The assessment of minor neurological dysfunction in infancy using the Touwen Infant Neurological Examination: strengths and limitations

Abstract

AIM Little is known of minor neurological dysfunction (MND) in infancy. This study aimed to evaluate the inter-assessor reliability of the assessment of MND with the Touwen Infant Neurological Examination (TINE) and the construct and predictive validity of MND in infancy.METHOD Inter-assessor agreement was determined in a sample of 40 infants (24 males, 16 females) aged 3 to 12 months (25 born at term: gestational age 37-41wks, median 39; and 15 born preterm, gestational age 24-35wks, median 32). Thirty typically developing term infants (18 males, 12 females; gestational age 37-42wks, median 40) and 59 preterm infants (34 males, 25 females) born at <35 weeks' gestation (gestational age 25-34wks, median 29) participated in the validity study. They were neurologically assessed with the TINE at the corrected ages of 4, 6, 10, and 12 months and with the Hempel assessment at 18 months. RESULTSThe findings indicated that MND can be assessed reliably (inter-assessor agreement: kappa=0.83). MND during infancy was related to prenatal, perinatal, and social factors, and in particular to preterm birth. Neurological condition during infancy was prone to change, but was related to neurological condition at 18 months at all ages tested. INTERPRETATIONWe conclude that MND can be determined reliably in infancy. Important considerations in the construct of MND in infancy are its relation to prenatal and perinatal factors, its limited stability, and its moderate predictive value.Neurological assessment is one of the clinical tools used to monitor development in infants at risk for developmental disorders, such as infants born preterm. Multiple methods are available, such as the Amiel-Tison neurological examination, 1 the Touwen Infant Neurological Examination (TINE), 2 the Hammersmith Infant Neurological Examination (HINE), 3 and the neurofunctional assessment of Picciolini et al. 4 Little is known about the reliability of these widely used methods. 5 The validity of neurological assessments has been studied to some extent; marked neurological dysfunction during infancy has considerable power to predict developmental disability such as cerebral palsy (CP). [5][6][7] However, knowledge about the significance of signs of minor neurological dysfunction (MND) during infancy is scarce.Our knowledge of MND is based in particular on data of children above preschool age. Two distinct forms of MND have been distinguished: simple and complex MND.8 Before the onset of puberty the distinction is based on the number of dysfunctions present; after the onset of puberty classification is based on the type of dysfunction. Simple MND may be regarded as the expression of a normal but non-optimally functioning nervous system (minor neurological difference). In contrast, complex MND is the form of MND which is strongly related to pre-and perinatal adversities and to learning and behavioural disorders. From an aetiological point of view, this suggests that it may be considered as a borderline form of CP.8 It is uncertain whether the concept of simple ...

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“…Complex MND is the form which is strongly related to prenatal and perinatal adversities; moreover this form is clearly associated with developmental co-ordination disorder (DCD) and behavioural problems. The age specific assessments of the neurological examination have a satisfactory reliability (κ =0.71-0.83) and validity [7,10,11].…”

“…At the end of each video session the child was neurologically assessed by MHA with an age specific technique for the evaluation of MND [7][8][9]. Two forms of MND can be distinguished: simple and complex MND.…”

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“…The latter sign may be the most specific expression of an early lesion of the brain, 55,58,101 whereas the other signs may be the result of a lesion of the brain but also may be related to other types of adversities during early development, such as low-risk preterm birth. [102][103][104] Reduced variation in motor behavior is well expressed in the quality of GMs: abnormal GMs are characterized by limited variation and limited complexity. Interestingly, definitely abnormal GMs are related to white matter pathology and not to abnormalities of the brain's gray matter.…”

“…110 Prediction also is largely facilitated when longitudinal series of assessments are used. 104,111 The various instruments available to evaluate the infant's neuromotor and 113 Neurological assessments pair information on motor performance with specific details on sensorimotor function in terms of muscle tone and reflexes. 110 The growing awareness that the quality of motor behavior may assist in the evaluation of the child's neuromotor condition inspired the development of 3 new assessment methods; the Test of Infant Motor Performance (TIMP), 114 the GM method, 58,115 and the Infant Motor Profile (IMP).…”

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“…Examples are fine motor function (reaching and grasping), gross motor function, brain stem function, visuomotor function and sensorimotor function. Each cluster can be scored as typical or deviant (criteria are reported in Hadders-Algra et al (2009). Major neurological dysfunction means the presence of a distinct neurological syndrome, such as a hemisyndrome, irrespective of the number of deviant clusters.…”