The Hammersmith Infant Neurological Examination (HINE) has been proposed as one of the early neurological examination tools for the diagnosis of cerebral palsy (CP). The aim of the present study was ...to critically review the existing literature and our experience with the use of the HINE in infants at risk of CP. The published papers confirm that the HINE can play an important role in the diagnosis and prognosis of infants at risk of developing CP, and provide information on aspects of neurological findings impaired in different forms of CP and brain lesions.
What this paper adds
Review of the Hammersmith Infant Neurological Examination (HINE) in the early diagnosis of cerebral palsy (CP).
The HINE can be reliably used to assess infants at neurological risk, both preterm and term born.
The HINE identifies early signs of CP in infants with neonatal brain lesions.
Longitudinal assessments will allow differentiation of transient and more permanent abnormalities.
This article is commented on by Haataja on page 219 of this issue.
In the last years, new evidence has increased the attention on sex differences in the development of children with cerebral palsy (CP). Males seem to present with a higher risk for severe motor ...impairment and in the response to chirurgical and rehabilitative interventions. The published data confirmed a higher incidence of CP in males than in females. The aim of this literature review was to evaluate the impact of the sex on the most important areas that characterized CP: motor function, comorbidities (pain, cognitive impairment, communications skills, epilepsy, sleep, and behavior), and the different kind of interventions.
Aim
We explored the ability of the Hammersmith Infant Neurological Examination (HINE) to identify typical and delayed cognitive performance in a large population of infants born preterm, both with ...and without cerebral palsy (CP).
Method
We conducted a retrospective study of infants born preterm who had repeated HINEs between 3 and 12 months corrected age. At 2 years, cognition was assessed using the Mental Development Index (MDI; from the Bayley Scales of Infant Development, Second Edition) and the presence and severity of CP was determined. All children were classified as cognitively typical/mildly delayed or significantly delayed (MDI <70) and CP. The predictive validity of HINE scores for significantly delayed cognitive performance, in children with and without CP, was calculated using specific cut‐off scores according to age at assessment.
Results
Of 1229 eligible infants (gestational age 25–36wks, mean SD 34.9 2.3; 646 males, 583 females), 1108 did not develop CP, 891 had an MDI that was typical/mildly delayed, and 217 had an MDI less than 70. Of the 121 infants who developed CP, the MDI was typical in 28, mildly delayed in 27, and less than 70 in 66. HINE scores showed a good sensitivity and specificity, especially after 3 months, for detecting significantly delayed cognitive performance in infants without CP. In those who developed CP, the score was associated with their cognitive level.
Interpretation
The HINE provides information about the risk of delayed cognitive performance in infants born preterm with and without CP.
What this paper adds
The Hammersmith Infant Neurological Examination (HINE) can be used in the first year to identify infants born preterm at risk for delayed cognitive performance.
Age‐dependent HINE cut‐off scores are proposed for detecting increased risk of delayed cognitive performance.
Examen neurológico infantil de Hammersmith para bebés prematuros: predicción de resultados que no sean parálisis cerebral
Objetivo
Exploramos la capacidad del examen neurológico infantil de Hammersmith (HINE) para identificar el rendimiento cognitivo típico y retrasado en una gran población de recién nacidos prematuros, con y sin parálisis cerebral (PC).
Método
Realizamos un estudio retrospectivo de los recién nacidos prematuros que tenían HINE repetidas entre los 3 y los 12 meses de edad corregida. A los 2 años, se evaluó la cognición utilizando el Índice de Desarrollo Mental (MDI, de las Escalas de Desarrollo Infantil de Bayley, Segunda Edición) y se determinó la presencia y severidad de PC. Todos los niños fueron clasificados como cognitivamente típicos / levemente retrasados o significativamente retrasados (MDI <70) y PC. La validez predictiva de las puntuaciones HINE para el rendimiento cognitivo significativamente retrasado, en niños con y sin PC, se calculó utilizando puntuaciones de corte específicas según la edad en el momento de la evaluación.
