King, A. R., Machipisa, C., Finlayson, F., Fahey, M. C., Novak, I., & Malhotra, A. (2021). Early detection of cerebral palsy in high-risk infants: Translation of evidence into practice in an Australian hospital. Journal of paediatrics and child health, 57(2), 246–250. https://doi.org/10.1111/jpc.15191

Aim: The early diagnosis of cerebral palsy (CP) allows children timely access to early intervention. In 2018, Monash Children's Hospital established an Early Neurodevelopment Clinic based upon evidence-based guidelines for the early diagnosis of CP in high-risk infants. In this study, we aimed to characterise the infants presenting to the clinic and determine the rate of CP diagnosis.

Methods: This study analysed data from infants attending the Early Neurodevelopment Clinic between May 2019 and April 2020. Infants at high-risk for CP attended the clinic at 3 months corrected age. Neuroimaging reports were reviewed, and a Prechtl's General Movement Assessment and Hammersmith Infant Neurological Examination were performed. Infants were diagnosed as having typical development, delayed development, high-risk of CP or CP at the time of clinic attendance and referred on to the appropriate pathway.

Results: Ninety-six high-risk infants attended the clinic over the 1 year study period. Sixty-eight (71%) infants were extremely preterm or extremely low birthweight, and 28 (29%) were infants at born at older gestation with evidence of moderate to severe brain injury. Nine (9.6%) infants received a CP diagnosis and 12 (12.5%) were considered high-risk of CP. All infants with CP or high-risk of CP were referred to the Victorian Paediatric Rehabilitation Service.

Conclusions: It is feasible to implement the early CP diagnosis guidelines into a high-risk infant follow-up clinic. Implementation of the guidelines allows for early diagnosis of CP and appropriate referral of high-risk infants.

Keywords: Hammersmith infant neurological examination; follow-up; general movement; neuroimaging.

Romeo, D. M., Cowan, F. M., Haataja, L., Ricci, D., Pede, E., Gallini, F., Cota, F., Brogna, C., Vento, G., Romeo, M. G., & Mercuri, E. (2020). Hammersmith Infant Neurological Examination for infants born preterm: predicting outcomes other than cerebral palsy. Developmental medicine and child neurology, 10.1111/dmcn.14768. Advance online publication. https://doi.org/10.1111/dmcn.14768

Romeo, D. M., Bompard, S., Serrao, F., Leo, G., Cicala, G., Velli, C., Gallini, F., Priolo, F., Vento, G., & Mercuri, E. (2019). Early Neurological Assessment in Infants with Hypoxic Ischemic Encephalopathy Treated with Therapeutic Hypothermia. Journal of clinical medicine, 8(8), 1247. https://doi.org/10.3390/jcm8081247

Early neurological assessment in infants with hypoxic ischemic encephalopathy (HIE) treated with hypothermia has not been systematically explored. The aims of the present study were to assess whether the Hammersmith Infant Neurological Examination (HINE) is a good tool to predict later neurodevelopmental outcomes at 2 year from birth in this population of infants. A total of 41 term born infants with HIE treated with hypothermia performed the HINE at 12 months and a neurodevelopmental assessment at 24 months. All the infants who had a global HINE score between 67 and 78 were able to walk independently at 2 years and reported a normal developmental quotient; language disorders were observed in a limited number of infants. HINE scores <67 were always associated with motor impairment. In conclusion, the HINE confirms its role as one of the early neurological examination tools for the diagnosis of high risk infants, even in infants with HIE treated with hypothermia. These results can be useful for clinicians involved in the follow up of these infants for early identification of motor disabilities and in planning appropriate intervention.

