General movements and magnetic resonance imaging in the prediction of neuromotor outcome in children born extremely preterm
Introduction
Extremely preterm (EPT) birth is a major risk factor for brain injury with potentially lifelong sequels. However, even in the absence of overt damage, many preterm infants suffer suboptimal brain growth [1] and a range of impairments [2]. Early identification of infants at risk is vital for counselling of parents regarding the prognosis of their child, both to enable appropriate support for the family and for individualized treatment of the child.
Early prediction of outcome is notoriously difficult. Heinz Prechtl developed a tool to assess the quality of an infant's spontaneous motor repertoire before goal directed movements emerge, the so-called general movements (GMs) observation [3], [4]. The GMs assessment is based on the Gestalt evaluation of movement complexity, fluency and variation at different ages: “preterm age” (from gestational age 28 weeks up to around 36–38 weeks), “writhing age” (up to 6–9 weeks post term) and finally at “fidgety age” (up to 2–4 months post term) [5]. There is some evidence that abnormal GMs predict cerebral palsy (CP) [6], [7] and that they may predict minor neurological dysfunction [8]. Abnormal GMs are frequently observed in preterm infants at “writhing age”; however, this may normalize within the first months of life [9] resulting in an intermediate specificity for these early assessments [10]. Later assessment of GMs (i.e. at “fidgety age”) is a better tool for prediction of neuromotor outcome [11] although additional studies are warranted [12]. The predictive power may be enhanced when GMs observation is combined with other tools such as magnetic resonance imaging (MRI) at term equivalent age (TEA) [13] but reports are sparse, especially in EPT children.
The main objective of the present study was to investigate the predictive value of GMs at “fidgety age” for neurological status in EPT infants at age 30 months, in comparison as well as in combination with findings from visual assessment of structural MRI at TEA.
Section snippets
Participants
The participants were part of a prospective population-based study of EPT infants who had MRI at TEA and neurodevelopmental follow-up at age 30 months corrected [14]. All infants born in Stockholm (2004–2007) with a gestational age (GA) of < 27 weeks + 0 days were eligible for inclusion. Between December 2005 and June 2007, 53 infants were prospectively enrolled in the sub-study which is the subject of this paper. Children with malformations, chromosome aberrations, malignant disorders or congenital
Results
Sixty-eight percent (36/53) of infants had normal GMs: 14/53 (26%) had normal optimal and 22/53 (42%) had normal suboptimal. Thirty-two percent (17/53) had abnormal GMs: 11/53 (21%) had mildly abnormal and 6/53 (11%) had definitely abnormal. Quality of GMs was not related to gender or associated with lower weight or gestation at birth; neither were any of the other perinatal factors or neonatal morbidities studied significantly associated with abnormal GMs at fidgety age.
In total, 66% of the
Discussion
The present study investigates the early motor repertoire of EPT infants in relation to their neurological outcome at age 30 months and MRI findings at TEA. Abnormal GMs (i.e. the categories mildly abnormal and definitely abnormal considered together) at “fidgety age” were a common finding, but a poor predictor of CP. However, the presence of definitely abnormal GMs according to the categories of Hadders-Algra et al., [15] was a better predictor of CP, although not as good as using information
Conclusion
The present study investigated the early motor repertoire in EPT infants in relation to their neurological outcome. The presence of definitely abnormal GMs was predictive of CP. Prediction was, however, significantly enhanced when GMs assessment was combined with findings from MRI obtained at TEA.
Conflict of interest
The authors do not have any potential, perceived, or real conflict of interest relevant to this article to disclose, especially no financial arrangement with a company whose products are discussed in the manuscript.
Financial disclosure
The authors have no financial relationships relevant to this article to disclose.
Acknowledgements
The authors would like to thank all the participating children and their parents. We thank Patricia Dessing for assisting with video recordings. We also thank Sandra Horsch, Boubou Hallberg, Mats Blennow and Mikael Mosskin for participating in the scoring of MR images. We are grateful to the Express Study Group, and our research nurses Elinor Ihre, Jessica Schiött and Lena Swartling. Furthermore, we acknowledge the MR physics group and the MR radiology staff at Astrid Lindgren Children's
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