The Neurologic and Adaptive Capacity Score

THE Neurologic and Adaptive Capacity Score (NACS) was described in 1982 by Amiel-Tison et al. 1It was developed to evaluate the neurobehavior of term, healthy newborns; specifically, to detect central nervous system depression from drugs administered to the mother during labor and delivery and to differentiate these effects from those associated with perinatal asphyxia and trauma at birth.The 20-item instrument contains items from the Brazelton Neonatal Behavioral Assessment Scale (NBAS), 2the Scanlon Early Neonatal Neurobehavioral Scale (ENNS), 3and the Amiel-Tison Neurologic Evaluation. 4Several review articles have described these tests in detail and compared the NBAS and ENNS to the NACS. 5–7The NACS emphasizes muscle tone more than the ENNS and NBAS. It takes less time to complete without subjecting neonates to aversive stimuli such as pinpricks and repeated Moro maneuvers.The original article 1provided instructions on how to use the scale, outlining the appropriate testing environment, the state of the neonate at the time of testing, and the order in which to conduct the test items. Instructional text and photographs illustrated the correct technique for performing the assessments.The NACS items are organized into two scales: adaptive capacity and neurologic assessment. The latter is further divided into four subscales: passive tone, active tone, primary reflexes, and a general neurologic status assessment. Items are scored 0 (absent or grossly abnormal), 1 (mediocre or slightly abnormal), or 2 (normal), for a maximum score of 40. A score of ≥ 35 was arbitrarily deemed to be normal. 1The NACS has been used extensively for research purposes during the past 16 yr to evaluate the neurobehavior of neonates. We undertook this systematic literature review to examine how it has been used in obstetric anesthesia research and to determine whether there is evidence that it is a reliable and valid tool for detecting drug effects in neonates. In addition, we assessed whether the scale had been used as originally described, paying particular attention to the timing of the tests and the neonatal environment.The review included published articles that met the following inclusion criteria: English language, NACS administered in its original form, and NACS used to assess neonatal outcome after maternal administration of medications during labor and vaginal or cesarean delivery. The following databases were used for computer-assisted searches of published literature from 1982 to 1997: MEDLINE using Pubmed, EMBASE, Scientific Citation Index, the Cochrane Library, CINAHL, and HealthStar. “Neurologic and Adaptive Capacity” and “NACS” were searched as text words, with NACS limited to human studies. The subjects of neurobehavior and neurologic examination were limited to studies on newborn infants. The “see related articles” option was used in Pubmed when relevant articles were identified. The references of selected articles and textbook chapters on neonatal neurobehavioral assessment were useful in identifying some articles not found through computer searches. The authors’ personal files were also reviewed.A computerized database was developed to record the data of interest in the articles. This consisted of the publication date and country of origin, type of medication administered, method of delivery, and which neonatal outcomes were measured. Details of study design, including sample size, number of comparison groups, number of study dropouts, randomization of subjects, and blinding of data collectors, were recorded.To determine whether the instrument was used as the original article intended, we compared information about the testing times and environment with the instructions provided in the article. We also noted whether preterm or breech neonates were included in the analyses.To establish the reliability of the test, we recorded information about the training of those who performed the NACS, including the training process, inter-rater reliability, and whether a single scorer was used for the entire study.We sought to verify the validity of the scale by determining whether a dose–response relationship could be demonstrated between the dose of medication administered and the NACS. We noted if differences in the NACS were detected in studies with a no-drug control group. When opioids were administered to the treatment group, we observed whether the NACS differed significantly between control and treatment groups, because opioids are known to depress the central nervous system. We examined whether studies correlated the NACS with umbilical concentrations of the drugs administered to the treatment group. Finally, we observed whether the NACS increased over time in the same sample of newborns.To determine whether the NACS was a sensitive test that could differentiate between groups of subjects, we sought statistically significant differences in the NACS and other indicators of neonatal well-being. The results were tabulated, and descriptive statistics were used to summarize the characteristics of the studies.The search yielded 71 articles that met the inclusion criteria. 8–78Forty-six (65%) of these were published since 1990 (table 1). Research using the NACS had been conducted in 15 countries. The NACS has been used to evaluate fetal exposure to a variety of medications used in labor and delivery (table 2). Thirty studies (42%) included neonates that had been delivered by cesarean section alone, 8 (11%) included spontaneous vaginal or instrumental deliveries alone, 28 (39%) included a combination of vaginal and operative deliveries, and the remaining 5 (7%) did not report the method of delivery. Breech presentation or malpresentation was listed as an indication for cesarean section in 7 (10%) of the investigations. 