THE NEURODEVELOPMENTAL ASSESSMENT OF THE HIGH RISK INFANT V Magasiner, C Molteno* SUMMARY This article describes how postural tone, postural reactions and basic reflexes can be used to evaluate the neurodevel- opmental status of the infant. It includes a simple assessment which can be used in a practical setting. INTRODUCTION Many infants who would formerly have died now survive thanks to improvements in neonatal intensive care. Over the past three years, a num ber o f these survivors have been successfully assessed at the G roote Schuur High Risk Follow-up Clinic, using the infant-neuro- developmental assessment outlined in this paper. T he majority o f infants seen fall into two main groups: very low birth weight (V L B W ) infants; and full term infants w ho have presented with clinical signs o f hypoxic-ischaemic encephalopathy. V LBW infants (below 1 500 grams) are at risk for long-term neurodevelopmental handicap because the im m ature brain has been exposed to potentially damaging insults both before and after d e ­ livery. In these neonates there is increased incidence o f asphyxia neonatorum , hyaline m em brane disease and anoxic spells due to an im m ature respiratory centre. Resultant hypoxia may lead to periven­ tricular leucomalacia and intraventricular haem orrhage (IV H ), A p­ proximately 45% VLBW infants dem onstrate IV H . Many o f these haem orrhages are small and do not cause clinical problems. A bout 10% o f VLB W infants develop neurodevelopmental problems. In full term infants, hypoxic ischaemic encephalopathy may lead to neuronal damage. It is therefore imperative that neurodevelopm ental assessment form part o f the long-term follow up o f these infants as early diagnosis and treatm ent can lead to improved long-term outcome. T he aim o f the initial neurodevelopmental assessment is to categorize infants into three groups: 1. Normal: In Cape Town these infants are followed up by paediatri­ cians at Midwife Obstetric U nits situated in the community. 2. Some ab n o rm al signs b u t no serious abnorm alities: T hese infants are seen again at our High Risk Clinics at six, nine and 12 m onths chronological age. 3. D efin ite n eu ro lo g ical im p a irm e n t: These infants are referred to the Cerebral Palsy Clinic at R ed Cross W ar Memorial Child­ ren’s Hospital. T h e first assessment is not strongly predictive but gross ab n o r­ mality can be identified and abnorm al signs followed up. METHODS AND OBSERVATIONS Full term infants (37 to 42 weeks) are first assessed neurode- velopmentally at 4.5 months chronological age. V L B W infants are first assessed neurodevelopmentally at 4.5 months corrected age (ie 40 weeks post conception plus 18 weeks). This is a good age at which OPSOMMING Hierdie artikel beskryf hoe posturale tonus, posturale reaksies en basiese reflekse gebruik kan word om die neurologiese vlak van ontwikkeling van die kind te evalueer. Dit sluit in ’n eenvoudige evaluering wat in die praktyk gebruik kan word. to begin assessing V L B W infants as most o f the preterm m ovement patterns associated with low tone should no longer be present, eg head lag, lack o f trunk control, increased range o f movement and exten­ sion in the legs. T herefore both groups o f infants should exhibit the sam e m ovement patterns a t the tim e o f neurodevelopm ental assess­ ment. T he assessment follows a definite sequence from gentle to m ore vigorous movement. This reduces the likelihood o f crying which leads to increased tone. T here are two stages to the assessment: In the first stage, the infant is assessed fu lly dressed while sitting sideways on the m other’s lap. • A bangle is held in front o f the infant’s face to assess ability to focus the eyes. • T he bangle is positioned within the infant’s grasp to test midline hand function and symmetry. • T he bangle is then moved to each side to assess eye following. • A rattle is shaken behind each ear to test for awareness o f sound. In the second stage the infant is undressed and the assessment follows the routine illustrated in the Figure. 