Morgan, C., Romeo, D. M., Chorna, O., Novak, I., Galea, C., Del Secco, S., & Guzzetta, A. (2019). The Pooled Diagnostic Accuracy of Neuroimaging, General Movements, and Neurological Examination for Diagnosing Cerebral Palsy Early in High-Risk Infants: A Case Control Study. Journal of clinical medicine, 8(11), 1879. https://doi.org/10.3390/jcm8111879

Introduction: Clinical guidelines recommend using neuroimaging, Prechtls' General Movements Assessment (GMA), and Hammersmith Infant Neurological Examination (HINE) to diagnose cerebral palsy (CP) in infancy. Previous studies provided excellent sensitivity and specificity for each test in isolation, but no study has examined the pooled predictive power for early diagnosis.

Methods: We performed a retrospective case-control study of 441 high-risk infants born between 2003 and 2014, from three Italian hospitals. Infants with either a normal outcome, mild disability, or CP at two years, were matched for birth year, gender, and gestational age. Three-month HINE, GMA, and neuroimaging were retrieved from medical records. Logistic regression was conducted with log-likelihood and used to determine the model fit and Area Under the Curve (AUC) for accuracy.

Results: Sensitivity and specificity for detecting CP were 88% and 62% for three-month HINE, 95% and 97% for absent fidgety GMs, and 79% and 99% for neuroimaging. The combined predictive power of all three assessments gave sensitivity and specificity values of 97.86% and 99.22% (PPV 98.56%, NPV 98.84%).

Conclusion: CP can be accurately detected in high-risk infants when these test findings triangulate. Clinical implementation of these tools is likely to reduce the average age when CP is diagnosed, and intervention is started.

Diagnosing different CP distributions 

Hay, K., Nelin, M., Carey, H., Chorna, O., Moore-Clingenpeel Ma Mas, M., Maitre, N., & NCH Early Developmental Group (2018). Hammersmith Infant Neurological Examination Asymmetry Score Distinguishes Hemiplegic Cerebral Palsy From Typical Development. Pediatric neurology, 87, 70–74. https://doi.org/10.1016/j.pediatrneurol.2018.07.002

Background: The Hammersmith Infant Neurological Examination is one of several useful tools for early identification of cerebral palsy; however, cut-off scores for cerebral palsy do not consistently distinguish infants with hemiplegia from those typically developing. We hypothesized that use of an asymmetry score, in addition to the assessment's standard total cutoff score, could remedy this problem in a clinical setting.

Methods: This retrospective study of a neonatal intensive care follow-up program with consistent clinical use of the Hammersmith Infant Neurological Examination matched infants with a diagnosis of cerebral palsy to infants without motor delays or evidence of neurodevelopmental impairments. Groups had same corrected and gestational ages at Hammersmith Infant Neurological Examination assessment. Asymmetry presence was recorded.

Results: Of 74 infants with cerebral palsy, 28 had quadriplegia, 11 had diplegia, and 35 had hemiplegia. Median total Hammersmith Infant Neurological Examination and asymmetry scores for hemiplegia were 57.5 and 10 versus 76 and 0 for those without cerebral palsy. Sensitivity and specificity to distinguish hemiplegia from typical development by combining a total Hammersmith Infant Neurological Examination score less than 63 and an asymmetry score greater than 5 were 91.8% and 100%, respectively.

Conclusions: In a clinical setting, combining total Hammersmith Infant Neurological Examination and asymmetry scores can help providers differentiate infants with hemiplegia from those typically developing.

Early intervention

Nampijja, M., Webb, E., Nanyunja, C., Sadoo, S., Nalugya, R., Nyonyintono, J., Muhumuza, A., Ssekidde, M., Katumba, K., Magnusson, B., Kabugo, D., Cowan, F. M., Martinez-Biarge, M., Zuurmond, M., Morgan, C., Lester, D., Seeley, J., & Tann, C. J. (2019). Randomised controlled pilot feasibility trial of an early intervention programme for young infants with neurodevelopmental impairment in Uganda: a study protocol. BMJ open, 9(10), e032705. https://doi.org/10.1136/bmjopen-2019-032705