Neonatal neurological examination as a predictor of neuromotor outcome at 4 months in term low-Apgar-score babies in Zimbabwe

Subtle bilirubin-induced neurodevelopmental dysfunction (BIND) in the term and late preterm infant: does it exist?

Subtle bilirubin-induced neurological dysfunction (BIND) is defined as disturbances in sensory and sensorimotor integration, central auditory processing, coordination, and muscle tone in the absence of the classical findings of kernicterus. This review is restricted to the (sensori)motor signs of BIND associated with unconjugated hyperbilirubinemia in term and late preterm neonates. The diagnosis of BIND at follow-up requires validated, age-specific techniques that are designed to identify these disturbances in infancy and later childhood. The (sensori)motor signs of BIND are compatible with the pathological substrate of unconjugated hyperbilirubinemia and its known effects on the brain.

Apgar Scores: Examining the Long-term Significance

The Apgar scoring system was intended as an evaluative measure of a newborn's condition at birth and of the need for immediate attention. In the most recent past, individuals have unsuccessfully attempted to link Apgar scores with long-term developmental outcomes. This practice is not appropriate, as the Apgar score is currently defined. Expectant parents need to be aware of the limitations of the Apgar score and its appropriate uses.

Neonatal assessments for the preterm infant up to 4 months corrected age: a systematic review

AIM

The aim of this study was to systematically review the clinimetric properties of longitudinal neonatal neurobehavioural and neuromotor assessments for preterm infants.

METHOD

Twenty-seven assessment measures were identified. The following eight measures met the study inclusion criteria: Assessment of Preterm Infants' Behaviour (APIB), Neonatal Intensive Care Unit Network Neurobehavioural Scale (NNNS), Test of Infant Motor Performance (TIMP), Prechtl's Assessment of General Movements (GMs), Neurobehavioural Assessment of the Preterm Infant (NAPI), Dubowitz Neurological Assessment of the Preterm and Full-term Infant (Dubowitz), Neuromotor Behavioural Assessment (NMBA), and the Brazelton Neonatal Behavioural Assessment Scale (NBAS). The primary purposes included prediction (TIMP, GMs, Dubowitz), discrimination (all assessments), and evaluation of change (TIMP, NAPI). Measures of assessment were included in the study if they were (1) primarily neurobehavioural or neuromotor assessments that were suitable for use with preterm infants (<37 weeks gestation) up to 4 months corrected age and were discriminative, predictive, or evaluative; (2) standardized procedures designed for serial/longitudinal use; or (3) criterion or norm referenced. However, all assessment tools that were not published in English in a peer-reviewed journal or were primarily neurological assessments, one-time evaluations, screening tools, or not commercially available were not used.

RESULTS

All of the measures included in the review demonstrated adequate content and construct validity. Concurrent validity was reported for APIB, NNNS, Dubowitz, and GMs. Predictive validity was high for GMs with studies reporting up to 100% senstivity for predicting cerebral palsy at the age of 12 to 24 months. Interrater reliability was strong for the TIMP (intraclass correlation=0.95), GMs (K=0.8), and moderate for the NAPI (r=0.67-0.97). Clinical utility was variable for ease of scoring, interpretability, cost, and access.

INTERPRETATION

In the absence of a criterion standard for neonatal neuromotor assessments, the NNNS and APIB have strong psychometric qualities with better utility for research. Similarly, the GMs, TIMP, and NAPI have strong psychometric qualities but better utility for clinical settings. The GMs has best prediction of future outcome and the TIMP has best evaluative validity.

The neurological examination of non-complicated preterm newborns using the Saint-Anne Dargassies Scale from birth to term

OBJECTIVE

To describe the maturational development of 20 (aged 32-36 weeks) premature newborns (PNBs) without clinical or neurological complications from birth until term.

METHOD

The Saint-Anne Dargassies Scale was applied every two weeks until the age of 37 weeks.

RESULTS

The PNBs showed normal Apgar and the growth in head circumference was adequate for postmentrual age. The Friedman ANOVA test found a significant difference only for the heel-to-ear angles from birth until term. The Saint-Anne Dargassies Scale detected changes in 11 PNBs and the most altered reflexes were: cardinal points, Moro, cross extension reflexe and automatic walking. These changes were found in the first 48 hours of life and in subsequent weeks until term.

CONCLUSION

This finding alone justifies the neurological examination of PNBs, even if they show no clinical/neurological complications in the perinatal period and the importance of neuromotor assessment in preterm infants, as it enables detection and appropriate intervention.

The predictive value of early neurological examination in neonatal hypoxic-ischaemic encephalopathy and neurodevelopmental outcome at 24 months

AIM

The clinical and electrographic signs of hypoxic-ischaemic encephalopathy (HIE) evolve over the first days of life. We examined the evolution of neurological signs over the first 3 days of life, and determined whether serial administration of the Amiel-Tison Neurological Assessment at Term (ATNAT) would predict neurodevelopmental outcome at 24 months.

METHOD

Term (>37 wks' gestation) neonates born with suspected HIE between May 2003 and May 2005 in a Cork maternity unit were recruited prospectively. Modified Sarnat grading was assigned. The ATNAT was administered on days 1, 2, and 3 of life and a discharge neurological examination. Time to oral feeding and demographic variables were recorded. Developmental status was assessed using the revised Griffiths Mental Development Scales at 6, 12, and 24 months.

RESULTS

Fifty-seven infants were recruited, with 51 (31 males, 20 females) included for follow-up. Neurological examination evolved and normalized over the first 3 days of life in many cases. At 24 months, 21 children had an adverse outcome, including six deaths. Examination at all time points correlated significantly with neurological outcome at 24 months. The best correlations were found to be (1) neurological examination at discharge (r=0.65, p<0.001), (2) Sarnat grading (r=0.64, p<0.001), and (3) ATNAT on day 3 (r=0.46, p<0.001). The best predictive value was seen with neurological examination at discharge (positive and negative predictive values of 86% and 72% respectively).

INTERPRETATION

Persistence of abnormal neurological signs correlates significantly with adverse outcome. The later a neonatal neurological examination was performed, the better its predictive ability.