1. Supine lie: T h e infant’s posture is assessed in the supine position. T he examiner looks to see whether: • the head is in the midline • the hands are brought to the m outh • the infant kicks his legs reciprocally • the infant is alert and responsive and w hether he smiles and babbles. T h e m other can verify each o f these items if necessary. In the Figure, “H ead asymm” (head asymmetrical) m eans the infant lies with his head tu rn ed to one side. “H ead symm” (head symmetrical) m eans the infant lies with his head in the midline. Sometimes lack o f hand function on o ne side is associated with the absence o f leg kicking on the sam e side. U se o f only one hand in an infant under one year needs to be referred for fu rth er assessment. D om inance begins gradually b e­ tween 12-18 months. T he “Angles” m ethod (according to Ellison1) tests tone in legs and arm s by moving the limbs through a range o f movem ent in a set pattern. O ften the expected norm al limit o f range can be reached but quality o f m ovement as the limb is moved through the range is also important. D oes the m ovement feel stiff o r floppy? N o infant should have a smaller range o f movem ent than indicated on the chart. All movements are perform ed smoothly. 2. Adductor angle: Examiner opens legs as far as possible. T he angle * V Magasiner, Dip Phys (UCT) C Molteno, MD, PhD, FCP (SA) Cerebral Palsy Clinic, Red Cross War Memorial Children’s Hospital, Rondebosch, Cape Town First published in the May/June 1990 issue of PEDMED, the South African Paediatric Medicine Journal, on page 23. PEDMED is published by the Medical Division of George Warman Publications (Pty) Ltd P O Box 704, Cape Town 8000 Physiotherapy, November 1990, vol 46 no 4 Page 13 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) form ed by the legs is m easured. 3. Head to ears: Buttocks on the table. T he legs are kept straight and moved towards the ears. W hen there is resistance to this move­ ment, the angle formed from table surface to legs is measured. 4. Popliteal angle: Buttocks on the table. T he hips are flexed to bring the knees to either side o f the abdom en, until there is resistance. Then knees are extended. When there is resistance to this movement, the angle formed between the lower and upper leg is measured. 5. Dorsiflexion angle o f the foot: T he knee is extended. T he foot is dorsiflexed and the angle between foot and leg is measured. 6. Scarf sign: The examiner takes infant’s hand and pulls arm across the infant’s chest until there is resistance. T he position o f the elbow is noted in relation to the midline. T h e scarf sign tests the m ovement o f the scapula around the chest wall. 7. With the infant in supine position, tractio n is applied to arm s until trunk forms an angle o f 45 degrees with the examination plane. G rasp at wrist level. D O N O T insert finger into palm as this initiates total flexion o f head and trunk2. • Com plete head lag with extended arms. • M oderate head lag • H ead is in line with the trunk, the arm s and legs are in flexion with feet elevated. • T he child actively flexes the head forward with strong elbow flexion. Knees go from flexion to extension. Sometimes the infant com es u p to the sitting position with the spine slightly extended. This is normal. However, if the infant pushes back actively into extension as the examiner pulls to sit, careful follow-up is indicated. 8. Sitting: • Com plete flexion o f trunk. • Extension down to thoracic spine. • Extension down to lum bar three. • P ro p sitting. Weight-bearing forward onto hands. • Extension with cervical lordosis. • Extension with cervical and lum bar lordosis. • Infant is able to ro tate his trunk sideways. 9. Prone lie: • Elbow flexion support. • Elbow extension support. 10. Landau: • Infant held in prone position with trunk supported. • H ead flexed, trunk curved. • H ead, cervical and thoracic regions form one horizontal plane. • Extension o f head above horizontal plane. Full extension o f trunk and pelvis. 11. Axillary hanging: Examiner holds infant from behind ju st below axillae with feet free o f table. • N o head control with legs in loose flexion. • Legs in strong flexion. • Preparation for weight bearing with extended legs. W atch for abnormal scissors pattern o f legs, th at is legs crossed with plantarflexed feet. An infant w ho hyperextends the spine during this test should be followed up carefully. 12. Votja side tilting: Infant is held vertically at chest level with back to examiner and then tilted into lateral horizontal position. • M oderate trunk flexion. Moro-like response in u p p er arm. U p p er leg should flex with underlying leg extending. • H ead and trunk righting, flexion o f u p p er arm , flexion o f both legs. 13. Collis horizontal: Infant lies on his side close to examiner with back to examiner. T he examiner’s hands grasp over shoulder and hip joints to prevent stretching ligaments. Raise infant ju st off table. • Flexion o f lower leg and arm. • Lower arm elbow extended with hand partially open touching table. • Elbow extended, palm supports body weight. • Lower arm and leg down on table. W atch for abnorm al stiff extension o f the lower leg. Lack o f weight-bearing in the lower arm as an isolated clinical finding is often found in infants who dislike prone lying. In both the V otja and Collis Horizontal responses trunk righting must be carefully watched. T he head and tru n k might right them ­ selves as the infant is tilted sideways, th at is, head and trunk m ust not rem ain in side flexion on the lower side. 14. Grasp reflex: Place index finger in palm from ulnar side. Fisting should cease at 3.5 months. 15. Moro response: Infant is supported on the examiner’s forearm with the head held in the examiner’s hand. T h e head is allowed to fall back. Normally the infant’s arm s go o u t into abduction and extension followed by flexion and adduction. Sometimes the preterm infant’s arm s d o not retu rn to flexion and adduc­ tion. 16. Asymmetrical tonic reflex (ATNR) is observed when testing following o r can be assessed by turning head. T he arm and leg on the skull side should flex and on the face side extend. Sometimes this response is only present in the arm . It is n o t an obligatory response. 17-20. Protective extension 17. Downwards: By 4.5 m onths the infant is held vertically and rapidly lowered. T he legs should extend with abduction and external rotation. T he infant should w eightbear on flat feet. 18. Sideways: By six m onths the infant is placed sitting and is pushed sideways on one shoulder with sufficient force to cause loss o f balance. T he opposite arm should abduct with extension o f elbow and wrist to weightbear. 19. Forwards: By seven m onths the child is held vertically and tilted forwards to the table. T he arm s project forwards with extended elbows, wrist and fingers. 20. Backwards: By nine m onths the child sits and is pushed back­ wards. Both arm s should extend backwards, although som e­ times the reaction is seen only in one arm. In categorising infants into groups, clusters o f signs should be sought. In the group “D efinite neurological im pairm ent”, abnorm al signs are: • M arked head lag • Lack o f trunk.righting • Increased tone in legs and arm s with decreased range o f m ovement • Scissoring • Opisthotonos • D efinite asymmetry • Irritability • Feeding problems • Apathy - not fixing o r following A bnorm al signs which call for fu rth er follow up include: • T he infant who pushes backwards into extension • M oderate head lag and lack o f trunk righting • M oderate asymmetry • Increased tone in legs with decreased range o f movem ent • Persistent standing on toes T hese signs may disappear b u t m ust be sought a t subsequent follow up. Drillien3 and T udehope4 call this condition “T ransient D ysto­ nia” and suggest that even though they disappear by 8-12 months, the signs may be predictive o f later learning difficulties. In such cases not only is the infant re-examined bu t advice is also given to the m other on correct handling, for example: • D iscourage the use o f walking rings and baby bouncers. • D iscourage lap bouncing with extended legs. R ath er en co u r­ age sitting to standing astride the m other’s leg. Bladsy 14 Fisioterapie, November 1990, deel 46 no 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) • T he infant should be held a t hip level when sitting on m other’s lap and not around the chest wall which encourages extension backwards. REFERENCES 1. Ellison P. Neurologic Development of the High Risk Infant. Clinical Perinatology Vol II, No 1,1984. 2. Dubowitz L. Personal communication. 3. Drillien C. et al. Low birth weight children at early school-age; a longitudi­ nal study. Dev M ed Child Neurol 1980;22:26-47. 4. Tudehope D. Minor neurological abnormalities during the first year of life in infants of birth weight of less than 1 500 grams. Aust Paediatr J 1981;17:265-268 5. Votja V. (1976): Die cerebralen Bewegungsstdnmgen en Sauglingpalter. Stuttgart, Enke. 6-. Milani Comparetti A. Routine Developmental Examination in Normal and Retarded Children. Dev M ed & Child Neurol 1967;9:631-638. The NCR Report ...continued from page 12 T he P P A is currently drawing up guidelines for the writing o f medico-legal reports. They negotiate the tariff structure annually with RAMS. They are also trying to bring about less restrictive rules relating to advertising. Miss S Irwin-Carruthers read the report on the W orld Con­ federation for Physical Therapy. Item s for the W C PT newsletter are now being subm itted regularly resulting in favourable com m ent from several o th er countries. Regionalisation is proceeding and the first meeting o f the Africa Region will be hosted by the Zimbabwe Physiotherapy Association. Arising o u t o f a joint W C PT/W H O venture on the care o f the elderly, P ro f J B eenhakker is investigating the needs o f the elderly in South Africa and the extent to which these needs are being m et by physiotherapists. T he W C PT Congress will be held at the Barbican Centre, London. T he them e is “C are in O u r H ands”. A bstracts are d u e by 30 Septem ber 1990. T he report o f the N ational Council fo r th e Physically Disabled in South Africa was written by M rs A Mathias and read by M rs J A C Gilder. M rs Mathias was re-elected to the Executive C om m ittee of the National Council and to the M anagem ent com m ittee o f the Cerebral Palsy Division. Physiotherapists are invited to contribute articles on aspects o f their work with the cerebral palsied to “The White Dove”. T h e Cerebral Palsy Division m et in Kimberley from 5 - 7 March 1990. A num ber o f workshops were held and the results discussed. W hat arose o u t o f the discussions were the need for increased physiotherapy services in particular, b u t also the general shortage o f supplem entary health profession m em bers working in the CP schools. A nother lack discussed was the dearth o f facilities in the Transvaal, but also generally throughout the country. Concern was also ex­ pressed at the overwhelming num ber o f learning-disabled children at CP schools resulting int the transfer o f CP children to inadequately staffed training centres. Miss M -A van d er Velde read the report o f the SA Neurodevel- opm ental Therapy Association. T he N D T Association continues to offer a variety o f courses. They have 150 therapists on the waiting list for the basic course. A congress was held for 19 - 21 April 1990 at the Forest Town School. Concern was expressed that many Black, Col­ oured and Asian neurologically impaired patients have little o r no access to N D T-trained therapists. Some o f the M a tte rs for Discussion: N atal C o astal suggested th e o rg an isatio n o f a N atio n al Physiotherapy Week. It was decided that Back W eek should not be replaced, but that an additional week be considered by the Action Com mittee. T he formation o f a special group for those interested in sports injuries was suggested. This was considered an excellent idea. THE LEPROSY MISSION is looking for a CHRISTIAN PHYSIOTHERAPIST * Tresting leprosy sufferers * In hospital and in community * Home industry training * Expect to travel * Commence as soon as possible Apply to : The Executive Director, Rev L Wiseman P O Box 89527, Lyndhurst 2106 Telephone (011)882-6156 CLASSIFIED ADVERTISEMENTS GEKLASSIFISEERDE ADVERTENSIES WORKING HOLIDAY IN THE UK AND CANADA CONTACT: Dr Chari Loubscher at P O Box 1774, George 6530 or telephone (0441) 74-5122. JOHANNESBURG Physiotherapist required for private practice in pleasant working condi­ tions. Hospital/orthopaedics. CONTACT: Sarina Dietrich (011) 782-6813 (w), 782-5944 (h). HERMANUS Full tim e physiotherapist required for private practice in pleasant work­ ing conditions. CONTACT: Lorna Sutcliffe (0283) 22735 (w) 23675 (h). EQUIPMENT FOR SALE LTU 904 Laserex laser therapy unit for sale. Hardly used. CONTACT: A Lewis (03231) 51806 (pm only). APPARAAT TE KOOP Carters Rosslyn traction couch. Baie goeie toestand - feitlik nuut. R2.000 of NKA. KONTAK (024) 53-4245. PRETORIA Oostelike voorstede. Voldag of halfdag fisioterapeut benodig in pri- vaat praktyk. Manipulatiewe opleiding belangrik. Ure en salaris onde- rhandelbaar. KONTAK : Hannelie Nel (012) 45-1367 (w) of (012) 345-1575 (h). BEDFORDVIEW Physiotherapist required to join busy practice. Knowledge of sports in­ juries and Maitland concept would be useful. CONTACT: Sue (011) 615-6205 (w) or (011) 615-1137 (h). T he rewording o f R ule 21 was further discussed. A motivation by the P P A would be sent to the Professional Board. From N orthern Transvaal cam e a num ber o f suggestions for the fu tu re administrative needs o f the Society. T he process o f cen­ tralisation has already been started. Annual subscriptions will be paid directly to head office which has also com puterized the full m em ber­ ship. TTie feasibility o f compiling a data base o f research, statistics and speakers for lectures were discussed. T he possibility o f holding a Council M eeting every year with fewer N E C meetings was presented. T he m ajor objection was th at by limiting the num ber o f delegates, the exchange o f ideas might be affected. W estern Province tabled their Community Physiotherapy state­ m ent and requested m ore input. Bladsy 16 Fisioterapie, November 1990, dee! 46 no 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )