Neeraj Gupta

Additional Professor

Department of Neonatology

All India Institute of Medical Sciences (AIIMS)

Jodhpur, Rajasthan, India

MD, DM (Neonatology), MAMS

Neonatal sepsis & resuscitation

Value of Neurological Examination

in NICU

Neeraj Gupta

All India Institute of Medical Sciences (AIIMS)

Jodhpur, Rajasthan, India

Neonatal Neurological Examination-

Is it really useful?

Truth!

What’s is the utility of neurological

examination in NICU?

Diagnosis

Treatment

Prognosis

What is it’s diagnostic role in NICU?...

Gestational age assessment- New Ballard Scoring

What is it’s diagnostic role in NICU?...

Part of daily assessment

Level of alertness

Posture

Response to handling

Spontaneous movements

Abnormal movements

Sepsis

Metabolic conditions (hypoglycemia, polycythemia)

Neurometabolic disorders

Picks abnormal infants warranting further

evaluation

What is it’s diagnostic role in NICU?...

27 week/800 g/SFD/M

Required PPV, APGAR 3 & 7/Surfactant & on CPAP/26

hours of life

Sudden stupor to comatose

Respiratory abnormalities (hypoventilation to apneas)

Decerebrate posturing

Picks catastrophic events

What is it’s diagnostic role in NICU?...

38 week/3000 g/AFD/M/70 hours of life/outborn

Referred due to significant jaundice with serum

bilirubin near exchange

On intensive phototherapy

After 4 hours, lethargic, not sucking on breast with

?retrocollis

Picks significant changes warranting

intervention

What is it’s diagnostic role in NICU?...

Neurological Examination- Diagnostic role

Identifies abnormality

Localize abnormality & determines severity

Help in making differential diagnosis

Diagnose a fixed deficit or syndrome

Serve as initial examination in continuing evaluation

How it helps in treatment?...

Infant ≥36 week, ≥ 1800 gm

ANDPostnatal age <6 hour

Evidence of asphyxia (Any one)1. Blood gas (pH or BD)

2. APGAR ≤5 at 10 min

3. Need of PPV at 10 min

AND

Criteria for administering Therapeutic hypothermia

1. Evaluation is primarily clinical

2. Important to select right infant at right time

3. Need of serial examination in first few hours

Evidence of moderate to severe HIE

Seizure OR Altered consciousness/tone/reflexes (Any two)

What are the various scoring systems used

for assessing HIE?

Alertness, Seizures, Tone, Reflexes

How it helps in prognosis?...

A peak score of ≥15 has PPV of 92% for abnormal outcome

How it helps in prognosis?...

Sarnat & Sarnat Staging

NICHD Network – Factors ↑ risk of death/disability at

18 months

1. Severe encephalopathy <6 hr

2. Persistence of moderate to severe encephalopathy

throughout 72 hr period of cooling

3. At discharge - hypertonia, fisted hands, abnormal

movements, need of gavage feeding

Shankaran S et al; J Pediatr 2012

What is it’s prognostic value?...

Abnormality Increased risk of CP (predominantly term infants

with asphyxia)

Tone abnormalities of limb ortrunk

12-15 times

Diminished cry > 1day 21 times

Weak or absent sucking 14 times

need for gavage or tube

feedings

16-22 times

Diminished activity >1 day 19 times

What is it’s prognostic value in preterm

infants?

Systematic review- 4 studies

High risk infants

Accuracy of predicting cerebral palsy at 2 years

88% sensitivity & 87% specificity

Bosanquet et al; Dev Med Child Neurol 2013

Does one scheme of examination suffices

all purpose across all gestations?...

Noble et al; Dev Med Child Neurol 2012

Does one scheme of examination suffices

all purpose across all gestations?

Discriminative Tool All assessment scales

Evaluative Tool

Prediction Tool

Test for Infant Motor

Performance (TIMP)

General Movements

Noble et al; Dev Med Child Neurol 2012

General Movements- What are these?...

Without being triggered, fetal & neonatal nervous system

generates variety of motor patterns involving whole body

(Prechtl 1990)

Consist of movements involving whole body in a variable sequence of arm, leg, neck, and trunk movements

Varies in intensity, force, speed, with a gradual beginning & end

Complexity makes them vulnerable to brain dysfunction,

therefore sensitive indicator of brain injury

General Movements- What are the various

types?

Normal general movements: Writhing, fidgety

Abnormal general movements: Poor repertoire, cramp synchronized

General Movements

Normal GM

1. Involving the whole body

2. Variable movement sequences

3. Wax and wane in intensity, force,

speed

4. Have gradual beginning & end

5. Superimposed rotational movements

6. Movements: fluent and elegant

General Movements

Poor repertoire

1. Look rigid

2. Lack normal smooth & fluent character

3. All limb and trunk muscles contract &

relax almost simultaneously

Cramped synchronized GMs

Fig. Pictures show synchronous lifting of the four limbs in sequence,

followed by extension and adduction

General Movements- Accuracy of

predicting cerebral palsy at 2 years

Modality No. of studies Sensitivity Specificity

Bosanquet et al; Dev Med Child Neurol 2013

What are the limitations in doing

comprehensive neurological exam in NICU?

Cardiorespiratory instability

Mechanically ventilated

Central lines

Monitoring devices

Sedation

Risk of causing IVH by undue & excessive

handling

What is feasible to assess in sick neonates

in NICU?

Level of consciousness

Seizures

Posture

Movements- General and on handling

Reflexes

Neonatal Intensive Care Unit Network Neurobehavioral

Scale (NNNS)- Research tool

How to improve yield of neurological

examination?

Perform serial examinations

Correlate with investigations - better diagnostic &

prognostic yield

Take Home Message

Neurological examination – inherent part of evaluation

Has diagnostic, therapeutic and prognostic importance

Simple assessment should be done in all neonates in

NICU

Comprehensive assessment in specific cases to fulfill

diagnostic or prognostic goal

Correlate with other diagnostic modalities

Thank you for your kind attention!