8–14It was not stated how the data from these newborns were used in the analysis of the NACS results. The sample sizes for the studies are presented in table 3. The number of neonates tested was not reported in 15 (21%) of the studies. 15–29In the studies in which the number of neonates tested was reported, 20 (36%) did not test all babies whose mothers participated in the study. 10,11,30–47Both mothers and neonates were divided among two to eight groups in 66 studies, with a two-group design being the most common (n = 44; 67%). Five case series (7%) contained only one treatment group. All newborns that underwent NACS testing were considered to be at term gestation. However, term gestation was not defined in 41 (58%) of the studies, and some included 36 weeks’ gestation. 10,18,31–36,38,48Sixty-one (86%) of the studies were randomized controlled trials. The methods used to randomize subjects were described in 15 reports (25%). 18,25,36,40,42,48–57Of the remaining studies, 5 (7%) were clinical trials without randomization of subjects, 9,13,58–60and 5 (7%) were case series. 8,16,61–63Twenty-one (30%) studies gave no details about the NACS administration other than the times that assessments were completed. 20,28–31,33,34,38,43,45,48,50,53,61,63–69The most common schedule was at 2 and 24 h after birth, omitting the recommended measurement in the delivery room at 15 min 1(table 4). Specific details about the testing environment were provided in one article. 15The investigators stated that attempts had been made to conduct all tests in a dimly lit room at a constant temperature. The neonate’s initial spontaneous state was also noted, and the 24-h assessment was performed between feedings. In another study, the 24-h assessment was postponed until 2 h after the last meal. 10The NACS examiner was blinded to treatment group and obstetric history in 57 (80%) of the studies. The qualifications or training of the NACS examiner was described in 46 (65%) of the reports. The most common examiners were pediatricians or pediatric nurses (n = 18; 25%), or anesthesiologists, anesthesia research fellows, and anesthesia residents (n = 12; 17%). The examiners were said to be “trained” in 13 (18%) of the studies, 12,22,26,27,40,44,46,47,52,58,59,62,70with two (3%) providing details about the training. 22,58An additional three (4%) described the observers as “qualified,”54,56,60and one (1%) reported that the observer was “experienced” in performing NACS assessments. 55In 16 articles (23%), it was explicitly stated that one examiner conducted all NACS testing. 9,11,14,21,35,36,39,54,55,70–76None of the remaining studies reported the NACS inter-rater reliability.We identified three studies in which the control group of neonates had not been exposed to any medications. The unmedicated groups consisted of 112, 19, and 15 neonates, respectively. 47,59,60In the first study, the investigators reported the mean NACS without specifying the range or SD. 60At 2–4 h after birth, the mean NACS was 33.5, and at 24 h it was 36.1. The NACS for unmedicated neonates was not significantly different when compared with neonates whose mothers had received various doses of intravenous fentanyl from 50 μg to > 200 μg. The other two studies reported the percentage of good scores (2/2) on each test item. No differences were found between neonates whose mothers had received no medications and those who had received one of three local anesthetics 47or alphaprodine. 59In all three studies, the total NACS for control and treatment groups improved from the 2-h to the 24-h assessment. By the 24-h assessment, control and treatment groups achieved similar scores.Three studies looked for a relationship between umbilical drug concentration and the NACS. There was a negative correlation between the NACS and umbilical vein propofol concentration at 15 min (r not reported;P = 0.01) but not at 2 and 24 h in one investigation. 21There was no correlation between the NACS and umbilical vein fentanyl levels with the combined spinal–epidural technique (r = 0.06;P > 0.05). 61In the third study, there was a weak positive correlation between the fetal plasma concentration of rocuronium and the NACS (r = 0.23;P > 0.05). 63A group of researchers demonstrated a relationship between the intravenous fentanyl dose received by the mother and the umbilical cord fentanyl concentration (r not reported;P < 0.05). 60NACS were similar for neonates in the control group that had no drug exposure and the treatment groups that had been exposed to varying doses of fentanyl. Other investigators found a weak relationship between the maternal epidural dose of fentanyl per kilogram of body weight and the NACS at 15 min (r = 0.12;P = 0.30), 2 h (r = 0.11;P = 0.37), and 24 h (r = 0.10;P = 0.39), 10but these results were not statistically significant.In the 31 opioid studies, few significant differences were found between treatment and control groups. One study reported superior NACS at 2 h with intrapartum administration of epidural bupivacaine alone compared with bupivacaine with fentanyl added (P < 0.05 by chi-square test, comparing the number of babies with NACS < 35 in both groups). 33In this same study, median NACS results did not differ by the Mann–Whitney U test. Another group of investigators found that epidural bupivacaine alone and bupivacaine with sufentanil yielded higher NACS than bupivacaine with fentanyl. 53This difference was found at the 24-h assessment (P = 0.02), with no differences noted at 15 min or 2 h. The NACS of the group that received bupivacaine with fentanyl decreased slightly from the 2-h to the 24-h assessment.It was not possible to assess whether the results of other opioid studies trended toward statistical significance because P values were not reported. There were instances where the group that received opioids had higher, although not statistically different, neurobehavioral scores than controls. 