatal determinants of infant and childhood neurodevelopment. While head circumference is important independent of gestational age, overall growth delay has the greatest impact in early onset FGR. Gestational age has an overriding negative effect on neurodevelopment until 32-34 weeks' gestation. Accordingly, the importance of Doppler status is demonstrated from 27 weeks onward and is greatest when there is reversed end-diastolic velocity in the UA or aorta. While these findings predominate in early-onset FGR, cerebral vascular impedance changes become important in late onset FGR. Abnormal motor and neurological delay occur in preterm FGR, while cognitive effects and abnormalities that can be related to specific brain areas increase in frequency as gestation advances, suggesting different pathophysiology and evolving vulnerability of the fetal brain. Observational and management studies do not suggest that fetal deterioration has an independent impact on neurodevelopment in early-onset FGR. In late-onset FGR further research needs to establish benefits of perinatal intervention, as the pattern of vulnerability and effects of fetal deterioration appear to differ in the third trimester.

The development of sucking patterns in preterm, small-for-gestational age infants

OBJECTIVE

To determine whether the development of sucking patterns in small-for-gestational age (SGA) preterm infants differs from appropriate-for-gestational age (AGA) preterm infants.

STUDY DESIGN

We assessed sucking patterns in 15 SGA and 34 AGA preterms (gestational age<or=36 weeks) longitudinally from 34 to 50 weeks postmenstrual age (PMA) using the Neonatal Oral-Motor Assessment Scale (NOMAS). At each measurement, we scored sucking as normal, dysfunctional, or disorganized. We examined the development of their sucking patterns in relation to clinical characteristics.

RESULTS

SGA preterms developed a normal sucking pattern later than did AGA preterms (median, 50 versus 44 weeks PMA, P=.002). At term-equivalent age, none of the SGA and 38% of the AGA preterms showed normal sucking (P<.05); at 48 to 50 weeks PMA this was 54% and 81%, respectively (P=.064). Abnormal sucking including "incoordination" and dysfunctional sucking were more prevalent in SGA preterms than in AGA preterms (median, 11% versus 0% per infant, P<.05). A higher gestational age and z-score for birth weight were predictive of normal sucking at 50 weeks PMA.

CONCLUSIONS

SGA preterms developed a normal sucking pattern later than AGA preterms. Many AGA preterms also developed a normal mature sucking pattern only after they had reached term age.

The early motor repertoire of children born preterm is associated with intelligence at school age

OBJECTIVE

The goal was to determine whether the quality of general movements (GMs) for preterm children had predictive value for cognitive development at school age.

METHODS

In this prospective cohort study, 60 preterm infants (gestational age, median: 30.0 weeks [range: 25-33 weeks]; birth weight, median: 1130 g [range: 595-1800 g]) without cerebral palsy were studied. The quality of GMs was assessed prospectively as normal or abnormal, from video recordings that were made at regular intervals until 17 weeks after term. At 7 to 11 years, intelligence was tested by using the Wechsler Intelligence Scale for Children III, Dutch version. Total IQ (TIQ), verbal IQ (VIQ), and performance IQ (PIQ) scores were calculated.

RESULTS

The median TIQ was 93 (range: 67-113), VIQ 96 (range: 68-117), and PIQ 92 (range: 65-119). Fifteen children (25%) had low TIQ scores (<85). When the quality of GMs normalized before 8 weeks after term, TIQ, VIQ, and PIQ scores were in the normal range. Consistently abnormal GMs to 8 weeks after term were associated with lower TIQ, VIQ, and PIQ scores. With correction for male gender and the educational levels of the parents, the likelihood ratio of consistently abnormal GMs for a low TIQ was 4.9 (95% confidence interval: 1.3-17.6). The model explained 22.4% of the variance.

CONCLUSIONS

The quality of GMs during the early postterm period is a marker for intelligence at school age. Abnormal GMs during the early postterm period may reflect injury or developmental disruptions of brain areas involved in cognitive development.

The quality of general movements in the first ten days of life in preterm infants

BACKGROUND

The assessment of the quality of general movements (GMs) in preterm infants early in life has been used mainly to determine temporary or permanent neurological dysfunction and not to predict outcome.

AIM

Assessing the quality and evolution of GMs during the first ten days of life in preterm infants, and relating them to clinical factors and neurological outcome at 24months' post-term.

