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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
Kvisoft PDF Merger DEMO : Purchase from www.kvisoft.com to remove the watermark
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KLE ACADEMY OF HIGHER EDUCATION AND
RESEARCH,
(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)
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
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KLE ACADEMY OF HIGHER EDUCATION AND
RESEARCH,
(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)
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
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KLE ACADEMY OF HIGHER EDUCATION AND
RESEARCH,
(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)
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
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V
KLE ACADEMY OF HIGHER EDUCATION AND
RESEARCH,
(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)
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
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KLE ACADEMY OF HIGHER EDUCATION AND
RESEARCH,
(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)
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
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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.
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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.
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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
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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
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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
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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.
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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
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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
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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
outcome at 12 months
101
08 Predictive validity of 8- month MAI for neuromotor
outcome at 12 months
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
11 Correlation between the 6-month MAI and BSID-II at
12 months
102
12 Correlation between the 8-month MAI and BSID-II at
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
abnormal neuromotor outcome
104
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XVI
Table No Particulars Pages
16 Eight-months MAI scores of infants with normal and
abnormal neuromotor outcome
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
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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
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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
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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 (
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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
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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
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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.
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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 ?
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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.
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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
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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.
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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
-
Review of Literature
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
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Review of Literature
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,
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Review of Literature
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
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Review of Literature
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.
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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.
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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
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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,
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'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
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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
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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
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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
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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
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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
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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
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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 (
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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
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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.
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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
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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
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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.
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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
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developmental quotient and 25.7% had motor developmental quotient score
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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
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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.
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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
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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
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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
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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
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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 (
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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
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Review of Literature
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
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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
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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
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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
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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