10,45,72Sixty-six (93%) of the studies included more than one NACS examination. Of these, 10 studies (14%) did not report the NACS results. The NACS improved over time in 46 (82%) of the remaining studies. Scores decreased over time in at least one of the groups in 10 studies (18%). 18,22,26,27,33,45,53,58,59,64Of the 71 studies reviewed, nine (13%) reported statistically significant differences in total NACS between groups, 14,33,53,55,58,66,71,75,76an additional two (3%) reported significance in individual items in the scale, 15,59and one (1%) found significance when comparing subscales. 10Most investigators obtained Apgar scores (n = 70; 99%) and umbilical cord acid-base measurements (n = 57; 80%) in addition to neurobehavioral testing to assess neonatal condition. Less frequently, fetal heart rate, umbilical drug concentrations, time to sustained respirations, need for ventilatory and of were reported. differences in these indicators are in table the of one study that reported significantly higher NACS with significantly higher Apgar that found significant differences in the NACS between groups did not report differences in other indicators of neonatal of the original of the NACS was by two that researchers that the scale and that it as a research that the was in its and to and evaluate the examination such that its and could be only one study has assessed the validity of the scale, another assessed inter-rater reliability both of these studies were and limited in use of the NACS as a research tool to evaluate the neurobehavior of term, healthy to detect central nervous system depression after intrapartum drug However, few studies have reported statistically significant differences in the total NACS. We three for this the is that differences did not that the medications used did not neonatal in the design, and sample of the studies have in type the that no differences and the tool be to detect sizes or from when in some of the studies have the of the NACS to detect drug effects if included sample the inclusion of neonates than inclusion of preterm and breech and of attention to the environment and timing of the et al. that in studies of neonatal the of obstetric and on neonatal outcome are not of obstetric maternal of cord vein and delivery of the between drug administration and delivery, cord vein drug and the of active the NACS was not the primary outcome being in of the studies, for this assessment were to Amiel-Tison et al. fetal breech presentation the testing of passive tone in the and neonatal such as It was more common for investigators to for cesarean section into the study than to the for operative However, when the indication for cesarean section was explicitly breech presentation was with no that these neonates were or in of or the NACS. 8–14It is that the neonate be at term gestation when using the NACS because the of and muscle tone on gestation was defined by Amiel-Tison et al. > The inclusion of neonates as as 36 weeks’ gestation have the validity of the assessments by related to than drug We that if the NACS is to newborns at < weeks’ be to that all groups have an of newborns that are not no clinical or for the assessment times are in the original more than of the studies from these times without the for Amiel-Tison et al. that the 24-h assessment be performed only if are detected at 2 h. It that if drug effects are in the neonate from drugs administered to the mother during labor and delivery, more be detected after than after 24 h have However, it was the assessment that was most investigators that this have with the newborn that takes during that time or with between mother and one of the studies reported that the environment where testing was the of the environment on test results be Another group of researchers noted that the NACS in all groups of study were related to at the including a of and that to and 20-item scale is in of its few items reliability, and results in increased and and reliability was performed on newborn by two observers who were by the original 1The blinded observers and scored these newborns at three time 2 and 24 reported an inter-rater reliability of The method for this was not were the No other of reliability was addition to the reliability testing conducted by the one other study tested the inter-rater reliability of the NACS. In this the NACS was not used to detect drug effects as it was originally intended, to examine the neurologic and adaptive capacity of newborn to mothers with clinical pediatricians newborn in correlation for the between and the sample of this study the to determine the for the of to the reliability of the NACS is the of individual of the the article that the neurologic of the examination be if the is or testing passive tone, it is that the be and for active tone it is recommended that testing of the be postponed until the is with testing, the examiner be blinded to the obstetric history and treatment group. Research data be more reliable if a single examiner is used the study or if examiners who have demonstrated inter-rater reliability are to the NACS assessed validity by comparing the NACS to the the most used neurobehavioral test at the the in which neonates scored on the NACS, scored with the The investigators this to between items contained in the two The was not and the were not of the NACS with clinical outcomes to validity were not the validity of the NACS when compared with the ENNS by the was this and that the of the two it did not evidence of The NACS has of its 20 items in common with the NBAS and in common with the studies have administered the NACS with the NBAS the of these did not detect significant differences between treatment and control groups with of the results the validity of the NACS, similar results were reported using the instrument and the and In the study reported significant differences in 10 of the 20 NACS items between groups, no significant differences were found with the the two being over