METHODS

Using Prechtl's method, the GM quality was assessed in 45 preterm infants on days 2, 4, 6 and 10. They were related to clinical factors and outcome. After GM assessment, an extra item was scored: chaotic features (ChF). ChF was defined as chaotic GMs or poor repertoire GMs+chaotic movements.

RESULTS

Abnormal GMs were seen mostly in early recordings. A better GM trajectory correlated with a higher birth weight, a higher gestational age and a lower Nursery Neurobiologic Risk Score (NBRS). Predictive value for normal outcome of at least one normal GM was 94%. Predictive value for abnormal outcome of only abnormal GMs was 21%. ChF were seen mostly in early recordings. Occurrence of ChF on day 2 correlated with lower serum calcium.

CONCLUSIONS

Preterm infants often showed abnormal GMs during the first few days. This was related mostly to a higher NBRS. Normalization of GMs during the first ten days was associated with a lower NBRS and was a reliable predictor for neurological outcome. ChFs could be a GM quality that is associated to lower calcium, indicating hyperexcitability of the nervous system.

Neurological outcome in preterm small for gestational age infants compared to appropriate for gestational age preterm at the age of 18 months: a prospective study

The aim of this study was to investigate the neurological outcome of premature small for gestational age infants at the corrected age of 18 months by the Hammersmith Infant Neurological Examination. A prospective trial was conducted comparing 41 preterm infants being small for gestational age with 41 appropriate for gestational age infants. Birth weight was significantly lower in small for gestational age infants compared with appropriate for gestational age infants (1724.6 +/- 433 versus 1221 +/- 328 g). There were no significant differences regarding the median gestational age and Apgar scores. Median global scores differ significantly between both groups: 75 (47-78) versus 76 (72-78) for the small for gestational age and appropriate for gestational age infants, respectively. Both groups had optimal scores. In conclusion, although the small for gestational age group scored lower in the Hammersmith Infant Neurological Examination, median global score in both groups was within optimal range.

Fetal general movements and brain sonography in a population at risk for preterm birth

BACKGROUND

General movements (GMs) assessed three months post term are related to brain injury and neurological outcome.

AIMS

To study GMs in fetuses and their predictive value for echogenicity changes in the fetal brain.

STUDY DESIGN

Prospective study of fetal GMs (classified as normal or abnormal) and echogenicity changes in the periventricular, basal ganglia/thalami area, and ventricular system (classified as absent, mild or moderate).

SUBJECTS

121 fetuses from pregnancies affected by hypertensive disorders and/or preterm labour, at risk for preterm birth (26-34weeks gestational age).

OUTCOME MEASURES

Prevalence of abnormal GMs, GM parameters (amplitude, speed and complexity), and moderate echogenicity changes in the fetal brain (periventricular >or=IB, intraventricular grade II/III, and basal ganglia/thalamus locally increased). Predictive values of GMs for clinical parameters and moderate echogenicity changes.

RESULTS

GMs were abnormal in 58%, with amplitude affected in 96%, and speed and complexity in 59%. Abnormal GMs correlated with oligohydramnios (p=0.002) and hypertensive disorders (p=0.015). Echogenicity changes of the brain were absent, mild and moderate in 27%, 39% and 31%, respectively. The sensitivity of GMs for moderate echogenicity changes in the three areas combined was 0.65, and the periventricular area 0.85, specificity both 0.44, negative predictive values 0.73 and 0.96 respectively.

CONCLUSIONS

Qualitative abnormal GMs are frequent in fetuses of compromised pregnancies, and correlate with hypertensive disorders and oligohydramnios. The amplitude of GMs was most frequently affected. Abnormal GMs relate to moderate echogenicity changes especially in the periventricular area of the fetal brain, while normal GMs predict absence of moderate echogenicity changes.

General movements in the perinatal period and its relation to echogenicity changes in the brain

BACKGROUND

In preterm born infants abnormal general movements (GMs) generally normalize before three months post term, but may persist when perinatal brain injury is present.

AIMS

To assess the continuity of GM quality from fetal to early neonatal period and its relation to brain echogenicity changes.

STUDY DESIGN

Prospective study examining GMs and three vulnerable brain areas before and 7days after birth. The quality of GMs was classified as normal or abnormal by Gestalt-perception. The brain was examined for moderate echogenicity changes (periventricular: brighter than choroid plexus, intraventricular: filling equal or more than 50% of the ventricle, and locally increased basal ganglia/thalami).