Resultados
De 1.229 lactantes elegibles (edad gestacional 25‐36 semanas, media DE 34,9 2,3; 646 varones, 583 mujeres), 1.108 no desarrollaron parálisis cerebral, 891 tenían un MDI que era típico / levemente retrasado y 217 tenían un MDI menos de 70. De los 121 niños que desarrollaron parálisis cerebral, el MDI fue típico en 28, levemente retrasado en 27 y menos de 70 en 66. Las puntuaciones HINE mostraron una buena sensibilidad y especificidad, especialmente después de 3 meses, para detectar retrasos cognitivos rendimiento en lactantes sin PC. En aquellos que desarrollaron PC, la puntuación se asoció con su nivel cognitivo.
Interpretación
El HINE proporciona información sobre el riesgo de retraso en el rendimiento cognitivo en bebés prematuros con y sin parálisis cerebral.
Exame neurológico infantil de Hammersmith para lactentes nascidos prematuros: prevendo outros desfechos além da paralisia cerebral
Objetivo
Exploramos a capacidade do Exame neurológico infantil de Neurological (HINE) em identificar desempenho cognitivo típico e atrasado em uma grande população de lactentes nascidos prematuros, com e sem paralisia cerebral (PC).
Método
Conduzimos um estudo retrospectivo de lactentes nascidos prematuros que tiveram examos HINE repetidos entre 3 e 12 meses de idade corrigida. Aos 2 anos, a cognição foi avaliada usando o Índice de Desenvolvimento mental (IDM), das Escalas Bayley de Desenvolvimento Infantil, Segunda edição) e a presença e severidade da PC foi determinada. Todas as crianças foram classificadas como cognitivamente típicas/levemente atrasadas ou significantemente atrasadas (IDM <70) e PC. A validade preditiva dos escores HINE para desempenho cognitivo significativamente atrasado, em crianças com e sem PC, foi calculada usando escores de corte específicos de acordo com a idade na avaliação.
Resultados
De 1229 lactentes elegíveis (idade gestacional 25–36 semanas, média DP 34,9 2,3; 646 do sexo masculino, 583 do sexo feminino), 1108 não desenvolveram PC, 891 tiveram IDM típico/levemente atrasado, e 217 tiveram IDM menor que 70. Dos 121 lactentes que desenvolveram PC, o IDM foi típico em 28, levemente atrasado em 27, e menor do que 70 em 66. Os escores HINE mostraram boa sensibilidade e especificidade, especialmente após os 3 meses, para detector desempenho cognitivo significativamente atrasado em lactentes sem PC. Naqueles que desenvolveram PC, o escore foi associado com seu nível cognitivo.
Interpretação
A HINE fornece informação sobre o risco de desempenho cognitivo atrasado em lactentes nascidos prematuros com e sem PC.
What this paper adds
The Hammersmith Infant Neurological Examination (HINE) can be used in the first year to identify infants born preterm at risk for delayed cognitive performance.
Age‐dependent HINE cut‐off scores are proposed for detecting increased risk of delayed cognitive performance.
This article's has been translated into Spanish and Portuguese.
Follow the links from the to view the translations.
This article is commented on by Bos on page 891 of this issue.
Aim
We explored the ability of the Hammersmith Infant Neurological Examination (HINE) to identify cognitive performance delay at 2 years in a large cohort of infants born at term.
Method
We conducted ...a retrospective study of infants born at term at risk of neurodevelopmental impairments assessed using the HINE between 3 and 12 months post‐term age and compared them with a cohort of typically developing infants born at term. All infants performed a neurodevelopmental assessment at 2 years of age using the Mental Development Index (MDI) of the Bayley Scales of Infant Development, Second Edition; the presence of cerebral palsy (CP) was also reported. The infants were classified as being cognitively normal/mildly delayed or significantly delayed (MDI < 70). The predictive validity of HINE scores for significantly delayed cognitive performance, in infants with and without CP, was calculated using specific cut‐off scores according to age at assessment.
Results
A total of 446 at‐risk and 235 typically developing infants (345 males, 336 females; mean SD gestational age 38.7 weeks 1.4, range 37–43 weeks) were included. Of the at‐risk infants, 408 did not have CP at 2 years; 243 had a normal/mild delayed MDI and 165 had an MDI less than 70. Of the at‐risk infants, 38 developed CP. HINE scores showed a good sensitivity and specificity, mainly after 3 months, for identifying significantly delayed cognitive performance in infants without CP. In those with CP, the score was associated with their cognitive performance. The comparison group had the highest HINE scores.
Interpretation
The HINE provides evidence about the risk of delayed cognitive performance at age 2 years in infants born at term with and without CP.
RESUMEN
Examen neurológico infantil de Hammersmith en bebés nacidos a término: su uso para predecir otras condiciones además de la parálisis cerebral
Objetivo
Valoramos la capacidad del examen neurológico infantil de Hammersmith (HINE) para identificar el retraso en el rendimiento cognitivo a los 2 años en una cohorte grande de bebés nacidos a término.
Método
Realizamos un estudio retrospectivo de bebés nacidos a término con riesgo de trastornos del desarrollo neurológico evaluados mediante el HINE entre los 3 y los 12 meses de edad postérmino y los comparamos con una cohorte de bebés nacidos a término con un desarrollo típico. Todos los bebés realizaron una evaluación del desarrollo neurológico a los 2 años de edad utilizando el Índice de Desarrollo Mental (MDI) de las Escalas de Desarrollo Infantil de Bayley, Segunda Edición; también se informó la presencia de parálisis cerebral (PC). Los bebés se clasificaron como cognitivamente normales/levemente con retreaso o significativamente con retraso (MDI < 70). La validez predictiva de las puntuaciones HINE para el rendimiento cognitivo con retraso significativo, en bebés con y sin parálisis cerebral, se calculó utilizando puntuaciones de corte específicas según la edad en la evaluación.
Resultados
Se incluyeron un total de 446 lactantes en riesgo y 235 con desarrollo normal (345 varones, 336 mujeres; edad gestacional media DE 38,7 semanas 1,4, rango de 37 a 43 semanas). De los lactantes en riesgo, 408 no tenían parálisis cerebral a los 2 años; 243 tenían un MDI con retraso normal/leve y 165 tenían un MDI inferior a 70. De los bebés en riesgo, 38 desarrollaron PC. Las puntuaciones HINE mostraron una buena sensibilidad y especificidad, principalmente después de 3 meses, para identificar un rendimiento cognitivo severo en lactantes sin PC. En aquellos con PC, la puntuación se asoció con su rendimiento cognitivo. El grupo de comparación tuvo las puntuaciones HINE más altas.
Interpretación
El HINE proporciona evidencia sobre el riesgo de retraso en el rendimiento cognitivo a los 2 años de edad en bebés nacidos a término con y sin parálisis cerebral.
This original article is commented on by Cao and Huang on pages 813‐814 of this issue.
Objectives To assess attention deficit hyperactivity disorder (ADHD) in boys affected by Duchenne muscular dystrophy (DMD) and to explore the relationship with cognitive abilities and genetic ...findings. Study design Boys with DMD (n = 103; 4-17 years of age, mean: 12.6) were assessed using a cognitive test (Wechsler scales). Assessment of ADHD was based on the Diagnostic Statistical Manual, Fourth Edition, Text Revision criteria and on the long version of the Conners Parents and Teachers Rating Scales. Results ADHD was found in 33 of the 103 boys with DMD. Attention problems together with hyperactivity (17/33) or in isolation (15/33) were more frequent than hyperactivity alone, which was found in 1 patient. Intellectual disability (ID) was found in 27/103 (24.6%). Sixty-two of the 103 boys had no ID and no ADHD, 9 had ID but no ADHD, 14 had ADHD but no ID, and 18 had both. ADHD occurred more frequently in association with mutations predicted to affect Dp140 expression (exon 45-55) and in those with mutations predicted to affect all dystrophin product, including Dp71 (ie, those that have promoter region and specific first exon between exons 62 and 63 but were also relatively frequent). Conclusions Our results suggest that ADHD is a frequent feature in DMD. The risk of ADHD appears to be higher in patients carrying mutations predicted to affect dystrophin isoforms expressed in the brain and are known to be associated with higher risk of cognitive impairment.
The aim of the present study is to assess the psychometric properties of the Sleep Disturbance Scale for Children (SDSC) in an Italian population of infants and toddlers.
The SDSC was distributed to ...the primary caregivers of infants aged 6–36 months recruited via nurseries in the urban area of Rome. Reliability analysis for evaluating internal consistency and item–total correlation coefficients, and factor analysis were performed.
During a 12-months study period, a total of 193 healthy infants (aged 6–36 months) were evaluated using a 22-item version of the SDSC for Italian infants and toddlers. Three of the 22 original items displayed a low item–total correlation (<30) and a low frequency and were eventually removed, resulting in a 19 items questionnaire. Six factors were derived from the factor analysis using the principal component method of extraction and rotated with the varimax method: Difficulty in initiating sleep, Difficulty in maintaining sleep, Sleep breathing disorders, Parasomnias, Disorders of excessive somnolence and Sleep hyperhidrosis. The SDSC adapted for infants and toddlers showed a good level of internal consistency (Cronbach's alpha: 0.83).
The statistical analysis, the internal consistency and the factor analysis encourage the use of SDSC as an evaluation tool even at this age. The six factors extracted represent the most common areas of sleep disorders at this age and could therefore help clinicians to detect the areas that need a deeper investigation.
•We report the psychometric properties of the SDSC for 6–36 months age infants.•A 19-items questionnaire with six sleep factors derived from the analysis.•The SDSC 6–36 months show a good level of internal consistency.•We encourage the use of SDSC as an evaluation tool for children aged 6–36 months.
Aim
To develop and validate the Visual Function Classification System (VFCS), which was created to classify how children with cerebral palsy (CP) use visual abilities in daily life.
Method
The ...process of development and validation of the VFCS involved four phases: (1) drafting of the five levels from the analysis of literature and clinical experience; (2) validation of constructs and revision of the levels for concept meaningfulness, using nominal group process; (3) refinement by international Delphi survey; and(4) assessment of interrater reliability among professionals and with caregivers, and of test–retest reliability.
Results
Five nominal groups involved 29 participants; 65 people completed the first round and 51 the second round of the Delphi survey. Construct validity was demonstrated within an expert group and external validation through several stakeholders, with the involvement of patients and families to ensure meaningfulness of the concept. Discussions continued until consensus was reached about the construct and content of the five levels. Participants in the reliability study included 29 professionals, 39 parents, and a total sample of 160 children with CP (mean age SD 6y 6mo 3y 4mo; median 5y 7mo, range 1–19y). Absolute interrater agreement among professionals was 86% (weighted κ=0.88; 95% confidence interval CI 0.83–0.93). Test–retest reliability was high (weighted κ=0.97; 95% CI 0.95–0.99). Parent–professional interrater reliability on 39 children was moderate (weighted κ=0.51; 95% CI 0.39–0.63).
Interpretation
The VFCS has been appropriately constructed and provides a reliable system to classify visual abilities of children with CP both in clinical and in research settings.
What this paper adds
The Visual Function Classification System is a valid and reliable system.
It classifies visual abilities of children with cerebral palsy in clinical and research settings.
At a clinical level, it can be used to harmonize communication among professionals and identify patients’ strengths and weaknesses.
In research settings, it can be used to stratify patients, define natural history evolution, and interpret intervention studies.
Resumen
Sistema de clasificación de la función visual para niños con parálisis cerebral: desarrollo y validación
Objetivo
Desarrollar y validar el Sistema de Clasificación de la Función Visual (VFCS, siglas en inglés), que fue creado para clasificar cómo los niños con parálisis cerebral (PC) usan las habilidades visuales en la vida diaria.