that the of the NACS had to was to have single number the Apgar that a or the NACS was first a score of was arbitrarily to a The investigators that with of neonates in these investigators have the clinical significance of a NACS < when differences between groups were statistically When as as of the NACS were less than the of neonatal outcome has been described as other investigators have described scores > as of the NACS instrument with neonates that have not been exposed to any medications in has not been and the range for the NACS has not been NACS was to between the who has depression and one whose depression results from or neurologic is not from the original how this is to be In a of the NACS, it was observed that a score of < 35 drug or between studies were because the NACS results were and reported in investigators reported the or the percentage of good scores (2/2) on all tests or the number or percentage of scores than or less than a the latter information is when a range of scores is to two than or less This is because the was selected the NACS is a valid tool for detecting drug the umbilical drug concentrations of central nervous drugs with the A study that propofol such a combined spinal–epidural opioid rocuronium that the effects of administered medications on neonates with time after the NACS We found that the NACS decreased over the 24-h testing in 10 studies. P values were not reported, and measurement be a this the the 31 opioid studies 2 provided some additional for the validity of the NACS. One study compared neonates who were exposed to fentanyl in with those that were NACS results were similar = not in the two groups. When the number of babies who had NACS was compared between groups of 46 in the fentanyl group, of 50 in the a statistical difference was found (P = However, the P and the that two statistical tests were performed on the same data the validity of this A study compared newborn who were exposed to fentanyl (n = or sufentanil (n = in to those whose mothers received no epidural opioid (n = all groups, the NACS increased slightly over although statistical were not This study reported a statistically significant difference in the NACS between exposed to fentanyl and those who were not at 24 h (P = 0.02), but not at 15 min or 2 h of when the fentanyl concentrations have been There was no difference between NACS in neonates exposed to sufentanil and the control group. The number of subjects and the number of between groups of the the breech Amiel-Tison et al. that the scores for and of the be scores for and of be included This is by the passive tone is in the one it also have been in the had the been in the this is there be the However, if the were including breech neonates the validity of the for the NACS were on the clinical and whether with the instrument that scores a particular of assessments be more than the total NACS. of individual items or be because there is no evidence that all assessments be the same or the of the instrument has not been and the has not been reported, has the correlation of the to the total investigators whether intrapartum the of investigators have that be more if the of epidural was that the opioid sufentanil be superior to fentanyl with to results of neurobehavioral testing in and the NACS in have been used to these it is as as in the to have a valid of et al. that of the studies NACS results detected an to the validity and the of the NACS examination by comparing the scores of neonates whose mothers had received general or The study had a = = 18; = NACS were significantly at 15 min and 2 h (P < in neonates delivered with general anesthesia than those delivered with epidural or on this the investigators that the scale was valid and were not and the NACS examiner was not blinded to the treatment similar study performed in randomized of to or general sample was = and a examiner who was blinded to the treatment group conducted all NACS This study also found significantly NACS at 15 min (P < and 2 h (P < 0.01) with general results the of the NACS by its to differentiate between the neurobehavioral effects of general and is not how the of the NACS with other of neonatal well-being. the NACS was also to differentiate between depression from drugs and the effects of trauma and Apgar fetal heart rate, or umbilical also with the NACS. It be to that a significantly be more to and ventilatory have a time to sustained respirations, and a higher umbilical drug one study, which compared two of intravenous for cesarean detected both significantly higher NACS and higher Apgar scores in the same group of this was not because the mean Apgar scores only differed by of and range of mean of and range of No other studies have found differences in of neonatal where differences in the NACS were reported, were there differences in the NACS when the other detected in NACS was published as a in However, researchers have been using the NACS as a without further testing its reliability and validity the performed publication of the two reports the NACS reliability that it be a reliable research with is to these results. that the NACS differentiate between the neurobehavioral effects of and general anesthetics have the validity of the Other indicators of validity have had results that be review that researchers in obstetric anesthesia have not used the tool as it was originally the NACS has not been as a and Research is to establish the reliability and validity of the NACS. testing inter-rater reliability, reliability, and an analysis of the NACS that umbilical cord drug levels of drugs known to depress the central nervous system with the NACS into the validity of the the NACS with clinical outcomes such as umbilical cord Apgar and assess This information is to determine if the NACS is a sensitive test for detecting neurobehavioral effects when

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.