Predictive value of neurodevelopmental assessment versus evaluation of general movements for motor outcome in preterm infants with birth weights <1500 g

Validity of General Movement Assessment Based on Clinical and Home Videos

INTRODUCTION

The purposes of this study were to develop an instructional leaflet on home video recording for the General Movement Assessment (GMA) and to examine the concurrent and predictive validity of the GMA completed by physical therapists (PTs) and completed by parents.

METHODS

The GMA and the Alberta Infant Motor Scale (AIMS) were completed by PTs in the clinic. Parents completed the GMA following the instructional leaflet.

RESULTS

The content validity of the leaflet was 0.83. The consistency of the GMA results between sources was κ = 0.869. The concurrent validity of the GMA at a corrected age of 3 months was κ = 0.266 (PT) versus 0.525 (parent) using the 10th-percentile cutoffs of the AIMS. The positive likelihood ratio was 26 (PT) versus 25 (parents) at a corrected age of 12 months based on 5th-percentile cutoffs of the AIMS.

CONCLUSIONS

Home GMA videos are valid for clinical assessment following the instructional leaflet.

Predictive validity of spontaneous early infant movement for later cerebral palsy: a systematic review

AIM

To systematically review the predictive validity of spontaneous early infant movements for later cerebral palsy (CP).

METHOD

Cohort studies with published data to calculate predictive validity of early spontaneous movements for later CP were searched in four electronic databases: CINAHL, Embase, MEDLINE, and PsycINFO.

RESULTS

Forty-seven studies met inclusion criteria. The Prechtl General Movements Assessment (GMA) during the fidgety period (10-20wks corrected age) had the strongest sensitivity: 97 per cent (95% confidence interval [CI] 93-99) and specificity: 89% (95% CI 83-93). The sensitivity and specificity of the Prechtl GMA during the writhing period (birth-6wks) was 93% (95% CI 86-96) and 59% (95% CI 45-71) respectively. Cramped-synchronized movements in the writhing period according to Prechtl had the best specificity (sensitivity: 70% [95% CI 54-82]; specificity: 97% [95% CI 74-100]). Hadders-Algra's method of assessing general movements had a pooled sensitivity and specificity of 89% (95% CI 66-97) and 81% (95% CI 64-91) respectively. Presence of asymmetric postures and movement quality/quantity were reported under the Hammersmith Infant Neurological Examination, Hammersmith Neonatal Neurological Examination, and Movement Assessment of Infants but had weak associations with later CP.

INTERPRETATION

Fidgety movements assessed by the Prechtl GMA have the strongest predictive validity for later CP, but cannot be considered in isolation because of the presence of false positive results.

WHAT THIS PAPER ADDS

Fidgety general movements (Prechtl) are most predictive for later cerebral palsy compared with other spontaneous movements. False positive results are high among all spontaneous movement assessments.

Predictive value of General Movement Assessment for preterm infants' development at 2 years - implementation in clinical routine in a non-academic setting

BACKGROUND

General movements (GM) are used in academic settings to predict developmental outcome in infants born preterm. However, little is known about the implementation and predictive value of GM in non-academic settings.

AIMS

The aim of this study is twofold: To document the implementation of GM assessment (GMA) in a non-academic setting and to assess its predictive value in infants born preterm.

METHODS AND PROCEDURES

We documented the process of implementing GMA in a non-academic outpatient clinic. In addition, we assessed the predictive value of GMA at 1 and 3 months' corrected age for motor and cognitive development at 2 years in 122 children born <33 weeks' gestation. Outcome at two years was based upon the Bayley Scales of Infant Development-II (mental/psychomotor developmental index (MDI, PDI)) and a neurological examination. The infants' odds of atypical outcome (MDI or PDI ≤70 or diagnosis CP) and the predictive accuracy of abnormal GMA were calculated in a clinical routine scenario, which used all available GM information (primarily at 3 months or at 1 month, when 3 months were not available). In addition, separate analysis was undertaken for the samples of GMA at 1 and 3 months.

OUTCOMES AND RESULTS

Tips to facilitate GMA implementation are described. In our clinical routine scenario, children with definitely abnormal GM were more likely to have an atypical two-year outcome than children with normal GM (OR 13.2 (95% CI 1.56; 112.5); sensitivity 55.6%, specificity 82.1%). Definitely abnormal GM were associated with reduced MDI (-12.0, 95% CI -23.2; -0.87) and identified all children with cerebral palsy (CP) in the sample of GMA at 3 months only.

CONCLUSIONS AND IMPLICATIONS

GMA can be successfully implemented in a non-academic outpatient setting. In our clinical routine scenario, GMA allowed for adequate prediction of neurodevelopment in infants born preterm, thereby allaying concerns about diagnostic accuracy in non-academic settings.

Very low birth weight infants in China: the predictive value of the motor repertoire at 3 to 5months for the motor performance at 12months

BACKGROUND

Studies on motor performance and its early markers are rare in China, especially in very low birth weight (VLBW) infants.

OBJECTIVE

Apart from the assessment of the inter-scorer agreement, we aimed to analyze to what extent the motor repertoire at 10 to 18weeks postterm was related to neonatal complications, and gross and fine motor performance at 12months after term.

STUDY DESIGN

Exploratory prospective study.

SUBJECTS

Seventy-four VLBW infants (58 males; mean gestational age=29weeks; mean birth weight=1252g).

METHOD

Five-minute video recordings were performed at 10 to 18weeks after term; fidgety movements and the concurrent motor patterns (resulting in a motor optimality score) were assessed according to the Prechtl general movements assessment (GMA). The gross and fine motor performance was assessed by means of the Peabody Developmental Motor Scales, second edition, at 12months.

RESULTS

Reliability was excellent. Pneumonia was associated with absent fidgety movements; the motor optimality score was lower in infants with pneumonia and/or bronchopulmonary dysplasia. Both absent fidgety movements and a lower motor optimality score were associated with a poor or very poor gross and fine motor performance at the 12-month-assessment.

CONCLUSION

Both the assessment of fidgety movements and the evaluation of the concurrent motor repertoire contribute significantly to an identification of VLBW children with a poor gross and fine motor outcome at 12months. The results of this study document the need for an early identification of infants at high risk for a poor motor performance.

Early prediction of typical outcome and mild developmental delay for prioritisation of service delivery for very preterm and very low birthweight infants: a study protocol

INTRODUCTION

Over 80% of very preterm (<32 weeks) and very low birthweight (<1500 g) infants will have either typical development (TD) or mild developmental delay (MDD) in multiple domains. As differentiation between TD and MDD can be difficult, infants with MDD often miss opportunities for intervention. For many clinicians, the ongoing challenge is early detection of MDD without over servicing the population. This study aims to: (1) identify early clinical biomarkers for use in this population to predict and differentiate between TD and MDD at 24 months corrected age. (2) Determine the extent to which family and caregiver factors will contribute to neurodevelopmental and behavioural outcomes.

METHODS AND ANALYSIS

Participants will be a prospective cohort of 90 infants (<32 weeks and/or <1500 g). Between 34 weeks gestational age and 16 weeks post-term, infants will have a series of 5 neurological, neuromotor, neurobehavioural and perceptual assessments including General Movement Assessment at preterm, writhing and fidgety age. Primary caregivers will complete questionnaires to identify social risk, maternal depression and family strain. Extensive perinatal data will be collected from the medical record. At 24 months, corrected age (c.a) infants will be assessed using standardised tools including the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley III). Longitudinal trajectories of early assessment findings will be examined to determine any predictive relationship with motor and cognitive outcomes at 24 months c.a. Published data of a cohort of Australian children assessed with the Bayley III at 24 months c.a will provide a reference group of term-born controls.

ETHICS

Ethical approval has been obtained from the Queensland Children's Health Services Human Research Ethics Committee (HREC/13/QRCH/66), the University of Queensland (2013001019) and the Sunshine Coast Hospital and Health Service, SC-Research Governance (SSA/13/QNB/66). Publication of all study outcomes will be in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12614000480684; Pre-results.

Fidgety movements - tiny in appearance, but huge in impact

OBJECTIVES

To describe fidgety movements (FMs), i.e., the spontaneous movement pattern that typically occurs at 3-5 months after term age, and discuss its clinical relevance.

SOURCES

A comprehensive literature search was performed using the following databases: MEDLINE/PubMed, CINAHL, The Cochrane Library, Science Direct, PsycINFO, and EMBASE. The search strategy included the MeSH terms and search strings ('fidgety movement*') OR [('general movement*') AND ('three month*') OR ('3 month*')], as well as studies published on the General Movements Trust website (www.general-movements-trust.info).

SUMMARY OF THE DATA

Virtually all infants develop normally if FMs are present and normal, even if their brain ultrasound findings and/or clinical histories indicate a disposition to later neurological deficits. Conversely, almost all infants who never develop FMs have a high risk for neurological deficits such as cerebral palsy, and for genetic disorders with a late onset. If FMs are normal but concurrent postural patterns are not age-adequate or the overall movement character is monotonous, cognitive and/or language skills at school age will be suboptimal. Abnormal FMs are unspecific and have a low predictive power, but occur exceedingly in infants later diagnosed with autism.

CONCLUSIONS

Abnormal, absent, or sporadic FMs indicate an increased risk for later neurological dysfunction, whereas normal FMs are highly predictive of normal development, especially if they co-occur with other smooth and fluent movements. Early recognition of neurological signs facilitates early intervention. It is important to re-assure parents of infants with clinical risk factors that the neurological outcome will be adequate if FMs develop normally.

Predictive value of general movements' quality in low-risk infants for minor neurological dysfunction and behavioural problems at preschool age

BACKGROUND

General movement (GM) assessment is a well-established tool to predict cerebral palsy in high-risk infants. Little is known on the predictive value of GM assessment in low-risk populations.

AIMS

To assess the predictive value of GM quality in early infancy for the development of the clinically relevant form of minor neurological dysfunction (complex MND) and behavioral problems at preschool age.

STUDY DESIGN

Prospective cohort study.

SUBJECTS

A total of 216 members of the prospective Groningen Assisted Reproductive Techniques (ART) cohort study were included in this study. ART did not affect neurodevelopmental outcome of these relatively low-risk infants born to subfertile parents.

OUTCOME MEASURES

GM quality was determined at 2 weeks and 3 months. At 18 months and 4 years, the Hempel neurological examination was used to assess MND. At 4 years, parents completed the Child Behavior Checklist; this resulted in the total problem score (TPS), internalizing problem score (IPS), and externalizing problem score (EPS). Predictive values of definitely (DA) and mildly (MA) abnormal GMs were calculated.

RESULTS

DA GMs at 2 weeks were associated with complex MND at 18 months and atypical TPS and IPS at 4 years (all p<0.05). Sensitivity and positive predictive value of DA GMs at 2 weeks were rather low (13%-60%); specificity and negative predictive value were excellent (92%-99%). DA GMs at 3 months occurred too infrequently to calculate prediction. MA GMs were not associated with outcome.

CONCLUSIONS

GM quality as a single predictor for complex MND and behavioral problems at preschool age has limited clinical value in children at low risk for developmental disorders.

Computer-based analysis of general movements reveals stereotypies predicting cerebral palsy

AIM

To evaluate a kinematic paradigm of automatic general movements analysis in comparison to clinical assessment in 3-month-old infants and its prediction for neurodevelopmental outcome.

METHOD

Preterm infants at high risk (n=49; 26 males, 23 females) and term infants at low risk (n=18; eight males, 10 females) of developmental impairment were recruited from hospitals around Heidelberg, Germany. Kinematic analysis of general movements by magnet tracking and clinical video-based assessment of general movements were performed at 3 months of age. Neurodevelopmental outcome was evaluated at 2 years. By comparing the general movements of small samples of children with and without cerebral palsy (CP), we developed a kinematic paradigm typical for infants at risk of developing CP. We tested the validity of this paradigm as a tool to predict CP and neurodevelopmental impairment.

RESULTS

Clinical assessment correctly identified almost all infants with neurodevelopmental impairment including CP, but did not predict if the infant would be affected by CP or not. The kinematic analysis, in particular the stereotypy score of arm movements, was an excellent predictor of CP, whereas stereotyped repetitive movements of the legs predicted any neurodevelopmental impairment.

INTERPRETATION

The automatic assessment of the stereotypy score by magnet tracking in 3-month-old spontaneously moving infants at high risk of developmental abnormalities allowed a valid detection of infants affected and unaffected by CP.

General movements and magnetic resonance imaging in the prediction of neuromotor outcome in children born extremely preterm

BACKGROUND

Extremely preterm (EPT) birth is a major risk factor for brain injury and neurodevelopmental impairment. Reliable tools for early prediction of outcome are warranted.

AIM

To investigate the predictive value of general movements (GMs) at "fidgety age" for neurological outcome at age 30 months in EPT infants, both in comparison and in combination with structural magnetic resonance imaging (MRI) at term equivalent age (TEA).

STUDY DESIGN

Fifty-three infants born <27 weeks of gestation were included prospectively. MRI was performed at TEA and images were evaluated for white and grey matter abnormalities. GMs were assessed at age 3 months corrected ("fidgety age").

OUTCOME MEASURES

Neuromotor outcome was assessed at age 30months corrected. Children were classified as having a normal neurological status, unspecific signs, or cerebral palsy (CP).

RESULTS

Abnormal GMs were a common finding, seen in 32% (17/53) of infants. Of these, six infants (11%) had definitely abnormal GMs. Four infants (8%) had a diagnosis of CP at follow up. Definitely abnormal GMs were significantly associated to CP at 30 months (Fisher's Exact test p=0.03, sensitivity 50%, specificity 92%). Moderate-severe white matter abnormalities on MRI were more strongly associated with CP (Fisher's Exact test p<0.001, sensitivity 100%, specificity 98%) than GMs. Combining GMs with MRI-findings at TEA increased the predictive specificity to 100% (Fisher's Exact test, p=0.005), whereas sensitivity remained unchanged.

CONCLUSIONS

The presence of definitely abnormal GMs was predictive of CP: prediction was significantly enhanced when the GMs assessment was combined with findings from MRI obtained at TEA.

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.

Early markers for cerebral palsy: insights from the assessment of general movements

Overt clinical symptoms of cerebral palsy do not emerge before a child is at least half a year old. Among the most reliable early markers for cerebral palsy are abnormal ‘general movements’ (GMs). Two specific abnormal GM patterns predict cerebral palsy: cramped-synchronized GMs (during preterm and term age), which lack the usual smoothness and fluent character; and limb and trunk muscles contract almost simultaneously and relax almost simultaneously. In addition, the absence of so-called fidgety movements at 3–5 months post-term age. Fidgety movements are small movements of the neck, trunk and limbs in all directions and of variable acceleration. Beside a high sensitivity (>91%) and specificity (>81%), the assessment of GMs is quick, nonintrusive and easy to acquire.

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.

Assessment of specific characteristics of abnormal general movements: does it enhance the prediction of cerebral palsy?

AIM

Abnormal general movements at around 3 months corrected age indicate a high risk of cerebral palsy (CP). We aimed to determine whether specific movement characteristics can improve the predictive power of definitely abnormal general movements.

METHOD

Video recordings of 46 infants with definitely abnormal general movements at 9 to 13 weeks corrected age (20 males; 26 females; median gestational age 30wks; median birthweight 1200g) were analysed for the following characteristics: presence of fidgety, cramped synchronized, stiff, or jerky movements and asymmetrical tonic neck reflex pattern. Neurological condition (presence or absence of CP), gross motor development (Alberta Infant Motor Scales), quality of motor behaviour (Infant Motor Profile), functional mobility (Pediatric Evaluation of Disability Inventory), and Mental Developmental Index (Bayley Scales) were assessed at 18 months corrected age. Infants were excluded from participating in the study if they had severe congenital anomalies or if their caregivers had an insufficient knowledge of the Dutch language.

RESULTS

Of the 46 assessed infants, 10 developed spastic CP (Gross Motor Function Classification System levels I to V; eight bilateral spastic CP, two unilateral spastic CP). The absence of fidgety movements and the presence of predominantly stiff movements were associated with CP (Fisher's exact test, p=0.018 and p=0.007 respectively) and lower Infant Motor Profile scores (Mann-Whitney U test, p=0.015 and p=0.022 respectively); stiff and predominantly stiff movements were associated with lower Alberta Infant Motor Scales scores (Mann-Whitney U test, p=0.01 and p=0.004 respectively). Cramped synchronized movements and the asymmetrical tonic neck reflex pattern were not related to outcome. None of the movement characteristics were associated with Pediatric Evaluation of Disability Inventory scores or the Mental Developmental Index.

INTERPRETATION

The assessment of fidgety movements and movement stiffness may improve the predictive power of definitely abnormal general movements for developmental outcome. However, the presence of fidgety movements does not preclude the development of CP.

Neurodevelopmental assessment of the newborn: An opportunity for prediction of outcome

Over the decades, the evolution of neonatology has been a continuum. After intense focus on cardiac and respiratory support, now more time, effort and research are concerned about brain development of the term and preterm infants. There is no single standardized neurodevelopmental assessment tool that can be advocated for infants in the neonatal intensive care unit. The tools that are currently available vary in their physiological bases, pre requisite training and expertise, time allotted to perform and score, and clinical utility and validity. In this communication, we describe the neurobehavioral and sensory capabilities of the neonate. We then compare the commonly used neurobehavioral examinations with an emphasis on premature infants. We envision this effort as an essential step before the development of a universal and comprehensive assessment tool.

Variation and variability: key words in human motor development

This article reviews developmental processes in the human brain and basic principles underlying typical and atypical motor development. The Neuronal Group Selection Theory is used as theoretical frame of reference. Evidence is accumulating that abundance in cerebral connectivity is the neural basis of human behavioral variability (ie, the ability to select, from a large repertoire of behavioral solutions, the one most appropriate for a specific situation). Indeed, typical human motor development is characterized by variation and the development of adaptive variability. Atypical motor development is characterized by a limited variation (a limited repertoire of motor strategies) and a limited ability to vary motor behavior according to the specifics of the situation (ie, limited variability). Limitations in variation are related to structural anomalies in which disturbances of cortical connectivity may play a prominent role, whereas limitations in variability are present in virtually all children with atypical motor development. The possible applications of variation and variability in diagnostics in children with or at risk for a developmental motor disorder are discussed.

Does perinatal asphyxia contribute to neurological dysfunction in preterm infants?

BACKGROUND

Children born preterm are known to be at risk for neurodevelopmental disorders. The role of perinatal asphyxia in this increased risk is still a matter of debate.

AIM

To analyze the contribution of perinatal asphyxia in a population of preterm infants admitted to a secondary paediatric setting to neurological dysfunction in the first months after birth and to the development of cerebral palsy.

METHODS

17 preterm infants with perinatal asphyxia born before 35 weeks postmenstrual age (PMA) and 34 carefully matched preterm controls without asphyxia were studied. Neuromotor outcome was examined by means of three assessments of the quality of general movements (GM) at "preterm" (around 34 weeks PMA), "writhing" (around term age) and "fidgety" GM age (around 3 months post term). Follow-up until at least 18 months corrected age focused on the presence of cerebral palsy (CP).

RESULTS

GM-quality of infants with asphyxia and of those without did not differ. Multivariate analysis revealed that abnormal GMs at "preterm" age were associated with respiratory problems, those at "writhing" age with none of the assessed risk factors, and those at "fidgety" age with the severity of periventricular leukomalacia (PVL) on neonatal ultrasound scan. Perinatal asphyxia was not associated with the development of CP. CP was associated with PVL and the presence of abnormal GMs at "fidgety" age.

CONCLUSION

Perinatal asphyxia in preterm infants is not associated with an increased risk for neurodevelopmental problems including CP. Respiratory problems during the neonatal period are associated with PVL and adverse neurological outcome.

Predictive value of definitely abnormal general movements in the general population

AIM

Definitely abnormal general movements in populations of high-risk infants predict serious neurodevelopmental impairment. This study aimed to assess predictive values of definitely abnormal general movements at 3 months for serious neurodevelopmental impairment in a representative sample of the general population.

METHOD

A prospective cohort study of 455 3-month-old infants was performed (241 females, 214 males; mean birthweight 3452g, SD 604g; mean gestational age 39.4wks, SD 1.96; n=32 born preterm). At enrolment, general movement quality was assessed by means of video recording. At 4 years, all participants were reassessed by well-baby health clinicians; if serious neurodevelopmental impairment was identified, clinical records were reviewed. Predictive values of definitely abnormal general movement quality for major neurodevelopmental impairment were calculated.

RESULTS

Five children were diagnosed as having a major neurodevelopmental disorder with serious implications for daily life, including three children with cerebral palsy (CP). Three out of the five had shown definitely abnormal general movements; they had lesions involving the periventricular white matter. Two children did not show definitely abnormal general movements; one had unilateral spastic CP due to a cortical lesion and the other had ataxia due to cerebellar atrophy. The positive predictive value of definitely abnormal general movements for major neurodevelopmental impairment was 18/100, and for CP it was 12/100. Negative predictive values approached 100%.

INTERPRETATION

The good predictive value of general movement assessment in high-risk populations cannot be generalized to the general population.

Delayed acquisition of neonatal reflexes in newborn primates receiving a thimerosal-containing hepatitis B vaccine: influence of gestational age and birth weight

This study examined whether acquisition of neonatal reflexes in newborn rhesus macaques was influenced by receipt of a single neonatal dose of hepatitis B vaccine containing the preservative thimerosal (Th). Hepatitis B vaccine containing a weight-adjusted Th dose was administered to male macaques within 24 h of birth (n = 13). Unexposed animals received saline placebo (n = 4) or no injection (n = 3). Infants were tested daily for acquisition of nine survival, motor, and sensorimotor reflexes. In exposed animals there was a significant delay in the acquisition of root, snout, and suck reflexes, compared with unexposed animals. No neonatal responses were significantly delayed in unexposed animals. Gestational age (GA) and birth weight (BW) were not significantly correlated. Cox regression models were used to evaluate main effects and interactions of exposure with BW and GA as independent predictors and time-invariant covariates. Significant main effects remained for exposure on root and suck when controlling for GA and BW, such that exposed animals were relatively delayed in time-to-criterion. Interaction models indicated there were various interactions between exposure, GA, and BW and that inclusion of the relevant interaction terms significantly improved model fit. This, in turn, indicated that lower BW and/or lower GA exacerbated the adverse effects following vaccine exposure. This primate model provides a possible means of assessing adverse neurodevelopmental outcomes from neonatal Th-containing hepatitis B vaccine exposure, particularly in infants of lower GA or BW. The mechanisms underlying these effects and the requirements for Th requires further study.

Interexaminer reliability of Amiel-Tison neurological assessments

Both the Amiel-Tison Neurological Assessment at Term and the Amiel-Tison Neurological Assessment From Birth to 6 Years Old are based on the same conceptual framework and both can be used throughout childhood; however, interobserver reliability must be evaluated before these assessments can be introduced into neurodevelopmental follow-up. The aim of this study was to evaluate the interobserver reliability of both assessments. Infants between 29 and 37 weeks gestation were examined with the Amiel-Tison Neurological Assessment at Term (n = 33) and with the Amiel-Tison Neurological Assessment From Birth to 6 Years Old (n = 26). The infants were assessed by two examiners, one after and in the absence of the other. The kappa coefficient and percentage of agreement were calculated. The majority of items in both assessments showed an excellent reliability. The kappa coefficient for the final synthesis was also excellent in both cases. Future studies on the predictive validity of both assessments are required to determine their utility in predicting long-term neurodevelopmental outcome.

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.

Prevalence of abnormal general movements in three-month-old infants

BACKGROUND

The quality of general movements (GMs) is a sensitive tool to measure neurodevelopmental condition in early infancy. No information is available on prevalence rates of abnormal GMs in the general population.

OBJECTIVE

To assess the prevalence of abnormal GMs in the general population of three-month-old infants and to evaluate the association of abnormal GM quality with medical and social risk factors.

METHOD

We recruited 535 infants in six well baby clinics in The Netherlands. GMs were video-taped at the corrected age of 2 to 4 months. GM-quality was assessed by two persons unaware of the infant's history. GM-quality was classified as normal optimal (NO), normal suboptimal (SO), mildly abnormal (MA) and definitely abnormal (DA). Only the last category implies clinically relevant dysfunction. Social, perinatal and postnatal characteristics were collected and their association with DA and abnormal (DA+MA) GMs were evaluated by means of univariate and logistic regression analyses.

RESULTS

GM-quality could be assessed reliably in 455 infants (85%). Seventeen infants (3.7%) showed DA GMs and 113 (25%) MA GMs. DA GMs were associated with preterm birth and smoking during pregnancy; abnormal (DA+MA) GMs with preterm birth, a relatively low level of paternal profession and urban living conditions. These factors explained between 3% and 7% of variance.

CONCLUSION

The study indicates that the prevalence of definitely abnormal GMs in the general population is 3.7% and that of mildly abnormal GMs 25%. The clinically relevant definitely abnormal GMs were associated with preterm birth and smoking during pregnancy.

Continuity between Fetal and Neonatal Neurobehavior

As the development of the brain is unique and continuing process throughout the gestation and after birth, it is expected that there is also continuity of fetal and neonatal movements which are the best functional indicator of developmental processes of the brain. Understanding the relation between fetal and infant behavior and developmental processes of the brain in different periods of gestation may make achievable the distinction between normal and abnormal brain development. Epidemiological studies revealed that many neurologically impaired infants belong to low risk population, which means that they seemed to be developmentally normal as fetuses and as infants, while later childhood neurological disability was diagnosed. Which methods of neurological assessment are available for that purpose? Prenatally we have not many possibilities for neurological assessment, while postnatally the repertoire of diagnostic possibilities is increasing. Among the postnatally available methods for neurological assessment, the most important are: clinical neurological assessment, neuroimaging methods, assessment of general movements (GMs) and combinations. Postnatal neurological assessment is probably easier to perform than prenatal, by using a simple and suitable for everyday work screening clinical test with good reliability, specificity and sensitivity.

There is a possibility for the early and simple neurological assessment of the term and preterm newborns with the aim to detect associated risks and anticipate long-term outcome of the infant, and to establish a possible causative link between pregnancy course and neurodevelopmental outcome. The evaluation of infant's developmental optimality should be assessed in order to investigate whether the infant is neurologically normal or damaged. Neurological assessment at term by Amiel-Tison (ATNAT) is taking into account neurological maturation exploring so called lower subcortical system developing earlier from the reticular formation, vestibular nuclei and tectum, and upper cortical system developing from the corticospinal pathways.

Conventional acquisition neuroimaging techniques together with modern diffusion neuroimaging techniques can identify typical patterns of brain injury, even in the early course of the disease. However, even though highly suggestive, these patterns cannot be considered as pathognomonic. Nevertheless neuroimaging methods alone are not sufficient to predict the neurological outcome in neonates from highrisk population.

Prechtl stated that spontaneous motility, as the expression of spontaneous neural activity, is a marker of brain proper or disturbed function. The observation of unstimulated fetus or infant which is the result of spontaneous behavior without sensory stimulation is the best method to assess its central nervous system capacity. All endogenously generated movement patterns from un-stimulated central nervous system could be observed as early as from the 7-8 weeks of postmenstrual age, with developing a reach repertoire of movements within the next two or three weeks, continuing to be present for 5 to 6 months postnatally. This remarkable fact of the continuity of endogenously generated activity from prenatal to postnatal life is the great opportunity to find out those high-risk fetuses and infants in whom development of neurological impairment is emerging. The most important among those movements are GMs involving the whole body in a variable sequence of arm, leg, neck and trunk movements, with gradual beginning and the end. They wax and wane in intensity, force and speed being fluent and elegant with the impression of complexity and variability. Assessment of GMs in high-risk newborns has significantly higher predictive value for later neurological development than neurological examination. Kurjak and co-workers conducted a study by 4D ultrasound and confirmed earlier findings made by 2D ultrasonography, that there is behavioral pattern continuity from prenatal to postnatal life. Assessment of neonatal behavior is a better method for early detection of cerebral palsy than neurological examination alone.

Are we approaching the era when there will be applicable neurological test for fetus and assessment of neonate will be just the continuation? This is still not easy question to answer, because even postnatally there are several neurological methods of evaluation, while in utero we are dealing with more complicated situation and less mature brain. Could neonatal assessment of neurologically impaired fetuses bring some new insights into their prenatal neurological status is still unclear and to be investigated. New scoring system for prenatal neurological assessment of the fetus proposed by Kurjak et al will give some new possibilities to detect fetuses at high neurological risk, although it is obvious that dynamic and complicated process of functional CNS development is not easy to investigate.

The aim of this review is to present continuity of the functional central nervous system assessment from prenatal to postnatal life.