Método
El proceso de desarrollo y validación del VFCS involucró cuatro fases: (1) elaboración de los cinco niveles a partir del análisis de la literatura y la experiencia clínica; (2) la validación de constructos y la revisión de los niveles para el significado de los conceptos, utilizando un proceso de grupo nominal; (3) refinamiento por encuesta internacional de Delphi; (4) evaluación de la confiabilidad entre evaluadores entre profesionales y con los cuidadores, y de confiabilidad de prueba y reevaluación
Resultados
Cinco grupos nominales incluyeron 29 participantes; 65 personas completaron la primera ronda y 51 la segunda ronda de la encuesta de Delphi. La validez de constructo se demostró dentro de un grupo de expertos y una validación externa a través de varias partes interesadas, con la participación de los pacientes y las familias para garantizar el significado del concepto. Las discusiones continuaron hasta que se llegó a un consenso sobre el constructo y el contenido de los cinco niveles. Los participantes en el estudio de confiabilidad incluyeron 29 profesionales, 39 padres y una muestra total de 160 niños con PC (edad media DS 6 años 6 meses 3 años 4 meses; mediana 5 años 7 meses, rango 1‐19 años). El acuerdo de evaluador absoluto entre profesionales fue del 86% (κ ponderada = 0,88; intervalo de confianza del 95% IC 0,83‐0,93). La fiabilidad de Test‐Retest fue alta (κ ponderada = 0,97; IC del 95%: 0,95 a 0,99). La confiabilidad entre los padres y profesionales entre 39 niños fue moderada (ponderada κ = 0,51; IC del 95%: 0,39 a 0,63).
Interpretación
El VFCS se ha construido de manera adecuada y proporciona un sistema confiable para clasificar las habilidades visuales de los niños con PC, tanto en el ámbito clínico como en el de investigación.
Resumo
Sistema de Classificação da Função Visual para crianças com paralisia cerebral: desenvolvimento e validação
Objetivo
Desenvolver e validar o Sistema de Classificação da Função Visual (SCFV), que foi criado para classificar como crianças com paralisia cerebral (PC) usam capacidades visuais na vida diária.
Método
O processo de desenvolvimento e validação do SCFV envolve quatro fases: (1) rascunho dos cinco níveis a partir da análise da literatura e experiência clínica; (2) validação de construtos e revisão dos níveis de significância dos conceitos, usando processo nominal de grupos; (3) refinamento por meio de levantamento Delphi internacional; (4) avaliação da confiabilidade inter‐examinadores entre profissionais e cuidadores, e confiabilidade teste‐reteste.
Resultados
Cinco grupos nominais envolveram 29 participantes; 65 pessoas completaram a primeira rodada e 51 a segunda rodada do levantamento Delphi. A validade de constructo foi demonstrada em um grupo de especialistas, e a validade externa por meio de vários interessados, com envolvimento de pacientes e famílias para assegurar a significância do conceito. As discussões continuaram até que fosse atingido consenso sobre o constructo e o conteúdo dos cinco níveis. Os participantes no estudo de confiabilidade incluíram 29 profissionais, 39 pais e uma amostra total de 160 crianças com PC (média de idade DP 6a 6m 3a 4m; mediana 5a 7m, variação 1–19a). A confiabilidade inter‐examinadores absoluta entre profissionais foi 86% (κ ponderado=0,88; intervalo de confiança IC a 95% 0,83–0,93). A confiabilidade teste‐reteste foi alta (κ ponderado =0,97; IC 95% 0,95–0,99). A confiabilidade inter‐examinadores pais–profissionais em 39 crianças foi moderada (κ ponderado =0,51; IC 95% 0,39–0,63).
Interpretação
O SCFV foi elaborado apropriadamente e é um sistema confiável para classificar as capacidades visuais de crianças com PC em ambientes clínicos e acadêmicos.
What this paper adds
The Visual Function Classification System is a valid and reliable system.
It classifies visual abilities of children with cerebral palsy in clinical and research settings.
At a clinical level, it can be used to harmonize communication among professionals and identify patients’ strengths and weaknesses.
In research settings, it can be used to stratify patients, define natural history evolution, and interpret intervention studies.
This article's has been translated into Spanish and Portuguese.
Follow the links from the to view the translations.
This article is commented on by Rosenbaum on page 14 of this issue.
Editor's Choice
My Editor's choice for the January 2020 issue is the newly developed Visual Function Classification System (VFCS). This issue features other important papers on vision. I hope the VFCS will usefully complement the existing family of classifications systems for gross motor functioning, manual ability, communication, and eating and drinking in children with cerebral palsy.
Over the past 20 years, the introduction of new neurodevelopmental assessments and neurophysiological techniques has improved the knowledge of the complexity of the central nervous system in the ...first period of development ....
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