Early motor function assessments to predict neurodevelopmental delay in preterm infants

Preterm infants are at risk of neurodevelopmental disorders. With the advances in perinatal care and neonatal critical care, the prevalence of severe cerebral palsy (CP) decreases with time.1Adams-Chapman I. Heyne R.J. DeMauro S.B. Duncan A.F. Hintz S.R. Pappas A. et al.Neurodevelopmental impairment among extremely preterm infants in the neonatal research network.Pediatrics. 2018; 141e20173091Google Scholar However, the prevalence of mild CP increases, and moderate-to-severe neurodevelopmental impairments constantly affect one-fifth to one-third of extremely preterm infants.1Adams-Chapman I. Heyne R.J. DeMauro S.B. Duncan A.F. Hintz S.R. Pappas A. et al.Neurodevelopmental impairment among extremely preterm infants in the neonatal research network.Pediatrics. 2018; 141e20173091Google Scholar As neurodevelopmental outcomes may be enhanced by introducing early intervention programs,2Vanderveen J.A. Bassler D. Robertson C.M. Kirpalani H. Early interventions involving parents to improve neurodevelopmental outcomes of premature infants: a meta-analysis.J Perinatol. 2009; 29: 343-351Google Scholar markers to identify infants at risk are emphasized. As the proposal of the general movement assessment (GMA) by Prechtl in 1990,3Prechtl H.F. Qualitative changes of spontaneous movements in fetus and preterm infant are a marker of neurological dysfunction.Early Hum Dev. 1990; 23: 151-158Google Scholar it has been used to correlate with motor function impairments and, most important of all, CP, in the preterm population. Beyond the scope of motor function, GMA in early life could indicate cognitive developmental delay and intelligence scores in children born preterm.4Einspieler C. Bos A.F. Libertus M.E. Marschik P.B. The general movement assessment helps us to identify preterm infants at risk for cognitive dysfunction.Front Psychol. 2016; 7: 406Google Scholar Based on the value of prognostication using GMA, different combinations or derivatives from the GMA subscales were proposed to be also effective in predicting neurodevelopmental outcomes. However, as several tools could exert the same efficacy, the comparison among different assessment tools in a specific patient population could help clinicians choose the proper one according to the clinical setting. Yildirim et al.5Yildirim C. Asalioğlu A. Coşkun Y. Acar G. