<p>Improved survival of high-risk neonates has been noted during last decades, this is also shown in NNF Perinatal Data Base between 1995 and 2000 (<xref ref-type="bibr" rid="bib001">1</xref>). During last two decades, with efforts of National Neonatology Forum, the problem of neonates are being recognized along with increasing availability of neonatal intensive care beds, equipments and improved skills of pediatricians caring forneonates. As the neonates with severe problems of respiration, birth asphyxia, sepsis and VLB W are being discharge home after stormy NICU stay, those with more problems may suffer later from a wide range of problems like cerebral palsy, vision, speech and hearing problems and developmental delay etc (<xref ref-type="bibr" rid="bib001">1</xref>,<xref ref-type="bibr" rid="bib002">2</xref>). All these babies need a close follow-up, as some conditions like tone abnormalities, hearing and vision problems etc can benefit from early intervention. As the pediatrician is actively involved with infants and their families up to about 2 years of age, they are in a position to have a significant impact on early screening for neuro-developmental handicaps, in addition to medical care of infants (<xref ref-type="bibr" rid="bib003">3</xref>,<xref ref-type="bibr" rid="bib004">4</xref>).</p></sec><sec id="sec001"><title>Follow-up Schedule

JNNFI

Journal of Neonatology

0973-2179

National Neonatology Forum

jn-18-2-002

Symposium on Follow-up Care of NICU Graduates

Rapid neuro-developmental screening in clinical practice

Kumari

Sudershan

Dadhich

Neonatal Division, Sunderlal Jain Hospital, Ashok Vihar - III, New Delhi - 110052

4-62004

1821217

<p>Improved survival of high-risk neonates has been noted during last decades, this is also shown in NNF Perinatal Data Base between 1995 and 2000 (<xref ref-type="bibr" rid="bib001">1</xref>). During last two decades, with efforts of National Neonatology Forum, the problem of neonates are being recognized along with increasing availability of neonatal intensive care beds, equipments and improved skills of pediatricians caring forneonates. As the neonates with severe problems of respiration, birth asphyxia, sepsis and VLB W are being discharge home after stormy NICU stay, those with more problems may suffer later from a wide range of problems like cerebral palsy, vision, speech and hearing problems and developmental delay etc (<xref ref-type="bibr" rid="bib001">1</xref>,<xref ref-type="bibr" rid="bib002">2</xref>). All these babies need a close follow-up, as some conditions like tone abnormalities, hearing and vision problems etc can benefit from early intervention. As the pediatrician is actively involved with infants and their families up to about 2 years of age, they are in a position to have a significant impact on early screening for neuro-developmental handicaps, in addition to medical care of infants (<xref ref-type="bibr" rid="bib003">3</xref>,<xref ref-type="bibr" rid="bib004">4</xref>).</p></sec><sec id="sec001"><title>Follow-up Schedule

It is ideal to track all nursery graduates for follow-up till 4 months of age, as by this time the influence of NICU problems has weaned off and primary reflexes have disappeared. Neurological assessment at 4 months if normal, indicates almost normal later developmental outcome in most babies. If it is not possible to follow periodically, then assessment at 2 months and 7 months have been suggested by Amiel Tison (5). Several studies have shown that 1-year of age in most infants and by 2 year in almost all; a prediction of later adverse outcome can be precisely made (6,7). A minimum follow-up is needed afterdischarge as follows:

3 months:	Detection of early NDA for early intervention
7-8 months:	Transitory tone abnormalities. They start disappearance by 9-18 months but have significant impact in child at school age.
12 months:	DQ < 80 associated with later low IQ
2 years:	Catch up growth, developmental status

Subsequently minimum follow-up would be at school age and 8-9 years age for learning disabilities and other behavioral problems. However neurological abnormality in NICU that lasts for more than 7 days or persists till discharge indicates close follow up with early developmental intervention.

Assessment should be performed with history, physical examination and age appropriate mile stones with specific objective of developmental testing, depending on pediatrician's suspicion of the problem (8). Emphasis should be laid on developmental history, observation and parents opinion.

Issues in Methodology

A history of known risk factors for developmental problems, physical findings or medical problems likely to be associated with delays are probably known to the practicing physician who is following the infant from an early age. However some developmental delays are difficult to assess early as delay in a skill becomes apparent only at the age when the developmental milestone is expected. Language skills are usually identified later, but are predictors of future intelligence and school performance.

The limited availability of infant tests for screening or definitive diagnosis has led to controversies in this use. When a physician use only his clinical impression, estimates of a child' developmental status are often inaccurate.

Denver II is brief validated test used all over the world and has been adapted in many countries but is hampered by over-referrals. The Indian adaptation of Bayley Scale of Infant Development (BARODANORMS) (9) has been further simplified as Baroda Developmental Screening Test and Trivandrum Developmental Screening test (10). A neurological examination in infancy, according to Amiel-Tison's method, is a valuable tool to identify infants with problems. Even a standard neurological examination may back up deviant problems. There are other tests used by various workers like Woodside Screening Test (11), DASH, DSS, etc. However, we should remember that parental concern about their child should never be ignored. Recently a Parents Evaluation Questionnaire (PEDS) has been developed which requires just 10 minutes. It has been shown that parents concerns are as accurate as quality screening tests. The Ten-Question Performa, validated in developing countries in multinational trials by WHO, is a quick and useful test (Table 1). A list of clinical alerts is given for physicians concerned for detailed evaluation (Table 2). Table 1

Ten Question Screen It assesses motor, cognitive, self help, language and socialization skills and can be used in office practice and community work.

Question	Answers

Compared with other children, did the Child particularly have any serious Delay in shifting, standing or walking.	YES	NO
Does the person have difficulty seeing?	YES	NO
Does the person appear to have difficulty hearing?	YES	NO
When you ask the person to do something. Does He/she seem to understand what you are saying?	YES	NO
Does the person have weakness and/or stiffness on the limbs and/or difficulty in walking or moving His arms?	YES	NO
Does the person sometimes have fits, become rigid Or loss consciousness?	YES	NO
Does the person learn to do things like other children of his age?	YES	NO
Does the person speak at all (can he make himself Understood in words, can he say any recognized Words)?	YES	NO
Is the person's speech in any way different from Normal (not clear enough to be understood by People other than his immediate family)?	YES	NO
Compared with other children of his age, Does the Child appear in any way backward, dull or slow?	YES	NO

Motor 1, 5; MR - 4,7, 10; Speech - 8,9; Visual - 2; Fits - 6; Hearing - 3
Name of the person doing assessment Date

Table 2

Alarm Symptoms of Deviant Development

Parameters	Age When Abnormal

Poverty of movements, Lack of initiative	Increasingly important after first month
Constant fisting	after First month
Asymmetrical limb movements, Hypotonia - Slips when Supported under axilla	Any age
Tremors at rest	After 5 weeks
Persisted & Obligatory ATNR	If obligatory, always suspect
No reaction to sound, blinking of eyes, head turning, startle	Any age, specially after first 2 months of life
Insufficient pursuit of eye movements	After 4-6 weeks
Constant Strabismus	Any age
Wide sutures, tense fontanel, Abnormal increase in head size	Any age
Constant sun set sign, Vomiting, anxious look	Any age
Abnormal tone - Increase	Any age
Pulled to sit from supine - stand	3-5 months
Sitting with lumbar lordosis	After 8 months
Not walking with support	After 16-18 months
Poor head control	After 5-6 months
No social smile	After 2 months
Not sitting	After 8 months
Left hand preference before	less than 14
No crawling	after 12 months

Table 3

Primary reflexes.

Reflex	Refle appears	Reflex disappears

Rooting	Birth	12 months
Sucking	Birth	3 months
Palmar grasp	Birth	4 months
Plantar grasp	Birth	12 months
Moro	Birth	6 months
Asymmetric tonic	Prenatal	4 month
Neck (ATNR) Symmetric tonic	6 month	8 months
Neck (STNR)

Essentials of developmental screening test

Screening should be performed on a periodic basis.

Procedures should be reliable and

Screening is more effective when familiar tasks and sittings are used.

Procedures must be culturally sensitive

Multiple sources of information should be utilized

Social and medical risk factors should be included in the evaluation

Screening does not measure the intelligence quotient; it aims to identify those who need further evaluation, leading to an interdisciplinary comprehensive plan.

Definitions

Impairment:

Loss or abnormality of function -psychological, physiological or anatomic

Disability

Restriction or lack of ability to perform an activity in a normal manner.

Handicap:

Disadvantage to an individual that limits or prevents fulfillment of a role considered normal for age, sex and cultural factors.

Screening:

A brief assessment procedure designed to identify children who should receive more intensive diagnosis or assessment.

Trivandrum Developing Screening Chart (TDSC)

TDSC was designated by Nair et al who selected 17 items from Baroda scale of infant development (BSID - Baroda Norms)(12). It was validated against Denver development screening test (DDST) both at community and hospital clinic. TDSC had a sensitivity of 66.7% and specificity of 78.8%, which made it an acceptable simple tool for a busy practitioner and even a community level work. Individual items give a range of 3-97th percentile. A vertical line is drawn or a pencil kept vertically at the level of child's chronological age being tested. It child fails to achieve any items that fall short of 3rd percentile, the child is considered to have developmental delay. The test does not require a developmental kit. 17 test items include motor, mental, hearing and vision. TDSC is also used by IAP on its child health card for immunization and growth.

Baroda development screening test

A simple screening test with 22 motor items and 32 mental items. Uses commonly available material.

The items are sequentially arranged according to 97% pass age placement. They are grouped age-wise, monthly 0-12 months, 3 monthly 12-18 months and 6 monthly thereafter till 38 months.

A child who fails items according to his chronological age is screened out for detailed study.

Development age and quotient can be easily calculated.

Can be used by field workers and in office practice.

Screening validity, sensitivity and specificity 65%.

Woodside screening test (WSST)

The test consists of 4 charts of graphic representation of child development, i.e., gross motor, social, hearing and language, vision and fine motor.

Allows rapid visual comparison of the child's achievement with peers and his own previous levels.

Development is satisfactory if the tested item lies above the step, doubtful it is lies between the steps and the dotted line and abnormal if lies below the dotted line.

Clear threshold for referral to a specialist

Originally meant for use by health workers, this test is also useful in office practice with a little modification.

Denver development screening test (DDST)

DDST was designed in Denver in 1967; the thrust was to develop simple method to evaluate psychosocial status of children from birth to six year. The rationale was early identification of handicap for early management. This is one of the most widely used test in many countries. Test materials are simple and consist of a ball of red wool, a box of raisons, a rattle with handle, a small bottle, a bell, a tennis ball and & cubes.

DDST was revised and re standardized as Denver II test in 1992, as original DDST had less of language items. The Denver II contains 125 items. It is presented in graphic form like growth curves and contains a range of developmental skills for gross, Language, fine motor, adaptive and personal social up to 6 years of age. It is only a screening test and does not measure intelligence or development quotient. The only disadvantage in that it has high false positive rate.

The development-screening questionnaire has been adapted from the Denver Screening Questionnaire, devised by K. Frankenberg and the Singapore development-screening test. The advantage of this method is that parents can track their child's development at specific ages: 6 weeks, 3 months, 6 months, 12 months, 18 months, 3-4 years and 6 years. The different milestones are written in the form of a question with a “Yes‘ or sNo’ answer. The items are arranged in chronological order according to ages at which 90% of children could perform the test. A sNo’ response may indicate a delay if the child has not achieved a milestone which 90% of children have achieved. If you get a delay, repeat after a month; a delay again is an indication for referral to a developmental pediatrician or a clinical psychologist.

The test can be used by educated parents only or in office practice. There are 35 items during the first year, 22 during the second and 21 from 2+ to 6 years of age.

Neurological Examination during Infancy

In sick neonates in NICU, clinical assessment of neurological status in often difficult due to technical difficulties. When infant is in stable condition, neurological examination is essential in term neonates and at term gestation in preterm babies at 40 weeks gestation:

To determine central nervous system function.

Identification of abnormal neurological signs symptoms and extent of problem.

The examination does not require special equipment and can be performed in a limited space, over 5 to 10 minutes period. One year is divided into four three months periods. Transient abnormalities in muscle tone may appear by 7 months of age, to normalize by 12 months, in some cases by 18 months.

Neurological Examination

An abnormal neurological examination any time during infancy, even if transitory, is associated with problems during childhood in the form of low IQ, behavior problems, neurological soft signs and learning disabilities etc. Hence it is desirable for the clinician to be able to identify the clinical consequences of moderate or minor lesions of the CNS that may affect the future of the child.

Claudine Amiel - Tison (France) has devised a method for neurological examination during infancy that appears to be an excellent predictor from early month to previous years (5). The examination describes the active tone, passive tone and reflexes. Determination of angles like dorsiflexion of foot, popliteal angle, heel to ear, scarf sign, adductor angle, etc. helps to identify tone abnormalities and trunk asymmetries. Extensor hypertonia of neck and trunk may be normal before 3 months of age in 5% of normal andabout 15to20.1% of high risk infants. As the effect of neonatal period disappears by 4 months of age and primitive reflexes are disappearing, a neurodevelopmental examination at 4 months should be done in all infants, low and high risk. A 4-month normal examination has a good correlation with later outcome. Many maneuvers used in this method are familiar to pediatricians for Dubowitz's assessment of gestational age in neonates.

Amiel Tison has further simplified neurological assessment of term infants by including only 9 items.(13) They are Head circumference and cranial sutures (Temporal parietal ridge); visual pursuit, social interaction and sucking reflex pulled to sit, passive axial tone and cortical thumbs and lastly autonomic status during assessment. A ridge at temproparital suture soon after birth along with high arched palate and cortical thumbs indicate intrauterine hypoxia according to Amiel-Tison. Neurologic assessment after first year can be done by standard neurological examination.

Primitive reflexes

Primitive reflexes are critical for human survival and postural reflexes like stepping, righting, and postural reflexes that lead to complex voluntary movement of later infancy.(14) They are important for diagnosis of health and neurological normality.

Absence of plantar grasp in a neonate indicated brain damage. Assymetrical moro response suggests fracture clavicle, erb palsy or limb paresis due to cortical lesion. Tight popliteal angle in LEW may indicate intracranial hemorrhage.

Primary reflexes emerge during fetal life. Persistence of primary reflexes beyond normal interferes with subsequent development and indicates neurological abnormalities. As primary reflexes are initiated in first year of life, postural reflex system emerges.

Prolonged severe persistence of primary reflexes indicates problems like cerebral palsy, these children experience motor and reading difficulties, though intelligence may be normal. Hence examination for primary reflexes during routine examination is a simple way to check neurological normality in infancy.

If an abnormality is noted during first year on neurodevelopmental testing it should not be labeled as cerebral palsy, the term neurodevelopmental abnormality is better. These infants need further detailed assessment and investigations depending on availability.

References1

Amiel-Tison

Neurological assessment during first year of life.

Oxford University Press, 1986.2

Nair

M K C

A simplified developmental assessment.

Indian Pediatr1991; 28: 837-839.3

Phatak

Khurana Baroda development screening test for infants.

Indian Pediatr1991; 28: 31-37.4

Roth

Wyatt

Baudin

Neurodevelopment status at 1 year predicts neuropsychiatric outcome at 14-15 years of age in very preterm infants early human development

2001; 65: 81-89.5

Ellison

H P

Neurologic development of high risk infants.

clinic perinatol1984; 11: 41-57.6

Frankenburg

W K

Dodds

Archer

Shapiro

Bresnick

The Denver II: A major revision and standardization of DDST.

Peditrics1992; 89: 91-97.7

Amiel Tison

Clinical assessment of the infant nervous system. In fetal and neonatal neurology Fetal and neonatal neurology and neurosurgery3rd ed

Levene

Cherwank

Whitle

Churchill Livingstone, London, 2001, pp 99-120.8

Bohm

Salamon

Cognitive development at 5.5 years of children with chronic lung disease of prematurity.

Arch dis child2003; 88: f101-f105.9

Klassen

A F

Lee

S K

Raina

Health status and health related quality of life in a population-based sample of NICU graduates.

Pediatrics2004; 113: 593-600.10

Knobloch

Passamanick

Gesell

Amartudas

Developmental schedule

3rd edNEW YORK, Harpin & row, 1974.11

Narayan

Aggarwal

Upadhyay

Deorari

Paul

V K

Singh

Survival and morbidity in extremely low birth weight (ELBW) infants.

Ind pediatr200340130-5.12

Hadders-Algra

Huisjes

H J

Touwen

B C L

Perinatal correlates of major and minor school dysfunction at school age; a multivariate analysis.

Dev med child neurol1988; 30: 472-481.13

Pandit

Bhave

Developmental assessment, follow up and intervention in high risk neonates.

Proceedings of workshop at K. E.M. Hospital Pune, under auspices of NNF1990.14

NNF Perinatal Neonatal database.

2000.