Deepa Metgud

1

Predicting Neurological Outcome in Very Low Birth

Weight Infants Using Movement Assessment of

Infants-A Longitudinal Study.

Thesis Submitted to

THE KLE ACADEMY OF HIGHER EDUCATION AND RESEARCH, BELGAUM

(KLE DEEMED UNIVERSITY)

[Declared as Deemed-to-be-University u/s 3 of the UGC Act, 1956 vide Govt. of India Notification No.F.9-19/2000-U.3 (A)]

(Accredited A Grade by NAAC)

For the award of the Degree of

Doctor of Philosophy in the Faculty of

Medicine (Physiotherapy) by

Mrs. Deepa Metgud M.P.T. (Registration No: KLEU/Ph.D/07-08/DOUNO7044

Under the Guidance of Prof. Dr. V. D. Patil M.D., DCH

K.L.E. University J. N. Medical College, Belgaum 590010. Karnataka, India

April - 2011

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2

KLE ACADEMY OF HIGHER EDUCATION AND

RESEARCH,




BELGAUM

Certificate By the Dean

This is to certify that the thesis entitled Predicting Neurological

Outcome in Very Low Birth Weight Infants Using

Movement Assessment of Infants-A Longitudinal Study is a

bonafide and genuine research carried out by Mrs. Deepa.Metgud under the

guidance of Dr. V. D. Patil, Professor, Department of Pediatrics, K.L.E.

University, J. N. Medical college, Belgaum.

Place: Belgaum

Date:

Prof. Dr. V. D. Patil M.D.,DCH Dean Faculty of Medicine, K.L.E. University, J. N. Medical College, Belgaum -590010. Karnataka

III


RESEARCH,




BELGAUM

Declaration By the Candidate

I hereby declare that the thesis entitled Predicting Neurological

Outcome in Very Low Birth Weight Infants Using Movement

Assessment of Infants-A Longitudinal Study is a bonafide and original

research carried out by me under the guidance of Dr. V. D. Patil, Professor,

Department of Pediatrics and Dean Faculty of Medicine , K.L.E.U J N

Medical college, Belgaum. The thesis or any part thereof has not formed the

basis for the award of any degree/fellowship or similar title to any candidate of

any University.

Place : Belgaum Date :

Mrs. Deepa Metgud M.P.T. KLEU Institute of Physiotherapy, Belgaum

IV


RESEARCH,




BELGAUM

Certificate by the Guide

This is to certify that the thesis titled Predicting Neurological

Outcome in Very Low Birth Weight Infants Using Movement

Assessment of Infants-A Longitudinal Study is a bonafide research

work done by Mrs. Deepa.Metgud.

Place: Belgaum Date

Dr. V .D. Patil M.D., DCH Principal, Professor, Department of Pediatrics KLE University, J. N. Medical College, Belgaum

V


RESEARCH,




BELGAUM

Endorsement by the Principal

This is to certify that the dissertation titled Predicting

Neurological Outcome in Very Low Birth Weight Infants Using

Movement Assessment of Infants-A Longitudinal Study under the

guidance of Dr. V. D. Patil MD, D.C.H, KLE University, J N Medical college,

Belgaum.

Date : Place : Belgaum

Principal, Dr. Sanjiv Kumar

KLEU Institute of Physiotherapy,Belgaum

VI


RESEARCH,




BELGAUM

Copyright Declaration

We hereby declare that KLE Academy of Higher Education and

Research, Belgaum, Karnataka, shall have the rights to preserve, use and

disseminate this thesis in print or electronic format for academic/research

purpose.

Place: Belgaum Date

Dr. V. D. Patil M.D., DCH Mrs. Deepa Metgud M.P.T.

KLE ACADEMY OF HIGHER EDUCATION AND RESEARCH,

BELGAUM

VII

ACKNOWLEDGEMENT

I take this opportunity to thank all those people who have encouraged me right from

the conception of this work till its present form.

This masterpiece, the brainchild of my beloved guide and mentor Dr. V. D. Patil MD

Dean, K.L.E.U J.N.Medical College, Belgaum, without whose support, timely guidance and

continued inspiration, the mission would not have accomplished. I feel honored in

expressing my sincere gratitude for his valuable guidance.

I express my sincere gratitude to Dr. Dhaded MD, DM Professor and Head of

Department of Pediatrics J.N.Medical College Belgaum, for his valuable time, critical

suggestions and consistent support for my research work. Words are inadequate to express

my indebtness and deep respect to him for his able guidance and encouragement.

With great privilege, I take the opportunity to express my heartfelt thanks to

Honorable Chancellor KLE University, Dr. Prabhakar. B. Kore, MLC, Chairman K.L.E

Society for his encouragement and providing the opportunity to reach the goal.

I am grateful to Honorable Vice-Chancellor KLE University Dr. (Prof) C. K. Kokate,

Belgaum, for his timely motivation and inspiration throughout the course.

I am extremely happy to extend my heartfelt thanks to Dr. P. F. Kotur Registrar,

KLEs University Belgaum, for his support and encouragement.

With great respect, I extend my special thanks and gratitude to Mr. Sanjeev Kumar

MPT, Principal KLEU Institute of Physiotherapy, Belgaum for his continued support,

motivation and encouragement throughout the study.

VIII

My sincere thanks to Shri. M.D.Mallapur, Lecturer Department of Community

Medicine J.N.Medical College, Belgaum, for his valuable time, critical suggestions and

support in statistical analyses. I have no words to express my indebtness for his help and

patience for solving every single doubt about statistics in my work.

With great respect, I extend my special thanks and gratitude to Susan Harris,

Kathaleen Washington, Marcia Swanson and Jean Deitz from University of Washington

USA for their valuable guidance, encouragement and answering all my queries and

supporting me through out the study. It was my privilege to get the guidance from the

international faculty who were pioneers in research on Movement Assessment of Infants.

My sincere gratitude to Dr.Mahesh Kamate Pediatric Neurologist J.N.Medical

College Belgaum, for his valuable suggestions and guidance.

I extend my sincere and special thanks to Dr. Snehal Dharmayat, Dr. Anand

Heggannavar, Dr. Peeyusha, Dr. Arati Ramannavar, Dr. Renu Pattanshetty, Dr.

Santosh.Metgud, Dr. Vijay, Dr. Anil, Dr. Chitra and Dr Basavaraj, staff KLEU Institute of

Physiotherapy for their constant support, suggestion and motivation throughout the study.

I am greatful to my in-laws Smt and Dr.(Shri) S. S. Palled, former Registrar UAS

Dharwad, for their motivation and support throughout my research project. I am greatful to

my mother, brother and husband for their valuable support.

My gratitude to Mr.Raju, assistant at Child Development Centre, KLE Belgaum for

coordinating with me to arrange for the regular follow ups of the study participants.

IX

I am extremely grateful to my Post Graduate students Ms. Sonia, Ms. Sneha, Ms.

Suchitra, Ms. Komal, Ms. Yashoda, Ms. Pallavi, Ms. Neha, Ms Shukhra, and Ms. Namyata

for their every smiling and willing attitude to support me throughout the study.

I thank Mr. Mahesh for the technical help in accomplishing the thesis.

It would be unfair of me if I fail to give heartfelt gratitude to all the children and

parents for participating in the study and making it a success.

I certainly owe my gratitude to my family and for their never ending love, support

and encouragement. This task would not have been completed without the grace of

ALMIGHTY, the most beneficent and most merciful, the best healer.

Place : Belgaum

Date : Dr. Deepa Metgud

X

LIST OF ABBREVIATIONS

AIMS Albert Infant Motor Scale

AR Automatic Reactions

BOMT Bruininks- Oseretsky Test of Motor Performance

BSID Bayley Scale of Infant development

CLD Chronic Lung Disease

CNS Central Nervous System

CP Cerebral Palsy

CS Categorical score

DA Developmental Age

DASII Developmental Assessment Scale for Indian Infants

DDST Denver Developmental Screening Test

DQ Developmental Quotient

ELBW Extremely Low Birth Weight

GA Gestational Age

GM General Movements

HMD Hyaline membrane Disease

IMS Infant Motor Screen

IVH Intraventricular Haemorrhage

LBW Low birth Weight

MAI Movement Assessment of Infants

XI

MDI Mental Development Index

MMCL Meade Movement Check List

MT Muscle Tone

NICU Neonatal Intensive Care Unit

NPV Negative Predictive Value

PD-GMS Peabody Developmental Gross Motor Scale

PDI Psychomotor Developmental Index

PDMS Peabody Developmental Motor Scale

PPV Positive Predictive Value

PR Primitive Reflex

PVHI Periventricular Haemorraghic Infarction

ROP Retinopathy of Prematurity

RS Raw Score

SGA Small For Gestational Age

TIMP Test of Infant Motor Performance

TRS Total Risk Score

VLBW Very Low Birth Weight

VM Volitional Movements

WHO World Health Organization

XII

ABSTRACT

Background and Purpose- With the advances in neonatal intensive care, the survival of

Very low birth weight children has improved considerably in India. However, these children

are at risk for significant motor impairment with poor developmental outcomes. The

Movement Assessment of Infants is a widely used tool to assess motor dysfunction in high

risk infants with good predictive validity for its 4 and 8 months profiles but has no validity

studies for its preliminary 6-month profile. The predictive accuracy of Movement

Assessment of Infants for high risk Indian infants has not been examined at any age. Hence

the aim of this study was to evaluate the validity of the MAI to predict neuromotor outcome

in very low birth weight infants at specific corrected ages of four, six and eight months

during the first year of life.

Methodology- This hospital based prospective observational study consecutively recruited

72 babies with birth weight 1500gms; admitted to Neonatal Intensive Care Unit of which

60 babies completed the one year follow up . The infants were evaluated at 4, 6 and 8

months of corrected age using the Movement Assessment of Infants scale and risk scores

were recorded. A total score of 10 at 4 and 8 months evaluations was considered as risk for

abnormal neurodevelopmental outcome and a score of 6 was considered as risk for 6

month examination. This was followed by evaluation at 12 months using the gold standard

Bayley Scale of Infant Development-II by a clinical psychologist. The Psychomotor

Developmental Index and Mental Developmental Index scores were computed and a score

of 84 was considered as abnormal neurodevelopmental outcome.

XIII

Results- The incidence of neurodevelopmental problems in VLBW infants at one year was

28.33% with 16.66% of them having significantly delayed development. The predictive

validity of 4-month MAI relative to PDI 84 was good with a sensitivity of 82.3%,

specificity 74.4% and Negative predictive Value of 91.4%.The Positive predictive Value

was lower (56%) with higher rate of false positives at 4 months. The 6-month evaluation had

acceptable sensitivity of 70.6% and high specificity of 81.4%. The 8-month evaluation

showed the best combination of predictive values with sensitivity 82.3%, specificity 95.3%,

positive predictive value of 87.5% and negative predictive value of 93.2%.

The risk scores of Movement Assessments of Infants (Total Risk Score and

categorical scores) at four, six and eight months significantly correlated with both the

Motor and Mental scale of Bayley at one year value (p

XIV

CONTENTS

Sl. No. Sections Page no.

1. INTRODUCTION 1-4

2. RESEARCH QUESTION 5

3. OBJECTIVES 6

4. OPERATIONAL DEFINITION 7 - 8

5. REVIEW OF LITERATURE 9 - 42

6. METHODOLOGY 43 50

7. RESULTS 51 58

8. DISCUSSION 59 73

9. CONCLUSION 74

10. SUMMARY 75 - 78

11. BIBLOGRAPHY 79 97

12. ANNEXURE - I TABLES 98 106

13. ANNEXURE II GRAPHS 107 111

14. ANNEXURE III PHOTOGRAPHS 112 118

15. ANNEXURE IV

ETHICAL CLEARANCE, CONSENT FORM,

PROFORMA

119 124

16. ANNEXURE V

MAI - TEST MATERIAL, DIRECTION FOR

TESTING, RECORDING & SCORING, PROFILE

SHEETS (4, 6 & 8 MONTHS)

BSID II CUE SHEET

125

17. ANNEXURE VI

PUBLICATIONS & PRESENTATIONS

18. ANNEXURE VII

MASTER CHART

XV

LIST OF TABLES

Table No Particulars Pages

01 Maternal Characteristics 98

02 Infant Characteristics 99

03 Neonatal problems during their NICU stay 99

04 Mean scores of MAI at 4, 6 and 8 months 100

05 Mean Mental and Motor scores of BSID-II at 12

months

100

06 Predictive validity of 4 month MAI for neuromotor

outcome at 12 months

101

07 Predictive validity of 6- month MAI for neuromotor


101

08 Predictive validity of 8- month MAI for neuromotor


101

09 Comparison of predictive validity of 4, 6 and 8 months

MAI for neuromotor outcome at 12 months

102

10 Correlation between the 4-month MAI and BSID-II at

12 months

102


12 months

102


12 months

103

13 Neurodevelopmental problems in VLBW at one year

based on BSID-II score

103

14 Four-months MAI scores of infants with normal and

abnormal neuromotor outcome

103

15 Six-months MAI scores of infants with normal and


104

XVI

Table No Particulars Pages

16 Eight-months MAI scores of infants with normal and


104

17 Mean Bayley Mental Scale scores of infants with

normal and abnormal outcome at 12 months

104

18 Mean Bayley Motor Scale scores of infants with

normal and abnormal outcome at 12 months

105

19 Association of MAI and BSID-II scores with maternal

characteristics

105

20 Correlation between the number of days in NICU with

MAI and BSID-II

105

21 Correlation between the number of neonatal problems

with MAI and BSID-II scores

106

XVII

LIST OF GRAPHS

Graph No Particulars Pages

01 Maternal characteristics 107

02 Sex distribution 107

03 Distribution of infants based on gestational age 108

04 Mean scores of MAI at 4, 6 and 8 months 108

05 Mean Mental and Motor scores of BSID-II at 12 months 109

06 Comparison of predictive validity of 4, 6 and 8 months

MAI for neuromotor outcome at 12 months 109

07 Neurodevelopmental problems in VLBW at one year based

on BSID-II score 110

08 Mean MAI scores at 4, 6 & 8 months for infants with

normal and abnormal neuromotor outcome 110

09 Mean Bayley Mental Scale scores of infants with normal

and abnormal outcome at 12 months 111

10 Mean Bayley Motor Scale scores of infants with normal

and abnormal outcome at 12 months 111

XVIII

LIST OF PHOTOGRAPHS

Photograph

No Particulars Pages

01 MAI Manual and Test material 112

02 BSIDII Manual and Test material 112

03 Plantar grasp 113

04 Extensibility of adductor muscles 113

05 Placing of hands 113

06 Head Righting Lateral 114

07 Landau reaction 114

08 Reach out for object in supine and head centering 114

09 Rolling from supine to side lying 115

10 Prone weight bearing on palms 115

11 Head Righting flexion 115

12 Sits when placed and back straight in sitting 116

13 Equilibrium reactions in sitting 116

14 Walking with one hand support 116

15 Picks up cube 117

16 Finds toy under the cups 117

17 Places cube in cup 117

18 Retrieves toy 118

19 Places circle in the board 118

20 Turns pages of book 118

Introduction

1

INTRODUCTION

Low birth weight (LBW) is a major public health problem worldwide, and the

burden is considerably higher in the developing countries. The percentage of low birth

weight babies in developing countries (16.5percent) is double that of the developed

countries. India alone accounts for 40 per cent of low birth weight babies in the developing

world and more than half of those in Asia.1

The category of Very Low Birth Weight

(VLBW) infants has an incidence of less than 2% of the births globally.2 In India, VLBW

infants constitute approximately 4% 7% of all live births and contribute to as much as

30% of early neonatal deaths.3 Although VLBW is a relatively small proportion of total

births globally, this category of infants accounts for the highest neonatal mortality and

greatest morbidity among newborns.

Low birth weight babies are at high risk of immediate problems like birth asphyxia,

hypoglycemia, convulsions, apnea, sepsis, hypothermia, and feeding problems. They are

more prone for long-term problems such as mental retardation, cerebral palsy, impairment of

lung function, visual and hearing impairment. Minor neurological deviations like attention

deficit hyperactivity disorder, 4

clumsiness, and intention tremors are also common in them.

They show functional disabilities of 26.7% and the factors associated with functional

disability include neonatal illness, poor weight gain and rehospitalization.5

With the advances in neonatal intensive care, the survival of VLBW infants (

Introduction

2

is around 8-15%.7 Cerebral palsy is the most common major neurological abnormality seen

in very low birth weight children. Studies have reported a high prevalence of severe

neurological impairments and minor psychomotor deficits in VLBW infants.8,9,10,11

They

have problems with fine motor functions ,coordination 12,13

and visual-motor integration.14

They present with poor quality of motor function and coordination, even without evident

neurological impairment. There is increased risk of delayed attainment of walking in these

children.15

This indicates that the presence of motor dysfunction due to very preterm and

VLBW may crucially affect the childs exploration of the world, attainment of handwriting

skills, and involvement in social activities.16,17,18

Due to this effect on adaptive functioning,

impaired motor development is a risk factor for later poor cognitive performance,19,20

learning disabilities, and behavior problems.21,22,23

This clearly highlights the need for an

accurate and early prediction of motor consequences of very premature and VLBW infants.

This has led to development of extensive follow up programs worldwide to

determine which of these infants needs intervention. Early identification of motor

dysfunction in monitoring programs are essential to implement appropriate intervention as

the infants brain development and myelination are rapid in first year of life.24

Numerous tools like Gesell Development Schedules Test,25

Peabody Developmental

Motor Scales,26

Denver Developmental Screening Test,27

and Bayley Scale of Infant

Development28

have been developed to assess motor development in children.

Physiotherapists have been increasingly involved in using these tools as they are primarily

concerned with motor behavior. An important limitation of the vast majority of the existing

tools is that they focus on the acquisition of motor milestones and lack the sensitivity in

Introduction

3

identifying infants with subtle movement disorders. The development of an infant refers to

both qualitative and quantitative changes for optimal functioning. An infant may show

clinical improvement in pattern and quality of movement, but this may not be reflected in

the acquisition of motor milestones. In order to improve the accuracy of early identification,

tests of motor development for infants should include quality of movement component.29, 30

The neuromotor tools that assess quality of movement like Alberta Infant Motor

Scale31

Test of Infant Motor Performance,32

and General Movements33

primarily focus on

gross motor development and do not include fine motor and neurological components

necessary for performance of motor function. Tools which are based on normative data are

not suitable to identify neuromotor dysfunction in preterm VLBW infants as they have

variations in motor development although that may not necessarily be abnormal.34

For this

reason, criterion-referenced tools designed specifically for preterm infants to discriminate

between typical and atypical development are appropriate in children with variation in motor

patterns of development.

The Movement Assessment of Infants (MAI) Scale addresses most of the limitations

of the traditional diagnostic tools and the currently developed motor performance tools.

Hence it was considered as an appropriate tool and was used in the present study to identify

neuromotor dysfunction.

The MAI is a landmark tool and a sensitive measure of quality of movement in high

risk infants as early as four months of age. It is a criterion referenced scale with risk profiles

available for four, six and eight months of age that can appropriately measure movement

performance even in preterm infants with variation in motor development. It is a potentially

useful and cost-effective assessment tool .It has been shown to be sensitive and specific for

Introduction

4

detecting neurological disorders at four and eight months in both pre term and term

infants.35,36,37

In India comprehensive assessment tools that focus on acquisition of motor milestones

are used in monitoring programs for high risk infants. There is no much published evidence

on the use of motor tools that measure quality of movement performance except the one

published on the use of Infant Motor Screen tool in early intervention program for high risk

infants.38

Predictive validity of MAI has been established for the originally developed 4 and 8

months profiles for high risk infants like preterm, low birth weight, cocaine abuse and

infants at social risk in western countries.39,40,41

Although literature demonstrates the clinical

utility of the MAI with good predictive validity, its applicability for Indian infants with

VLBW has not been studied at 4 or 8 months.

Babies can report at any age for developmental concerns and may require sequential

longitudinal assessments rather than single assessment. Despite the availability of the

published preliminary 6-month MAI profile based on normal term infants its predictive

validity for neurodevelopmental outcome in high risk infants has not been explored either in

Indian or western population.42

This limits the clinical utility of the tool. Hence this study

was undertaken in an effort to evaluate the validity of MAI at 4, 6, and 8 months of

corrected ages to predict neuromotor outcome in Indian population of VLBW infants and

broaden the scope of use of MAI in clinical practice.

Research Question

5

RESEARCH QUESTION

What is the validity of the Movement Assessment of Infants tool for predicting

neuromotor outcome in very low birth weight infants at specific corrected ages of

four, six and eight months during the first year of life ?

Objectives

6

OBJECTIVES

Primary Objective:

To assess the validity of the Movement Assessment of Infants for predicting

neuromotor outcome in very low birth weight infants at specific corrected ages of

four, six and eight months during the first year of life.

Secondary Objective:

To determine the incidence of neurodevelopmental problems in very low birth

weight infants during the first year of life.

Operational Definition

7

OPERATIONAL DEFINITIONS

Age of mother: Age was recorded to the nearest completed years.

Primary education: The person who had studied from first to seventh standard.

Secondary education: The person who had studied from eighth to tenth standards.

Higher secondary: The person who had studied from 10th to 12th standard.

Graduate: Bachelor degree

Postgraduate: Masters degree

Socioeconomic status: Socioeconomic status was based on per capita income in

rupees per month and was classified using the modified BG Prasad classification.

Modified B. G. Prasad Classification

Socioeconomic

class

Modified Prasad's classification in the study period 2009.

Per capital per month income (Rs.)

I 3600 & Above

II 1800 & 3599

III 1080 & 1799

IV 540 & 1079

V

Operational Definition

8

Age of baby: Chronological age: Date of testing minus date of birth.

Corrected Age: Chronological age minus Days of prematurity

Days of prematurity- (40 weeks minus gestational age in weeks)X 7

Gestational age: Age or duration of the gestation, from the last menstrual period to

birth.

Birth

o Term birth: Delivery occurring between 37 and 42 weeks of gestational age.

o Preterm birth: Delivery occurring before 37 weeks of gestational age.

Birth weight

o Low-birth-weight infant: Infant with birth weight less than or equal to 2500

grams, regardless of gestational age.

o Very Low birth weight-Infant with birth weight between 1000 to 1500

grams regardless of gestational age.

Review of Literature

9

REVIEW OF LITERATURE

MAGNITUDE OF THE PROBLEM

Low birth weight has been defined by the World Health Organization (WHO) as

weight at birth of less than 2,500 grams (5.5 pounds).43

Low birth weight neonates are

further classified as very low birth weight (VLBW


10

25% to 45% occur within the first 24 hours. The main causes of newborn deaths are

prematurity and LBW (30%), infections (25%), asphyxia and birth trauma (23%). These

causes account for nearly 80% of deaths in this age group. Close to 25,000 children die

every day, mostly due to pneumonia, diarrohea and newborn problems.46

The factors influencing LBW of baby include short gestational period, socio economic

standard, nutritional status and environmental factors. Low birth weight continues as an

important social health problem. It is one of the most serious challenges in maternal and

child health in both developed and developing countries. It is the single most important

factor that determines the changes of child survival.

NEONATAL PROBLEMS AND ITS ASSOCIATED RISK IN VLBW INFANTS:

VLBW infants face immediate serious health problems as newborn and also later

long term developmental problems. Low birth weight infants could be preterm or small for

gestational age and are prone for multisystemic complications during neonatal period and

may have long-term implications.48

The following are the most common problems in VLBW

infants which are associated with potential risk of poor developmental outcomes :

Delivery Room Care and Resuscitation

Premature infants require additional special care in delivery room such as

precautions to prevent heat loss because of thinner skin and an increased surface area to

body-weight ratio, respiratory support for apnea due to respiratory insufficiency which is

more likely at lower gestational age. Depending on the reason for premature birth, perinatal

infection is more likely in premature infants, which increases their risk of perinatal

depression. Preterm and IUGR babies are at risk of meconium aspiration and birth asphyxia

and may require to be delivered by cesarean section and may be depressed at birth.49


11

Hypothermia

Hypothermia in newborns is commonly due to lack of awareness and knowledge

about the importance of maintenance of temperature amongst the health care personnel, than

due to lack of equipment. In the developing countries, hypothermia contributes significantly

to neonatal morbidity and mortality. The low birth weight infant is particularly at increased

risk of hypothermia because of larger surface area to weight, increased transepidermal water

loss, increased exposed area, thin and immature skin, increased cutaneous blood flow,

decreased energy stores, less brown fat, limitation of oxygen consumption because of

pulmonary problems and increased respiratory rate.49

Hypoglycemia

Hypoglycemia is common in VLBW due to their poor ability to breast feed

immediately after delivery because of poor oromotor control and reduced respiratory effort.

They are more prone to get neonatal seizures which may cause neurological damage.

Neonatal hypoglycemia, independent of HIE, has been associated with adverse

outcome in both term and preterm infants.50

However, no conclusive evidence on the

severity and duration of hypoglycemia causing brain damage has been reported. 51, 52

A study was done to find the adverse neurodevelopmental outcome of moderate

neonatal hypoglycemia in a multicentre trail of 661 preterm infants. The number of days on

which moderate hypoglycemia occurred was strongly related to reduced mental and motor

developmental scores at 18 months , even after adjustment for a wide range of factors

known to influence development. The mental and motor developmental scores at 18 months

(corrected age) were significantly reduced and the incidence of neurodevelopmental

impairment (cerebral palsy or developmental delay) was increased. These data suggest that,


12

contrary to general belief, moderate hypoglycemia may have serious neurodevelopmental

consequences, and reappraisal of current management is urgently required.53

Prospective serial evaluation was done on 85 small for gestational age preterm

neonates with hypoglycemia to investigate the effects of neonatal hypoglycemia on physical

growth and neurocognitive function They found that recurrent hypoglycemic episodes were

correlated with neurodevelopmental and physical growth deficits till five years of age and

long term effects.54

Respiratory

In preterm VLBW infants respiratory difficulties constitute the commonest cause of

morbidity and pulmonary pathology is the most frequent autopsy finding; the commonest

conditions in this group include aspiration, infections, HMD, massive pulmonary

hemorrhage, pneumothorax and congenital malformations.

A retrospective case-control study was done to describe the clinical course, neonatal

morbidity, and neurodevelopmental outcomes of VLBW children who develop pulmonary

hemorrhage. They found that pulmonary hemorrhage occurred in 5.7% of the total

population of VLBW infants. There were no significant differences in neurodevelopmental

outcomes at 20 months' corrected age. It was concluded that although mortality is high,

pulmonary hemorrhage does not significantly increase the risk of later pulmonary or

neurodevelopmental disabilities among those who survive.55

Premature infants may adapt poorly to air breathing and present with perinatal

depression in the delivery room. Respiratory distress syndrome may occur because of

surfactant deficiency in babies


13

Apnea may occur because of immaturity of the mechanisms controlling breathing

and ineffective ventilation.57

Meconium aspiration syndrome is commonly the result of fetal

distress and is frequently associated with small for gestational age babies.58

Finally oxygen

therapy for respiratory distress needs to be monitored as it has its long term side effects.59

Low Apgar

Low birth weight and immaturity are associated with a low Apgar score.60

More

recent studies have found a strong association between low Apgar score and cerebral palsy

in children born at term or with normal birth weight 61, 62

whereas studies in children with a

low birth weight or born preterm have shown conflicting results.63,64

In a population based

cohort study the low Apgar score was strongly associated with cerebral palsy. This

association was high in children with normal birth weight and modest in children with low

birth weight.65

Cardiovascular

Premature infants may present with hypotension due to hypovolemia, cardiac

dysfunction and vasodilatation due to sepsis. Patent Ductus Arteriosus is common and may

lead to congestive heart failure.

Gastrointestinal

Prematurity is single greatest risk factor for necrotizing enterocolitis.66

Feeding

problems are common in LBW babies because of immaturity of the suck-swallow-breathing

coordination.67,68

Renal

The preterm babies are characterized by low glomerular filtration rate, an inability to

handle water, solute and acid load because of immature kidneys. Therefore fluid and

electrolyte management can be difficult.


14

Hematological

Polycythemia is common in babies who are small for gestational age secondary to

placental insufficiency and chronic hypoxia. Anemia and hyperbilirubinemia are other

hematological problems in preterm VLBW infants. Anemia is frequently seen in preterm

babies because of decreased RBC mass and iron stores. Infants needs extra concern as iron

is actively transferred from mother to fetus during pregnancy, the maximal time of transfer

being during the third trimester. As a consequence the premature infant is born with

relatively lower iron stores depending on the gestational age. Iron deficiency causes varying

degrees of impairment in cognitive performance; reduced psychomotor skills and lower

immunity to infections.69

Premature babies are more likely to develop hyperbilirubinemia

and can develop kernicterus at low levels of bilirubin.70

Poor weight gain

The low birth weight babies frequently show an exaggerated weight loss and slower

rate of weight gain in the postnatal period due to inadequate calorie intake, frequent

illnesses, hypothermia and sepsis.71

Infections

Low birth weight infants are particularly vulnerable to infections because of epidermal

barrier immaturity, poor defense mechanisms, interventions and procedures carried out for

routine monitoring and treatment.70

Rate of infection increases with decreasing gestational

age. Moreover, postnatal infection is associated with an increased risk of neonatal

complications, prolonged hospitalization, and death.


15

In a cross sectional study to know the incidence, presenting features, risk factors and

significance of late onset septicemia in very low birth weight infants it was found that

sixteen percent of VLBW infants developed septicemia at a median age of 17 days. Factors

associated with septicemia included male gender, lower gestational age, birth weight and

decreased baseline serum IgG concentrations. Septicemia infants, compared with non

septicemia infants, had significantly increased mortality, longer hospital stay and more

serious morbidity. They concluded that late onset septicemia is common in very low birth

weight infants, and the rate is inversely proportional to gestational age and birth weight.72

A

casecontrol study found that prematurity and neonatal infection were the dominant factors

associated with neurological morbidity in VLBW infants.73

Neurological

The main causes of newborn deaths are prematurity and low-birth-weight (30%),

infections (25%), asphyxia and birth trauma (23%). Combinations of antenatal and perinatal

problems rather than single event, in combinations with suboptimal socioeconomic and

environmental conditions in infancy, contribute most to poor long term neurodevelopmental

outcome. LBW babies are more prone for perinatal depression, seizures and intracranial

bleeds that may have long term implications.74

The incidence of severe perinatal asphyxia in resource-rich countries, (causing death

or severe neurological impairment) is about 1/1000 live births75

where as in resource-poor

countries, the incidence is about 5 to 10/1000 live births.76

It is inversely related to

gestational age and birth weight. The factors that increase the risk of perinatal asphyxia

include decreased blood flow from mother to placenta or placenta to fetus, fetal anemia,

infection severe cardiac and circulatory insufficiency. It causes increased ICP or cerebral


16

edema which often reflects extensive prior cerebral necrosis rather than the swelling of

intact cells. It carries poor prognosis. The risk of the CP in survivors of perinatal asphyxia is

5% to 10% compared to 0.2% in the general population.

Seizures occur in 20 to 50% of preterm infants and usually start between 6 and 24

hours after the insult. Neonatal seizures are the clinical manifestation of serious underlying

neurologic disease and can cause additional brain injury. About 45% have mild to severe

disabilities (25% neuromotor, 20% sensory). Recurrent seizures occur in approximately

20%. The worst prognosis is for infants with tonic seizures, seizures resulting from IVH or

hypoxic ischemic encephalopathy and seizures lasting more than three days (66%).77

Periventricular leukomalacia is necrosis of the cerebral white matter dorsal and

lateral to external angle of the lateral ventricles. In premature infants especially the ill ones

have pressure passive cerebral circulation. The periventricular region is particularly

vulnerable to ischemia because arterial border and end zones are vulnerable to decreased

perfusion pressure and decreased cerebral blood flow.78

Periventricular hemorrhagic infarction (PVHI) is most common in the premature

infants. It is characterized by a large region of hemorrhagic necrosis in the periventricular

white matter that is usually unilateral or bilaterally asymmetric. The overall incidence of

IVH in premature infants is approximately 30%, but it can be over 70% in ELBW infants

weighing less than 750 gm at birth.79

A case control study was done to identify factors during the neonatal period in babies

born at term and preterm that are associated with the subsequent development of cerebral

palsy (CP). They found that seizures, congenital abnormalities of the brain and elsewhere,


17

'other lesions', abnormal muscle tone and meconium aspiration were common in term

babies. Among babies born preterm; seizures, IVH, periventricular leukomalacia, 'other

lesions' and abnormal muscle tone were seen. They concluded that the neonatal factors

which best identify neonates who will subsequently develop CP are different for term and

preterm babies. 80

Visual problems

Visual function of LBW children is poorer than that of normal birth weight babies.

The vision is a crucial determinant of early motor and cognitive development. They are at

increased risk for retinal and non retinal ophthalmic disorder that leads to visual disability.

The degree of visual impairment correlates very strongly with degree of neurodevelopmental

impairment. The VLBW infants are also at increased risk of developing severe retinopathy

of prematurity (ROP).81

These children with the most severe ROP have disproportionately

high rates of severe multiple developmental disabilities and severe functional

limitations.82

Severity of neonatal ROP seems to be a marker for functional disability at age

5.5 years among very low birth weight survivors. High rates of functional limitations in

multiple domains occur in children who had threshold ROP, particularly if they have

unfavorable visual acuity.83

This evidence emphasizes the importance of ocular assessment of LBW children

with CNS damage and neurodevelopmental assessment in LBW children with visual

disabilities. Studies done on the impact of LBW on the visual pathway showed that

impairments was highest for those under 1500 grams, decreasing with increasing birth

weight for those over 3500 gms.84, 85


18

Hearing loss is more likely in premature babies. Strong evidence indicates increased

risk of speech and language delays in LBW babies. There is 25% incidence of language

delay among premature infants with birth weight at


19

motor, adaptive, and personal social and language development in first 5 years, further

studies between 6-10 years for intelligence, academic achievement, behavior orientation

confirmed the previous results of disadvantage of being born LBW. Though the LBW had

test results within normal range, they scored significantly less than the controls.

Another hospital- based study where in children born during 1983-1989 were followed

up to 1995 with a mean age of 8.5 years.90

The follow up of unimpaired survivors along with

matched normal weight children revealed that LBW children had significantly lower scores

for tests of intelligence, visuomotor co-ordination. Also neurological soft signs, behavior

problems and learning disabilities were more in LBW infants. Follow up of preterms during

first 18 months revealed that out of 150 LBW followed up, 7.0 % had developmental delay,

4 % had cerebral palsy and 10% had transitory dystonia which resolved by 18 months. Pune

study showed that the LBW children are at disadvantage for poor visuomotor co-ordination,

reading, writing and mathematical skills. 91

A cohort study at a tertiary care neonatal service in Delhi, was undertaken to

determine the neurodevelopmental outcome of neonates who required intensive care. They

observed that 85% of subjects had normal neurodevelopmental outcome, and 15% had

adverse outcome. Among the neonatal risk factors, seizures, sepsis and hypoxic ischemic

encephalopathy had a significant association with adverse outcome. Despite serious neonatal

morbidity, the early neurodevelopmental outcome of nursery children was reasonably

good.92

The longitudinal and cross-sectional studies on the cognitive development of 83

children of VLBW, ages three to seven years, were evaluated on the McCarthy Scales of


20

Children's Abilities. The factors related to lower cognitive scores included

neurological

complications during hospitalization in the NICU, the child's age, and the mother's level

of

education. In the cross-sectional study, the VLBW children were compared with control

groups of children from middle class families (MC) and lower class families (LC). The

VLBW group scored significantly lower than the MC group on all the McCarthy scales, but

did not differ from the LC group.93

A study was conducted to document the psychomotor development and general health

of former VLBW infants born between 1980 and 1986 from birth up to school age in Central

Switzerland and found that 1/5th of these infants had transient motor problems treated by

physical therapy. Twenty-three percent of the infants seen in follow-up had persistent but

mainly minor motor handicaps, and only two infants (2%) had multiple handicaps. Ninety-

six percent attended regular school, but almost half of them had significant school problems

and required professional help.94

A recent comparison made in various European, American

and Australian Centers reveals an average of 7% of cerebral palsy and 15% of mental

retardation among VLBW infants. 47

In a study on development of healthy VLBW preterm infants they found that even if

they are healthy as a group, they suffer from a larger proportion of developmental

difficulties in comparison to the general population. Their academic, social and behavioral

achievements are lower as a group than full term infants. The source of the developmental

risk factors is both biological and environmental in origin. It is hypothesized that the source

of these risk factors is at least partially due to differences in the development of specific

brain areas such as the hippocampus.95


21

A study was done in Chandigadh on the neurodevelopmental and behavioral

assessment of VLBW at corrected age of 2 years and they found that 17% of the children

had mean MDI score of


22

metabolic and cardiovascular risk later in life, these findings may have implications for the

future adult health of VLBW survivors.99

Studies examined Quality of life in preschool-aged

children who were born at VLBW and/or preterm. Significant differences in physical

functioning between study groups and controls were found in those studies, most notably in

motor functioning,100,101

with poorer performance by the preterm and/or VLBW children.

The Social functioning was found to be significantly lower for preterm and VLBW

preschool-aged children compared with those in the control groups.103,104

In some studies,

there was no significant difference between the 2 groups in emotional functioning,103,104

whereas in others, preterm children were significantly more anxious than those in the control

groups. 100,101

Studies explored Quality of Life in preterm adolescents and term peers using the

Health Utilities Index, and the Child Health Questionnaire. They found that the VLBW

teenagers did not rate themselves as significantly different from their peers on a generic

health measure. Parents of VLBW teenagers with low IQ indicated that their children

performed significantly lower in terms of global health and behavior, general health

perception, self esteem, and family activities. 105,106

A Meta-analysis of motor development in Very Preterm and VLBW Children was

done to investigate the relationship between very preterm birth and VLBW with motor

development. The results of the analysis were in comparison with term-born peers, very

preterm and VLBW children obtained significantly lower scores on all

3 motor tests that is

the BSID-II, Movement Assessment Battery for Children and BOTMP, indicating that


23

preterm or VLBW is associated with significant motor impairment persisting throughout

childhood.107

In a study on the developmental profile of 61 very low birth weight infants without

major cognitive, motor, or sensory deficits compared with that of 28 term infants at 1 year

chronologic age found that the VLBW infant's motor performance significantly correlated

with bronchopulmonary dysplasia, intracranial hemorrhage, and number of days spent

in the

hospital.108

A longitudinal study on was done to evaluate the stability of motor development and

its association with birth weight , gestational age at birth, intraventricular haemorrhage ,

periventricular leucomalacia and retinopathy of prematurity till 5.5 years found that fifty-

three percent of the VLBW infants displayed a stable motor development. Only

periventricular leucomalacia and birth weight contributed significantly to the variability in

their motor performance. Forty-seven percent of the infants exhibited an unstable motor

development with no association to risk factors.109

In a study on the characteristics of the VLBW babies suggested that they have an

increased risk for developmental delays and are apt to have difficult behavioral styles. There

was a negative relationship between infants with difficult behavioral styles and maternal

involvement and responsivity. 110

A study in Canada examined school performance at 8 years of preterm, small for

gestational age VLBW infants compared to that of VLBW children born appropriate for

gestational age. The IUGR children did not differ in school performance when compared to


24

either birth weight- or gestational-age-matched controls. All the VLBW groups had

significantly inferior outcomes when compared to a normal-birth weight control group.111

The age of gross motor milestone attainment and how it is affected by degree of

prematurity at delivery were studied in 100 high-risk, preterm (


25

review of published studies of infants born between 1960 and mid-1980s weighing less than

1500g at birth concluded that the median CP rate in all cohorts was 7.7%.115

The epidemiological study on sensorineural impairment in very premature infants

reports that the prevalence for CP remained unchanged in extremely and very preterm

infants since 1990. The prevalence estimates of moderate and severe cognitive impairments

were 15 to 25% in very preterm children.116

In the USA among the 80% survivors of

VLBW, 5-15% develop cerebral palsy.117

Literature overwhelmingly supports that the risk of CP and major neurologic disability

is increased among VLBW infants compared to full-term infants. The literature is consistent

in demonstrating that risk of CP or major neurosensory and/or neurologic disability is

inversely proportional to the degree of immaturity whether measured by gestational age or

by birth weight. The incidence of CP is currently stable compared to the 1980s (710%

VLBW infants; 717% ELBW infants) or modestly decreased despite improved survival of

extremely immature infants. This suggests that recent advances in neonatal care have had

either no or modest effect on further reduction in the incidence of Cerebral palsy. Studies

have demonstrated that the risk of major neurosensory or neurologic disability might range

from 1250 percent among VLBW and ELBW infants. Despite the stable risk of Cerebral

Palsy, the risk of disability primarily to visual disabilities has increased since the 1980s.

Differences among studies regarding the incidence of Cerebral Palsy, neurologic, and

neurosensory disability may be accounted for differences in the criteria for

neurologic/neurosensory disability, the era of study, the degree of immaturity, and other

characteristics or risk factors of the patient population, neonatal care practices, as well as

length and completeness of follow-up.118


26

A three year follow up study was done to find the neurologic sequelae in high risk

infants discharged from the Neonatal Special Care Unit (NSCU) of a referral hospital in

Pune. The Amiel-Tison Method, Bayley Scales of Infant Development and Raval's Scale for

social maturity were used to evaluate the babies and reported a low incidence of handicap in

their sample which could be due to good antenatal and perinatal care.119

Considering the extent and severity of various neurodevelopmental problems in

VLBW infants, early identification of the problems is very essential both for healthy and

risk VLBW infants in order to start timely intervention and prevent long term disabilities.

SCALES FOR ASSESSMENT OF NEUROMOTOR DEVELOPMENT

Developmental scales are used as screening tools which promotes early intervention

for deviation from the normal growth and development in young children. It can assist in

determining the diagnosis. It facilitates early identification of deviation; provide the

anticipatory advice to parents, clinicians and caregivers for future planning. It is helpful for

early recognition and focused plan for intervention which may prevent severe disability. It

facilitates the planning of a treatment program. It provides important information about the

level of operation of the child and milestones achieved. The test results may help the parents

to understand the child limitations, what can and cannot be expected makings it possible to

establish common goals and to plan for the future. The report of testing may reveal specific

areas of deficit that require additional evaluation to discover the underlying cause of the

delay. Sequential tests reveal the rate and trend of development of a child. It can be used to

monitor the progress and determine whether and when the child has achieved the goals.

Screening tests are intended to differentiate between those persons who are normal

and healthy in a particular aspect from those who are not.


27

Milani-Comparetti motor development test120

It is a screening test of motor development that evaluates infants on the basis of a

correlation between the functional motor achievements of the child and underlying reflex

structures. Test age for the scale is from birth to approximately two years of the age. During

the test the examiner physically manipulate the child for a particular motor response. Parents

can provide the information if the child is uncooperative. Experienced observes can do the

test in four to eight minutes.

The summaries of reports are shown by a vertical alignment of notations that is

consistent with the childs chronological age. A wider scattering of lines is an indicator of a

more severe, a possibly more specific motor dysfunction such as cerebral palsy. Test-retest

reliability results showed percentage agreement ranging from 82 to 100%. This screening

test can be done quickly and does not require any special equipment or setting. It can

provide early evidence of neuromotor delay of deficits.

Denver Development Screening Test (DDST) 27

It is used to screen for developmental delay. The Denver II screens general

development in five areas such as personal, social, fine motor adaptive, language, gross

motor and behavior. It is used to test children between birth to six years. The mean examiner

observer reliability was found to be 0.99. The test administration and scoring is done quickly

and the test is acceptable for both children and parents. This test is excellent for identifying

children who are at risk for developmental problems and for monitoring a child

longitudinally. The validity of this test in children below 30 months has been questioned.121


28

Alberta Infant Motor Scale (AIMS)31

It measures gross motor maturation in infants from birth (term 40 weeks post

conception) through independent walking (0 to 18 months of age). The focus of the

assessment is an evaluation of the sequential development of postural control relative to four

postural positions supine, prone, sitting and standing. The interrater reliability is 0.99 and

test - retest reliability is 0.99. The advantage of the test is it provides the ability to detect, as

early as possible, any deviation from the normal, thereby permitting early intervention to

minimize the effect of dysfunction. Although it has good concurrent validity, but its

predictive validity for major developmental disorders is only moderate.122

The other

limitation of the tool is it only evaluates gross motor behavior.

Amiel Tison test123

It was developed by Amiel Tison and Gosselin and is applicable for high risk infants.

The target population includes one month to six years. It is based on traditional

neuropediatric concepts (French School).It includes assessment of active and passive muscle

tone, reflexes, spontaneous motor behavior and qualitative abnormal behavior. 123

It is a pure

neuromotor test and does not take into consideration the mental development of the child at

all.122

Infant Motor screen (IMS) 124

IMS consists of 25 test items which assess muscle tone, primitive reflexes, automatic

reactions and asymmetry of motor skills. It is designed to be administered initially at 4

months and is useful till the development of independent walking. This test aids in

identifying early motor development and risk of abnormal development. There are three


29

levels of scoring: the test score, the item score and the test rating. The test rating is 0-9

points as normal, 10-14 points as questionable and 15 and above points as abnormal

development. A study has been done in Indian high risk infants using IMS and DDST at 4

and 8 months and the neurodevelopmental outcome was tested against BSID. They

concluded that both IMS and DDST have high accuracy in identifying neurodevelopmental

abnormalities.38

Test of Infant Motor Performance (TIMP) 32

TIMP is a functional motor scale for newborns and infants less than four months of

age. It has 59 items with observed scale items of 28, dichotomously scored and elicited scale

of 31 items scored on five, six or seven point scale. The observed scale examines infants

spontaneous movements such as head centering and individual finger, ankle and wrist

movements. The elicited scale tests the infants movement responses to placement in various

positions and to interesting sights and sounds. The maximum possible raw score is 170, and

the test can be used in infants from 32 weeks post-conceptional age through four months

post term. The purpose of TIMP is identification of children with developmental motor

delay and has test-retest reliability of 0.89.It has good construct and concurrent

validity.125,126

Limitation of the test is its applicability beyond four months of age , addresses

only gross motor behavior and requires training for administration.

General Movements (GMs) Assessment 33

It is more recently developed tool by Prechtls in 2004 for preterm infants to be used

from birth to four months of age. It is a criterion referenced tool used to discriminate and

predict neuromotor abnormalities. The test components include spontaneous movement and

neurological integrity. The infants spontaneous movements are videotaped and then scored.


30

It is good predictive tool but needs compulsory training to use from the general movements

trust which limits its clinical and research utility.122

There are others scales like, Posture and Fine Motor Assessment (PFMAI),127

Toddler

and Infant Motor Examination (TIME)128

and Neuro Sensory Motor Development

Assessment (NSMDA)29

which are used to assess motor performance in risk babies.

Peabody Development Motor Scale26

It provides a comprehensive sequence of gross and fine motor skills. Children from

birth through 83 months of age are included. Test retest reliability is 0.99 for fine motor and

gross motor scales. The disadvantage of this tool, is it does not provide all of the items

necessary for administration of the fine and gross motor scales.

Gesell Development Schedules Test25

It assesses behavior in the areas of adaptive, gross motor, fine motor, language and

personal social development. The test is appropriate for children ages of one month to 36

months. The test retest reliability is reported to be 0.82. The disadvantage of the test is that it

requires extensive practice and use in order to ensure valid results.

Developmental Assessment Scales for Indian Infants (DASII) 130

It is an Indian adaptation of Bayley Scale of Infant Development. It is standardized for

children of Baroda and is culturally relevant. It measures motor and mental development

from birth to 30 months. It provides overall motor and mental scores and in addition

indicates the specific clusters of delay in areas of motor and mental development. A study

was done in Chandighar on the neurodevelopmental and behavioral assessment of very low

birth weight babies (VLBW) using DASII at 18 months. They found that 17% had mental


31

developmental quotient and 25.7% had motor developmental quotient score


32

infants from 1month to 42 months of age. The BSID-II has good construct, content,

predictive, and discriminative validity.

Inter observer reliability rates for the mental scale and the motor scale were 89.4%

and 93.4% respectively. Test and retest reliability was 76.4 and 75.3% for the mental and

motor scale respectively. The tests represent the best standardized techniques for the

behavioral assessment available for infants. The major disadvantage is one must has to

undergo training sessions and validated as an examiner. It does not predict the long term

outcome. It can be widely utilize as formal indicator of need for timely intervention

services.133

Many studies of BSID have been carried out to discriminate between children

with risk of developmental delay and who are developing normally. Studies have reported

correlation of birth weight with BSID scores in preterm infants.134,135

There was

significantly lower MDI and PDI scores in premature infants compared to full term infants

at 1,4,8 and 12 months of corrected age.136

A study was done to describe the neurobehavioral and developmental profile of very

low birth weight preterm infants in early infancy at 3 and 6 months using the Bayley motor,

mental and behavior rating scales with control group. VLBW infants performed lower on the

Bayley Motor, Mental and Behavioral Rating Scale and concluded that most of the VLBW

infants showed non-optimal motor quality behavior at 6 months and encountered far more

problems with self-regulation compared with term infants.137

BSID II mental scores are sensitive to patterns of development changed in the first 2

years of life that are specific to infants with Downs syndrome and medically fragile infants.

But the authors cautioned that the results from the BSID II assessment of high risk infants in

the first year of life should not be used for predictive purposes.138


33

Concurrent validity study of the BSID-II with the Peabody developmental motor

scale in children with developmental delay at 12 months reported that the concurrent validity

of the tool is good for certain subscales age equivalent scores, particularly the BSID motor

scale with the PDMS-2 locomotor scale.139

BSID-II is a gold standard diagnostic tool with good content, concurrent and

criterion validity for developmental assessment and hence was used in the present study to

measure developmental outcome in VLBW infants.

Movement Assessment of Infants Scale (MAI) 140

MAI was developed by Lynette Chandler in 1975 at the Clinical Training Unit of the

Child Development and mental Retardation Center of the University of Washington .It was

created out of need for a uniform approach to the evaluation of high risk infants. MAI

provides a detailed and systematic appraisal of motor behaviors that occur during the first

year of life. It is a criterion-referenced scale which assesses motor dysfunction in high risk

infants from birth to 12 months of age. It has 65 items and evaluates four components;

Muscle tone (10 items), Primitive reflexes (14 items), Automatic reactions (16 items)

Volitional movements (25 items). It has established risk profiles for 4, 6 and 8 months based

on normative data. The indications of MAI are as follows:

1) To identify motor dysfunction in infants upto the age of 12 months.

2) To establish the basis for an early intervention program.

3) To monitor the effects of physical therapy on infants and on children whose motor

behavior is at or below 1 year.

4) To aid in research on motor development by using a standard system of assessment.

5) To teach skillful observation of movement and motor development through

evaluation of normal and handicapped children.


34

The assessment of infant movement patterns is an important evaluation component in

the early identification and management of high risk and handicapped infants. Difference in

infant movement patterns may provide early clues to diagnosis of cerebral palsy and other

developmental disabilities. Although the use of norm-referenced developmental assessment

tools is an important component of infant evaluation, a need exists for standardized

qualitative assessment tools as well. The MAI represents an important first step towards the

clinical measurement of qualitative aspects of infant movement.141

A review of the MAI by Campbell stated, "The MAI appears well-suited to the stated

purposes and is more comprehensive in its assessment of total motor performance than any

other published test. If the appropriateness of the MAI is to be demonstrated, both normal

and abnormal children must be studied, so advised for normative data collection on both

full-term and premature infants.142

This led to the study in 1988 in which they compared the test results of 50 healthy

normal 4-month-old infants on the Movement Assessment of Infants with the published

Movement Assessment of Infants a priori profile. Thirty percent of the infants tested had

total-risk scores greater than 7, which differed significantly from the 15% in the original

Movement Assessment of Infants data. On 18 of the 65 Movement Assessment of Infants

items, more than 15% of the study sample had risk scores that differed from Movement

Assessment of Infants profile normative scores. Suggestions for revising the Movement

Assessment of Infants were made that could improve the reliability and validity of the test

(especially the TRS>10).143


35

Although the MAI test was not yet normed in 1980s, some reliability and validity

studies have been reported for the a priori profile. The MAI authors originally stated that the

interrater reliability for the MAI was 0.90 or above.140

A reliability study conducted with 53 infants found an interrater reliability of 0.72 and

a test-retest reliability of 0.76. An analysis of item reliability using the same 53 infants

showed that 40% of the MAI items had poor inter-observer reliability, and 48% of the items

had poor intra -observer reliability. Further data are needed to clarify which MAI items may

warrant elimination or modification.144

But a subsequent study reported a higher reliability. It was done to compare the

standard and a revised version of the four-month Movement Assessment of Infants (MAI),

on a group of 60 high-risk infants to find the inter-rater and test-retest reliabilities. Based on

the results, the tests inter-rater and test-retest reliabilities were considered excellent on both

the standard (0.91 and 0.79, respectively) and revised (0.93 and 0.83, respectively) MAI.

The results of this study suggest that there is a high reliability for the MAI.145

In a review of instruments that measure quality of movement in cerebral palsy they

focused on the Volitional Movement section of the MAI, because this section describes both

functional and qualitative components of gross motor behavior. They commented that the

MAI is a landmark test, as it was the first to apply the assessment of movement performance

to children with disordered movement.146

Another review on reliability and validity of the Movement Assessment of Infants

reported that the Volitional Movement section was the best predictor of outcome. This

finding indicates the importance of items that assess function and performance in the

prediction of a diagnosis of cerebral palsy.147


36

The predictive validity of MAI was evaluated on 246 high risk infants admitted in

NICU. These babies were evaluated at 4 months and follow up examinations using BSID

were scheduled at 12 and 24 months. The results of the study showed a highly significant

correlation between the MAI risk score and the Bayley Motor and Mental scale at one and

two year indicating the clinical relevance of MAI in identifying neuromotor dysfunction as

early as four months of corrected age.36

A retrospective study was done to examine the sensitivity and specificity of the Bayley

motor scale and the MAI for early identification of cerebral palsy at 4-months of corrected

age with outcome tested at 3years and 8 years .The results demonstrated that the MAI was

more than twice as sensitive as Bayley motor scale (73.5% Vs 35.3%) in correctly identifying

children with later diagnosis of cerebral palsy as either suspect or abnormal at 4-months of

age. However the specificity of MAI was lower than Bayley motor scale (62.7%Vs 94.9).37

MAI was tested on 86 preterm infants of 32 wks and between 32 to 36 weeks to

establish two preterm four month risk profiles based on gestational age and the results

suggested that the current MAI risk profile may be applicable to infants of 32-36 weeks

gestation but not to infants < 32 weeks gestation.148

A prospective study was done on 160 risk babies to identify neurodevelopmental

abnormalities at 4 and 8 months by MAI with neurodevelopment outcome tested at 18

months using BSID scale. They evaluated high risk infants with preterm low birth weight


37

A study was done to present early developmental data on a group of low-birth weight

infants with normal developmental outcomes. Subjects were 118 infants initially assessed at

4 months corrected age on the Bayley Scales of Infant Development and the Movement

Assessment of Infants (MAI) with outcome evaluation at 12 months on the Bayley and

compared to that of a group of 36 infants later diagnosed as having cerebral palsy (CP).

Results for the infants with normal outcomes showed that the CP group had significantly

lower Bayley scores and significantly higher MAI total risk scores than the non handicapped

group.149

A prospective study to evaluate one year neurodevelopmental outcome using Bayley

Motor Scale for at risk infants assessed on MAI at 4 months reported a sensitivity of 67%,

specificity of 35% and PPV of 65% at a cut-off score of 8 and with a cut-off score of 13,

sensitivity dropped and specificity raised. They also reported that the volitional movement

and primitive reflexes section risk score on MAI were significantly negatively correlated

with Griffiths mental score and PDI at 12 months. They concluded that certain MAI risk

scores at 4 months enable prediction of one year outcome.150

The purpose of a retrospective study was to analyze which neuromotor behaviors in a

sample of four-month-old low-birth weight infants were most predictive of later cerebral

palsy. The infants (n=229) were evaluated at four months corrected age on the Movement

Assessment of Infants (MAI) and were followed to between three and eight years of age. For

the CP group as a whole, 17 neuromotor items from the MA1 were highly significant

predictors of cerebral palsy. A further 15 items also were significant, but less significant

than the other 17 items. Seven items were predictive of later spastic diplegia, seven for

spastic hemiplegia, and 35 items differentiated quadriplegic infants. The authors


38

recommended a shorter version of the MA1 should be developed to increase its over-all

reliability and validity in the early detection of cerebral palsy.151

A recent study in 2006 was done to study the item validity analysis of MAI to detect

cerebral palsy in 76 preterm infants assessed at 4 and 8 months. The results indicated

general suitability of the test to the expectations of the Rasch model to detect cerebral palsy.

Further analysis showed that a statistically significant number of items do not fit the model,

which compromises the construct validity of the test. They suggested that the erroneous

items should be revised or even eliminated, because there was no consistent information

about the motor development at the corrected ages of four and eight months. Even with the

restrictions MAI has positive aspects and suggestions were in this study to improve the

validity of the tool.152

A study examined the performance of Asian American infants on the Movement

Assessment of Infants (MAI). The sample consisted of 30 full-term 6-month-old Asian

American infants. These infants tended to have slightly slower integration of some primitive

reflexes and to acquire automatic reactions and volitional motor skills at a slightly different

rate than the predominantly Caucasian group of infants in a previous study. When the

Washington and Deitz 6-Month Profile was used with the Asian American infants, 40% of

them were identified as having risk scores higher than any of the infants in the Washington

and Deitz study. This finding suggests that clinicians should be cautious when using the

MAI 6-Month Profile to assess Asian American infants.153

A prospective study has evaluated the predictive validity of the MAI in extremely low

birth weight infants (


39

sensitive (64%) to detect cerebral palsy. The outcome was evaluated based on the BSID

scores at 2 years. They also evaluated the predictability of MAI for identifying minor

neurological disorders (MND) using a cuff-off score of five and found that MAI had

sensitivity of 44%,specificity of 71% and PPV and NPV of 50% and 67% respectively.39

A retrospective study was to examine the relationship between early neuromotor

findings, as assessed by the Movement Assessment of Infants (MAI), and later gross and

fine motor outcomes, as measured by the Peabody Developmental Gross Motor Scale and

the Frostig Eye-Motor Coordination Subtest. The sample consisted of 77 children who had

been identified in infancy as biologically at risk and who had 4-month MAI scores and 4.5-

year motor evaluation scores. Spearman's rank correlation between the MAI scores and the

two motor outcome measures yielded no clinically significant relationships. These findings

suggest that therapists should use the MAI as a reflection of an infant's performance at the

time of testing rather than as an indicator of future potential.154

A study examining the ability of the MAI "to detect subtle changes in motor

development of infants with Down's syndrome" over a six-week period in responsiveness to

the Peabody Gross Motor Scale and reported that the MAI was sensitive to developmental

changes in the subjects tested from initial test to follow-up, thus further suggesting the

predictive value of this tool in assessing a group of infants with known handicaps.155

In a prospective study the performance of 57 healthy full term 6-month old infants in

order to provide a standard against which to compare the motor performance of 6 month old

infants at risk for developmental abnormalities. The results included identification of those

motor behaviors which are both typical and infrequent for 6 month old infants with normal


40

motor outcome. A total risk score for the sample ranged from 0 to 5 and a score 6 was

considered as risk for abnormal development in 6-month old infants. There are no other

studies on performance of 6-month old infants on MAI .This study was used as the base to

study the predictive validity of MAI in 6 months old Very low birth weight infants.42

The predictive validity of the Movement Assessment of Infants (MAI) for the

detection of cerebral palsy was analyzed in 89 Brazilian infants, born with gestational age <

32 weeks and weight < 1500g. The infants were assessed with the MAI at 4 and 8 months,

corrected ages, and were submitted to a neurological evaluation between the ages 2 and 7

years old. Their results showed a high sensitivity of 4 and 8 month MAI for prediction of

Cerebral palsy with cut off score of >10. The best predictive values were obtained at 8

months, with a cut off > 13 risk points. A less restrictive criteria (> 10 points) might be

useful for the prediction of motor coordination problems at school age.156

A study was conducted to compare the predictive abilities of the AIMS with those of

the Movement Assessment of Infants (MAI) and the Peabody Developmental Gross Motor

Scale (PDGMS). One hundred and sixty-four infants were assessed at 4 and 8 months

adjusted ages on the three measures. A pediatrician assessed each infant's gross motor

development at 18 months as normal, suspicious, or abnormal. The MAI provided the best

specificity rates at 4 months while the AIMS were superior in specificity at 8 months.

Sensitivity rates were comparable between the two tests. 157

A prospective longitudinal study to evaluate whether the four-month Movement

Assessment of Infants (MAI), predicted two-year cognitive and motor developmental status.

The subjects were 134 infants born at term who were considered at developmental risk due


41

to biological and social risk factors. Infants average MAI total risk scores at four months

were negatively correlated with their BSID MDI scores but not PDI scores at two years.

Infants classified as high risk on the MAI were approximately three times more likely than

infants with a lower risk MAI classification to have a high-risk MDI scores. They concluded

that the MAI appears to be valid for use with infants born at term who are at risk of

developmental delay and may be a useful tool to help clinicians make decisions about

intervention services.41

The longitudinal motor development of a group of infants exposed to cocaine in utero

and was compared to an unexposed control group, and were evaluated at 1 month with the

AIMS, at 4 and 7 months with the AIMS and MAI, and at 15 months with the Peabody

Developmental Motor Scales (PDMS) and they concluded that in utero cocaine exposure has

a significant, although relatively small, effect on infant motor performance late in infancy.

However, regardless of exposure status, these infants had poor performance that may be

accounted for by a heavy accumulation of risk factors associated with poverty.40

Study in group of infants exposed in utero to multiple drugs was done to compare the

predictive power of the Alberta Infant Motor scale (AIMS) and the Movement Assessment

of Infants (MAI) administered at four and seven months for detection of gross motor delays

at 15 months based on the Peabody developmental motor scales (PDMS).The study reported

that the for both tests, the best combination of sensitivity and specificity values was at seven

months. The MAI over identifies infants with motor problems in comparison to the AIMS,

but neither test adequately identifies infants who go on to have poor motor scores on the

PDMS-GM.158


42

A study was conducted to evaluate whether Chronic Lung Disease (CLD) without

concomitant brain lesions constitutes a risk factor for adverse developmental outcome. Forty

three very low birth weight infants with CLD and without CLD were evaluated at 5 and 10

months of corrected age using the MAI scale. The Griffiths developmental test was carried

out at 10 months of age. The results indicated that CLD has a deleterious effect on the

control of hand and eye coordination and on perception and intelligence.159

A study conducted to validate a 2-step infant developmental screening protocol

administered by nonphysician health professionals in community clinics administered the

Bayley Scales of Infant Development II and Movement Assessment of Infants at 6 months

to compare the infants scores on The Parent Concerns Survey and the Meade Movement

Checklist (MMCL) at 4 months .The correlation between infant MMCL scores at 4months

and Movement Assessment of Infants was significant with Bayley Scales of Infant

Development II scores at 6 months. This 2-step screening by non physician health

professionals provides a valid, new perspective for screening young infants.160

Methodology

43

METHODOLOGY

Study Type: Observational Study

Study Design: - Prospective Longitudinal Study

Study Place: - The study was conducted in Department of Pediatrics Physiotherapy, KLES

Dr. Prabhakar Kore Hospital and Medical Research Centre, Belgaum

Study Duration: - January 2008 to December 2010.The babies were enrolled from January

2008 to June 2009 and followed up to one year of corrected age till December 2010.

Source of Data Collection: - Neonatal Intensive Care Unit (NICU) of KLEs Dr Prabhakar

Kore Hospital and Medical Research Centre, Belgaum -590 010, Karnataka State, India

Sample Size: - 60

Calculation of sample size: The sample size was calculated with the aim of obtaining at

least 80% sensitivity for the MAI tool to predict neurodevelopmental outcome at 12 months.

Sample size calculation for predictive validity studies to find the sensitivity of the test is

4Z 2pq

d 2

Where p=sensitivity of the tool

q = (100-p) %

d = error allowed

Z = Standard normal constant for (1-) %

For a Sensitivity (p)=80% based on previous studies, allowing 20% error(d) with 95%

confidence the required sample size is

4 x (1.96)2 x 80 x 20

= 61.46 20

2

Methodology

44

Sampling Design: - Non- probability sampling

Sampling method: - Consecutive sampling

Study Participants All male and female babies with birth weight of 1500gms admitted

to NICU

Instruments: -

1) Movement Assessment of Infants Manual- It is a criterion-referenced scale which

assesses motor dysfunction in high risk infants from birth to 12 months of age. It

assesses the quality of movement performance in children with disordered

movement. It has established risk profiles for 4 and 8 months based on degree of risk

approach .It also has a preliminary 6-month profile based on normative approach .It

is a comprehensive assessment and requires 30 to 45 minutes for administration and

scoring. It has 65 items and evaluates four components; Muscle tone (10 items),

Primitive reflexes (14items), Automatic reactions (16items) and Volitional

movements (25items). Maximum numbers of items that can be administered at 4

months of age are 48 and at 8 months of age are 61.140

2) Bayley Scale of Infant Development (BSID-II) Second Edition Manual-It is a

comprehensive diagnostic tool that evaluates children between birth and 42 months.

It is based on normative data and consists of a Mental Scale, a Motor Scale, and a

Behavior Rating Scale. According to the manual, the Motor Scale assesses degree of

control of the body, coordination of the large muscles, finer manipulatory skills of

the

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Deepa Metgud