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INFANTS MARTINE PABAN School of Physical and Occupational Therapy ' 0 PREDICTIVE VALUE OF EARLY ASSESSMENTS FOR "AT RISK" INFANTS MARTINE PABAN School of Physical and Occupational Therapy McGill University December 1984 A thesis submitted to the Faculty of Graduate Studies and Research in partial fulfillment of the requirements for the degree of Master of Science of Health Science (Rehabilitation) c ~MARTINE PABAN, 1984. PREDICTIVE VALUE OF EARLY ASSESSMENTS FOR "AT RISK" INFANTS i ABSTRACT 0 A prospective cohort study was conducted to determine the best early predictors of one year neurodevelopmental outcome of twenty-seven "at risk" infants. Results from early neuromotor assessments and measurements of physical growth were correlated with developmental and neurological outcomes at one year corrected age. Weight at three months corrected age was the earliest and best predictor of neurological status. Risk scores from the Movement Assessment of Infants administered at four months corrected age were significantly correlated with developmental outcome as assessed by the Griffiths Development Mental Scales, the Bayley Psychomotor Scale and the Wolanski Motor Evaluation. Heavier weight and 0 low risk scores on the Movement Assessment of Infants indicated neurologically normal infants with adequate developmental performances. Early identification of neuromotor disorders permits early treatment of affected infants even before manifesting overt symptoms. Longer studies with larger sample sizes need to be conducted to assess the long term predictive value of postnatal growth and the Movement Assessment of Infants. c ii c RESUME Une etude prospective a ete realisee en vue de determiner les meilleurs predicteurs precoces du statut neuromoteur i l'age d'un an, chez un groupe de vingt sept nouveau-nes "i risque". Resultats des examens neuromoteurs precoces et mesures de croissance somatique ont ete mis en correlation avec le developpement general et le statut neurologique i un an d'age corrige. Le poids i trois mois d'age corrige etait le meilleur et le plus precoce predicteur du statut neurologique. Scores de risque obtenus sur le "Movement Assessment of Infants" i quatre mois avaient des coefficients de correlation significatifs avec le developpement evalue par le "Griffiths Development Mental Scales", le "Bayley 0 Psychomotor Scale" et le "Wolanski Motor Evaluation". Les enfants qui pesaient les plus lourds et avaient de faibles scores de risque sur le "Movement Assessment of Infants" etaient neurologiquement normaux avec des quotients de developpement adequats. Le depistage precoce des troubles neuromoteurs permet de debuter le traitement tot, avant meme que des signes de pathologie evidente soient presents. De plus grands echantillons d'enfants doivent etre suivis plus longtemps afin d'evaluer le pouvoir de prediction a long terme de la croissance postnatale et du "Movement Assessment of Infants". c iii 0 ACKNOWLEDGEMENTS This project would not have been possible without the valuable assistance of many people and friends at McGill University. I particularly want to thank Professor Martha Piper, my advisor, from the School of Physical and Occupational Therapy, for her tremendous help and her guidance in the preparation of this text. Or Ildi Kunos from the Jewish General Hospital deserves special thanks for her advice and support during this project. Much gratitude goes to the people of the Neurodevelopmental Treatment Program. In assessing and measuring infants, collecting data, suggesting ideas and scheduling visits, they contributed much to this study. I am also very grateful to all the participating infants and their parents. Finally, I would like to thank all my friends, especially Paul, Jane and my proof-readers: Jennifer, Manni and Norman. 0 iv TABLE OF CONTENTS 0 Page ABSTRACT i RESUME ii ACKNOWLEDGEMENTS iii TABLE OF CONTENTS iv LIST OF TABLES vii LIST OF FIGURES X INTRODUCTION 1 CHAPTER I- LITERATURE REVIEW 3 0 I- DEFINITION OF "AT RISK" INFANTS 4 Il- NEONATAL MORTALITY OF VERY LOW BIRTHWEIGHT INFANTS 5 III- NEUROLOGIC MORBIDITY OF VERY LOW BIRTHWEIGHT INFANTS 10 IV- EARLY IDENTIFICATION OF NEUROMOTOR DISORDERS 16 1) SINGLE PREDICTORS 17 Apgar score 17 Physical measurements 19 2) NEUROMOTOR ASSESSMENTS 24 1) Classical method 24 2) Behavioral method 26 3) French "angle " method 27 4) Primitive reflex method 28 c 5) Motor milestone method 30 V CHAPTER II- METHODOLOGY 38 0 I- OBJECTIVES AND NULL HYPOTHESES 38 Objectives 38 Null hypotheses 41 II- METHODS 43 1) Design and subjects 43 2) Study description 45 Independent variables 46 Outcome: dependent variables 50 CHAPTER III- RESULTS 54 I- SUBJECTS 54 II- EARLY ASSESSMENTS 56 1) Term and three months neuromotor assessments 56 2) The Movement Assessment of Infants 58 3) Physical measurements 64 4) Comparisons of early assessments 66 III- ONE YEAR OUTCOME 68 1) Neurological outcome 68 2) Developmental outcome 76 3) Motor development 78 CHAPTER IV- DISCUSSION 88 CHAPTER V- SUMMARY AND CONCLUSIONS 99 SUMMARY 99 0 RECOMMENDATIONS 101 CONCLUSIONS 103 vi BIBLIOGRAPHY 105 0 APPENDICES A - L 114 c vii c LIST OF TABLES TABLE 1- Handicap rates for VLBW infants (< 1500g) 13 TABLE 2- Distribution of children with normal movement and children with cerebral palsy by total risk score on the MAI at 4 months (Chandler et al., 1980) 36 TABLE 3- Distribution of children with normal movement and children with cerebral palsy by total risk score on the MAI at 4 months (Harris et al., in press) 37 TABLE 4- Independent variables 47 0 TABLE 5- Dependent variables 51 TABLE 6- Descriptive information of study population 5"5 TABLE 7- Scores obtained on neuromotor assessments at 40 weeks and 3 months 57 TABLE 8- Risk points obtained on the Movement Assessment of Infants 59 TABLE 9- Distribution of risk points in the tone section of the MAI 63 c TABLE 10- Early physical measurements 65 viii TABLE 11- Correlations between early neuromotor assessments 0 and physical measurements 67 TABLE 12- Neurological status of abnormal/suspect at one year corrected age 69 TABLE 13- Comparisons of normal and suspect/abnormal infants on early physical measurements 71 TABLE 14- Comparisons of normal and suspect/abnormal infants on early neuromotor assessments 72 TABLE 15- Distribution of children with normal movement and children with suspect or abnormal ~ovement by 0 total risk score on the MAI at 4 months 75 TABLE 16- Correlations between developmental status at one year and early assessments 77 TABLE 17- Variables used in the multiple regression analyses to predict developmental quotients at 12 months 79 TABLE 18- Locomotor quotients on the Griffiths, scores on the Wolanski and Psychomotor index on the Bayley obtained at 12 months 80 0 TABLE 19- Comparisons of normal and suspect/abnormal infants on developmental and motor outcomes at 12 months 83 ix TABLE 20- Correlations between motor development at one year 0 and early assessments 84-85 TABLE 21- Variables used in the multiple regression analyses to predict motor outcome at 12 months 87 0 c X c LIST OF FIGURES FIGURE 1- Neonatal mortality rates of very low birthweight infants 8 FIGURE 2- Movement Assessment of Infants Distribution of total risk scores 60 FIGURE 3- Movement Assessment of Infants Distribution of risk points by item 62 c 1 INTRODUCTION 0 Over the past several years the marked decrease in neonatal mortality rates of the very low birthweight (< 1500g) infant has been attributed to the improvement in neonatal care. While the resulting increased number of survivors appears to be "at risk" for later neuromotor disability, no definite diagnosis of eventual motor delay is currently available at the time of birth or shortly thereafter. Thus, the majority of affected infants are not identified until the second half of their first year of life (Bennett et al., 1981). Early treatment of infants with central nervous system (CNS) dysfunction, while generally advocated, requires the 0 early identification of neuromotor disorders. Although several indices have been developed to assess the neuromotor status of the infant at birth and in the first months of life, none are able to identify with certainty the affected infants early in their lives. Therefore many investigators have attempted to determine the significant factors associated with later CNS dysfunction and the groups of infants who are at increased risk of disability. Because VLBW (< 1500g} infants are the most often cited "at risk" group, those infants are currently being assessed with a variety of instruments in order to detect as early as possible suspect or abnormal signs of motor development. The present cohort study aims to analyze the predictive c value of a variety of early assessments for the one year 2 neuromotor status of a group of "at risk" infants. c Chapter I reviews the literature and is divided into four sections: 1) Definition of "at risk" infants, 2) Neonatal mortality of VLBW infants, 3) Neurologic morbidity of VLBW infants and 4) Early identification of neuromotor disorders. Chapter II presents the objectives and hypotheses of the study. The inclusion criteria of the study sample, the methodology and the indices used will be also described. Chapter III presents the statistical analyses of the data in three sections: 1) Subjects, 2) Early assessments and 3) One year outcome. 0 Chapter IV discusses the results of the present study in light of previous findings. Chapter V summarizes the findings and proposes recommendations for further study. c 3 c CHAPTER I- LITERATURE REVIEW Early treatment of infants with central nervous system dysfunction, while generally advocated, requires the early identification of neuromotor disorders. Currently, no specific diagnostic procedure exists that can accurately identify infants with cerebral palsy. Therefore many investigators over the past several years have attempted to determine 1) the significant factors associated with later central nervous system dysfunction and 2) groups of infants who are at ·increased risk of disability. Very low birthweight (< 1500g) (VLBW} infants are most often cited as an "at risk" group for later neuromotor disorders.
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