General movements and magnetic resonance imaging in the prediction of neuromotor outcome in children born extremely preterm

https://doi.org/10.1016/j.earlhumdev.2013.03.014Get rights and content

Abstract

Background

Extremely preterm (EPT) birth is a major risk factor for brain injury and neurodevelopmental impairment. Reliable tools for early prediction of outcome are warranted.

Aim

To investigate the predictive value of general movements (GMs) at “fidgety age” for neurological outcome at age 30 months in EPT infants, both in comparison and in combination with structural magnetic resonance imaging (MRI) at term equivalent age (TEA).

Study design

Fifty-three infants born < 27 weeks of gestation were included prospectively. MRI was performed at TEA and images were evaluated for white and grey matter abnormalities. GMs were assessed at age 3 months corrected (“fidgety age”).

Outcome measures

Neuromotor outcome was assessed at age 30 months corrected. Children were classified as having a normal neurological status, unspecific signs, or cerebral palsy (CP).

Results

Abnormal GMs were a common finding, seen in 32% (17/53) of infants. Of these, six infants (11%) had definitely abnormal GMs. Four infants (8%) had a diagnosis of CP at follow up. Definitely abnormal GMs were significantly associated to CP at 30 months (Fisher's Exact test p = 0.03, sensitivity 50%, specificity 92%). Moderate–severe white matter abnormalities on MRI were more strongly associated with CP (Fisher's Exact test p < 0.001, sensitivity 100%, specificity 98%) than GMs. Combining GMs with MRI-findings at TEA increased the predictive specificity to 100% (Fisher's Exact test, p = 0.005), whereas sensitivity remained unchanged.

Conclusions

The presence of definitely abnormal GMs was predictive of CP: prediction was significantly enhanced when the GMs assessment was combined with findings from MRI obtained at TEA.

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

References (29)

  • K.R. Heineman et al.

    Evaluation of neuromotor function in infancy—a systematic review of available methods

    J Dev Behav Pediatr

    (2008)
  • J.L. Bruggink et al.

    The quality of the early motor repertoire in preterm infants predicts minor neurologic dysfunction at school age

    J Pediatr

    (2008)
  • N. De Vries et al.

    The motor repertoire of extremely low-birth weight infants at term in relation to their neurological outcome

    Dev Med Child Neurol

    (2011)
  • C. Einspieler et al.

    Prechtl's assessment of general movements: a diagnostic tool for the functional assessment of the young nervous system

    Ment Retard Dev Disabil Res Rev

    (2005)
  • Cited by (0)

    View full text