SUBJECTS

94 fetuses from pregnancies complicated by preterm hypertensive disorders or labour at a gestational age between 26 and 34weeks.

OUTCOMES MEASURES

Correlations of fetal GMs, echogenicity changes, and clinical parameters (e.g. gestational age, parity, hypertensive disorders or preterm labour, oligohydramnios and fetal growth restriction) with neonatal GMs.

RESULTS

Fetal GMs were abnormal in 64%, normalizing in 68% within 7days after birth. Fetal GMs were significantly related to postnatal GMs (p=0.045). Moderate fetal brain echogenicity changes and clinical parameters were not significantly related to neonatal GM.

CONCLUSIONS

In this population of pregnancies compromised by hypertensive disorders or preterm labour fetal GMs correlated with neonatal GMs. Presence of moderate echogenicity changes in the fetal brain was not related to neonatal GMs.

Infants born preterm exhibit different patterns of center-of-pressure movement than infants born at full term

BACKGROUND

Infants born preterm are at risk for developmental impairments related to postural control.

OBJECTIVE

The purpose of this study was to determine whether infants born preterm and infants born at full term differed in postural control at 1 to 3 weeks after term age.

DESIGN

This study included 17 infants born preterm (mean gestational age=31.9 weeks, range=25.0-34.6) and 15 infants born at full term (mean gestational age=38.9 weeks, range=37.3-40.6). All infants were without diagnosed neurological or genetic conditions.

MEASUREMENT

Center-of-pressure (COP) data were recorded at 5 Hz while each infant was positioned supine on a pressure-sensitive mat in an alert behavioral state. Root mean square (RMS) displacement and approximate entropy (ApEn) were used to describe the COP movement variability in the time series. Differences between groups were identified using independent t tests.

RESULTS

The COP time series were found to be deterministic, suggesting order in the time series. Infants born preterm exhibited significantly larger RMS values in the caudal-cephalic direction than infants born at full term (1.11 and 0.83 cm, respectively; t=-2.6, df=30, P=.01). However, infants born at full term had significantly larger ApEn values in the caudal-cephalic direction (1.19 and 1.11, respectively; t=2.4, df=30, P=.02). The 2 groups did not differ in RMS or ApEn values in the medial-lateral direction or the resultant.

CONCLUSIONS

Infants born at full term exhibited COP displacements in the caudal-cephalic direction that were smaller in amplitude, but may be considered more complex or less predictable, than those of infants born preterm. One explanation is that infants born preterm exhibited more stereotypic patterns of movement, resulting in large, but repetitive, COP excursions. A combination of linear and nonlinear measures may provide insight into the control of posture of young infants.

Early motor repertoire is related to level of self-mobility in children with cerebral palsy at school age

AIM

To determine the predictive value of the early motor repertoire for the level of self-mobility in children with cerebral palsy (CP) at school age.

METHOD

Video recordings were made at 11 to 17 weeks post-term of 37 preterm infants (20 males, 17 females) who later developed CP. The early motor repertoire was assessed by obtaining a motor optimality score. At 6 to 12 years, children were classified according to the Gross Motor Function Classification System (GMFCS).

RESULTS

Of 37 children (mean gestational age 29.1wks, SD 1.9; mean birthweight 1273g, SD 324), nine had unilateral and 28 had bilateral spastic CP. Twelve children were in GMFCS level I, three level II, 10 level III, four level IV, and eight level V. The absence of the age-adequate motor repertoire, a cramped motor repertoire, an abnormal kicking pattern, and a non-flat supine posture were associated with lower levels of self-mobility (chi(2) for trend test, p<0.05). Predictive for a low level of self-mobility was a cramped motor repertoire/non-flat supine posture (positive predictive values [PPV] 100%, negative predictive values [NPV] 54%). Predictive for a high level of self-mobility was a non-cramped repertoire/flat supine posture (PPV 80%, NPV 74%).

INTERPRETATION

Several aspects of the motor repertoire at 11 to 17 weeks post-term predicted the degree of functional limitations in children with CP at school age.

The predictive validity of general movements--a systematic review

BACKGROUND

The assessment of general movements (GMs), introduced by Professor Heinz Prechtl and his co-workers in the early 1990s, may offer the opportunity to identify infants with neurological deficits at a very early age.

AIM

The aim of this review was to systematically assess available data in order to determine the evidence of general movements in early infancy to predict the neurodevelopmental outcome in 12- and 24-month-old infants.

METHOD

A systematic literature search was performed using the following computerised databases: Medline, CINAHL, Pedro, The Cochrane Library, Science Direct, ProQuest: Science Journals, Medical Library & Social Science Journals, Journals @ OVID and PsycINFO. The following key terms were used: general movements, spontaneous motor activity, nervous system diseases [MeSH] and developmental disabilities [MeSH]. A comprehensive author search was also conducted. The methodological quality of eligible studies was critically appraised by two reviewers using the Critical Review Form for Quantitative Studies of the McMaster University Occupational Therapy Evidence-Based Practice Research Group.

RESULTS

Seventeen studies were eligible for this review. The average score of the studies was 8.82 (73.5%) from a total of 12 (SD 0.73). Fifteen of the 17 studies found a high relationship (sensitivity > or =92%; specificity > or =82%; p<0.01) between the quality of general movements at 8-20 weeks postterm (fidgety movements' period) and the infants' neurodevelopmental outcome.

CONCLUSION

The results of this systematic review indicate that the qualitative assessment of general movements, especially during the fidgety movements' period, can be used as a prognostic tool to identify infants with neurodevelopmental disabilities.

The quality of preterm infants' spontaneous movements: an early indicator of intelligence and behaviour at school age

BACKGROUND

The quality of very preterm infants' spontaneous movements at 11 to 16 weeks post-term age is a powerful predictor of their later neurological status. This study investigated whether early spontaneous movements also have predictive value for the intellectual and behavioural problems that children born very preterm often experience.

METHODS

Spontaneous movement quality was assessed, using Prechtl's method, at 11 to 16 weeks post-term in 65 infants born at <or= 33 weeks of gestation in a single centre. Intelligence and behaviour were assessed with standardised tests at 7 to 11 years of age. Neurological status was assessed with Touwen's test. Multiple regression was used to determine the predictive value of movement quality for intelligence and behavioural problems. The Sobel test was used to determine if neurological status mediated associations found between early movement quality and outcome.

RESULTS

Spontaneous movement quality at 11 to 16 weeks post-term was significantly, positively associated with later intelligence. The number of normal postural patterns displayed contributed most strongly to the association, which was not mediated by neurological status. Fidgety movements, strong predictors of later neurological dysfunction, were not associated with intelligence. Spontaneous movement quality was not associated with internalising or externalising problems but showed a trend to an association with attention problems.

CONCLUSION

These findings suggest that, in children born preterm, early spontaneous movement quality has clear prognostic value for neurological and intellectual outcome, and to a lesser extent, for attentional outcome. However, cognitive outcome was associated with the presence of specific, age-appropriate postural patterns, while neurological outcome has been associated with the presence of global movement abnormalities. The presence of specific, age-appropriate postural patterns may reflect the integrity of areas of the brain involved in cognitive processing and the regulation of attention later in childhood. Alternately, it may facilitate cognitive and attentional development.

Pilot use of the early motor repertoire in infants with inborn errors of metabolism: outcomes in early and middle childhood

BACKGROUND

Predicting later outcome in neonates presenting with severe inborn errors of metabolism (IEM) is difficult. The assessment of the early motor repertoire is a reliable method of evaluating the integrity of the central nervous system in young infants. This method is based on an age-specific qualitative assessment of general movements (GMs, 0-8 weeks of age), fidgety movements (FMs) and the concurrent motor repertoire (9-20 weeks of age).

AIM

To determine the quality of the early motor repertoire (at 0-20 weeks post term age) in relation to later neurological outcome in infants with severe IEM.

STUDY DESIGN

Prospective cohort study. The quality of the motor repertoire was assessed from serial videotape recordings.

SUBJECTS

Five infants with IEM. Four presented with a severe IEM in the neonatal period: an undefined gluconeogenesis defect, propionic acidemia, arginosuccinate synthetase and arginosuccinate lyase deficiency. One neonate was antenatally diagnosed with arginosuccinate synthetase deficiency.

OUTCOME MEASURES

Outcome at the age of at least 18 m was determined by neurological examination and developmental tests.

RESULTS

All infants initially had abnormal GMs: hypokinesia, followed by GMs of a poor repertoire. The quality of the early motor repertoire normalised in 3 infants, and remained abnormal in 2. The more severe and persistent abnormalities of the motor repertoire were considered with the more abnormal neurological and developmental scores, later on.

CONCLUSIONS

The quality of the early motor repertoire might be related to later neurological outcome in infants with inborn errors of metabolism.

Inter-observer reliability of the "Assessment of Motor Repertoire--3 to 5 Months" based on video recordings of infants

OBJECTIVE

A detailed analysis of infant motor behaviour can show up indicators for later neurological impairment. The "Assessment of Motor Repertoire--3 to 5 Months", which is part of Prechtl's general movement assessment, could potentially be used for this purpose. The aim of the present study was to investigate inter-observer reliability in this instrument.

METHOD

Video recordings of 24 infants (corrected ages 3 to 5 months, gestational ages 24 to 42 weeks) were analysed by four observers. Kappa and ICC statistics were applied in the reliability analysis.

RESULTS

High to very high inter-observer reliability was found in the assessment of "Fidgety Movements" (kappa 0.75-0.91). Agreement on the "Movement Character" was also high (kappa 0.54-0.84), while the assessment of the "Posture" showed the lowest inter-observer reliability (kappa 0.39-0.56). Moderate to high inter-observer reliability (kappa 0.51-0.84) was achieved in the field "Quality of Other Movements", and moderate in "Repertoire of Co-Existent Other Movements" (kappa 0.51-0.69). Inter-observer reliability in the assessment of the total "Motor Optimality Score" was very high between all four observers as intraclass correlation coefficient (2,1) was 0.87, and ICCs for the pairwise analyses ranged between 0.80 and 0.94.

CONCLUSION

Inter-observer reliability in the "Assessment of Motor Repertoire - 3 to 5 Months" was satisfactory in respect of the subcategories and in case of high and low total optimality scores in pairwise assessments. In the total optimality scores, however, there was some inconsistency in the middle range of the scale.

Quantitative aspects of the early motor repertoire in preterm infants: do they predict minor neurological dysfunction at school age?

BACKGROUND

Qualitative aspects of the motor repertoire, at 11-16 weeks post-term are predictive for minor neurological dysfunction (MND) at 7 to 11 years of age. Predictive value of quantitative aspects is unknown so far.

AIM

To investigate whether quantitative aspects of the motor repertoire between 6 and 24 weeks post-term also have predictive value for neurological outcome at 7 to 11 years of age.

STUDY DESIGN

Prospective cohort study.

SUBJECTS

Preterm infants from whom several quantitative aspects of the motor repertoire were assessed between 6 and 24 weeks post-term.

OUTCOME MEASURES

Neurological outcome at 7-11 years of age was assessed according to Touwens' neurological examination. Children were classified as neurologically normal, or as having complex MND or cerebral palsy (CP).

RESULTS

Eighty-two children were included. At 7 to 11 years of age 15 children (18%) had developed CP, 49 (60%) were neurologically normal, and 18 (22%) had MND. Multiple logistic regression analysis showed that, when the qualitative aspects of the motor repertoire known to predict neurological outcome were taken into account, only the asymmetric tonic neck (ATN) posture provided additional predictive value. In case of normal fidgety movements (FMs) accompanied by an abnormal concurrent motor repertoire, the presence of an obligatory ATN increased the risk for developing complex MND to 75%; absence of an obligatory ATN reduced the risk to 15% (p<0.05).

CONCLUSIONS

Quantitative aspects of the motor repertoire at 11-16 weeks post-term, in particular the presence of an obligatory ATN posture, contribute to the prediction of neurological outcome at 7 to 11 years of age.

General movements in the first fourteen days of life in extremely low birth weight (ELBW) infants

OBJECTIVE

To assess the quality of general movements (GMs) in the first fourteen days of life in relation to obstetric and postnatal risk factors and neurodevelopmental outcome in extremely low birth weight (ELBW) infants.

STUDY DESIGN

The GMs of nineteen infants were assessed on days 2, 4, 6, 10 and 14 with Prechtl's method. Additionally, detailed GM assessment produced optimality scores (OSs). GMs and the OSs were related to obstetric and postnatal data and to neurodevelopmental outcome at 18 months.

RESULTS

GMs and OSs fluctuated substantially during the first fourteen days of life. Most infants had abnormal GMs, especially poor repertoire (PR) GMs. No relation was found between GMs and obstetric factors. Regarding postnatal factors, septicaemia correlated to hypokinesia (H) and artificial ventilation correlated to a lower OS.

CONCLUSIONS

Due to physiological disturbances the quality of GM in ELBW infants fluctuates substantially during the first fourteen days of life. Abnormal GMs, especially PR GMs, are mostly seen for the same reason. Septicaemia and artificial ventilation are associated with deterioration of the GMs (lower OSs), and in case of septicaemia also with hypokinesia.

Upper limb movements and outcome in intrauterine-growth-retarded infants at 2 years

This study aims to examine the usefulness of spontaneous upper limb movements (ULM) as an early marker for predicting neurodevelopmental outcome in infants with intrauterine-growth retardation (IUGR). The assessment of general movements (GMs) during the first 20 weeks is an accepted method for early detection of brain dysfunction. During this period, spontaneous upper limb movements were examined in 32 infants with IUGR and 32 appropriate-for-gestational-age-matched controls. ULM (arms, forearms and hands) were scored as optimal or suboptimal by sequential videotape recordings in the writhing (term-2 weeks: score 0-5); early fidgety (9-11 weeks: score 0-6); and late fidgety (14-16 weeks: score 0-6) periods, and correlated with neurodevelopmental score at 2 years of age. The mean ULM score was lower in the IUGR infants than the controls (p<0.05) and in the IUGR group was lower in the infants with abnormal outcome (p<0.05). Significant correlations were found between ULM and 2-year neurodevelopmental scores in the IUGR group. The ULM during late-fidgety period was most predictive for 2-year neurodevelopmental score. No difference was found in the mean ULM score between the pre-term and term IUGR infants. We conclude that ULM score can serve as an early predictor for neurodevelopmental outcome at 2 years of age in infants with IUGR.

General movements in infants born from mothers with early-onset hypertensive disorders of pregnancy in relation to one year's neurodevelopmental outcome

BACKGROUND

Assessment of general movements (GMs) at three months is considered useful for prediction of adverse neurological outcome in high risk infants.

AIMS

To study the prevalence of abnormal GMs in infants born from women with early-onset hypertensive disorders of pregnancy and the association of GMs with neurodevelopmental outcome at one year.

STUDY DESIGN

Prospective study, part of a randomised controlled trial of pre-birth management strategies.

SUBJECTS

Infants born from women with early-onset hypertensive disorders of pregnancy.

OUTCOME MEASURES

GMs observation and neurological examination at term and three months corrected age; at one year neurological examination and Bayley Scales of Infant Development.

RESULTS

From 216 women included, 175 of 178 surviving infants (mean gestational age 31.6 weeks [SD 2.3], mean birth weight 1346 grams [SD 458]), were examined at three months. At term age normal, mildly abnormal and definitely abnormal GMs were observed in 54%, 36% and 10% respectively; and at three months in 47%, 40% and 13%. Mildly or definitely abnormal GMs at three months were not associated with abnormal neurological examination at one year, however, they were associated with delayed psychomotor development at one year (p = 0.01).

CONCLUSIONS

In this prospective study, including small for gestational age, preterm infants about half of them did not have normal GMs at term and three months. There was no association of GMs at term nor three months with neurological outcome at one year, but there was a significant association of GMs at three months with one year psychomotor development.

The quality of the early motor repertoire in preterm infants predicts minor neurologic dysfunction at school age

OBJECTIVE

The quality of a child's motor repertoire at age 3 to 4 months postterm is predictive of later cerebral palsy (CP). Its predictive power for minor neurologic dysfunction (MND) is unclear. This study aimed to investigate the predictive value of the quality of the early motor repertoire for the development of MND at school age.

STUDY DESIGN

We assessed the motor repertoire from video recordings made at 6 to 24 weeks postterm in 82 preterm infants (mean gestational age, 29.7 +/- 1.9 weeks; mean birth weight, 1183 +/- 302 g). At age 7 to 11 years, Touwen's neurologic examination was performed, and the children were classified as normal (n = 49; 60%), MND (n = 18; 22%), or CP (n = 15; 18%).

RESULTS

Multiple logistic regression analysis showed that the quality of fidgety movements (FMs) and the quality of the concurrent motor repertoire had independent prognostic value for MND at school age. Abnormal FMs evolved into MND in 64% of the children. Nine of the 28 children with normal FMs and an abnormal concurrent motor repertoire developed abnormally (32%). Only 1 child of the 21 children with normal FMs and a normal concurrent motor repertoire developed MND (5%).

CONCLUSIONS

Assessment of the quality of the early motor repertoire can accurately identify individual infants at high and low risk for MND at school age.

A systematic review of the clinimetric properties of neuromotor assessments for preterm infants during the first year of life

This systematic review evaluates assessments used to discriminate, predict, or evaluate the motor development of preterm infants during the first year of life. Eighteen assessments were identified; nine met the inclusion criteria. The Alberta Infant Motor Scale (AIMS), Bayley Scale of Infant and Toddler Development -- Version III, Peabody Developmental Motor Scales -- Version 2, Test of Infant Motor Performance (TIMP), and Toddler and Infant Motor Examination have good discriminative validity when examined in large populations. The AIMS, Prechtl's Assessment of General Movements (GMs), Neuro Sensory Motor Development Assessment (NSMDA), and TIMP were designed for preterm infants and are able to detect more subtle changes in movement quality. The best predictive assessment tools are age dependent: GMs, the Movement Assessment of Infants, and TIMP are strongest in early infancy (age 4 mo or less) and the AIMS and NSMDA are better at older ages (8-12 mo). The TIMP is the only tool that has demonstrated a difference between groups in response to intervention in two randomized controlled trials. The AIMS, TIMP, and GMs demonstrated the highest levels of overall reliability (interrater and intrarater intraclass correlation coefficient or kappa>0.85). Selection of motor assessment tools during the first year of life for infants born preterm will depend on the intended purpose of their use for discrimination, prediction, and/or evaluation.

Predictive values of cranial ultrasound and assessment of general movements for neurological development of preterm infants in the Maribor region of Slovenia

OBJECTIVE

The aim of the study was to assess the predictive values of cranial ultrasound (US) scans and assessment of general movements of fidgety character (GMs) for the later neurological development of preterm infants in the Maribor region of Slovenia.

METHODS

Results of cranial US scans done longitudinally from the day of birth until the end of three months of chronologic age and results of GMs at three months of corrected age were compared with traditional neurological examination and evaluation of psychomotor development of the same children at the corrected age of six years.

RESULTS

A total of 112 preterm infants (gestational age 37 weeks and below) were included in the study. The infants were classified as low-risk or high-risk for neurological impairment on the basis of cranial US scans. The scans classified as low-risk were followed by a normal neurological outcome in 74 (89%) of 83 infants; those classified as high-risk for neurological impairment were followed by abnormal neurological outcome in 21 (72%) of 29 infants. Of 77 infants with normal fidgety movements, 73 (95%) had a normal neurological outcome and 4 (5%) had an abnormal neurological outcome; of 35 infants with abnormal or absent fidgety movements, 26 (74%) had an abnormal neurological outcome and 9 (26%) had a normal neurological outcome. Of 30 children with abnormal outcome, cerebral palsy was diagnosed in 16, mental retardation in one, nine children had both of these, and four had complex minor neurological dysfunction. The validity of the scans was 85%, sensitivity 70%, specificity 90%, positive predictive value 72% and negative predictive value 89%; the validity of the GMs was 88%, sensitivity 87%, specificity 89%, positive predictive value 74% and negative predictive value 95%.

CONCLUSIONS

The sensitivity of the cranial US scans was clearly lower than that of assessment of general movements of a fidgety character. The specificities of the two methods were almost the same.

Are abnormal fidgety movements an early marker for complex minor neurological dysfunction at puberty?

BACKGROUND

Prechtl's method on the qualitative assessment of general movements (GMs) is a powerful tool for early and specific prediction of cerebral palsy. However, it is uncertain whether the GM assessment can be used to predict mild neurological impairment.

AIMS

To determine whether the quality of general movements (GMs) from the age of 3 to 5 months, i.e. fidgety movements, is related to the presence of complex minor neurological dysfunctions (MND) 13 to 15 years later.

STUDY DESIGN

Prospectively collected data on the quality of GMs during infancy were retrospectively analysed on the basis of MND at puberty.

SUBJECTS

Twenty-eight participants (14 girls and 14 boys) with a median gestational age of 40 weeks (range: 35 to 42 weeks) and an appropriate birth weight (median 3390 g; range 1900 to 4200 g).

OUTCOME MEASURES

Touwen's neurological examination.

RESULTS AND CONCLUSIONS

Abnormal fidgety movements were not related to later complex MND, but to fine manipulative disabilities (p<0.05). Normal fidgety movements, which are continually present in the whole body, might be required for optimal calibration of the proprioceptive system.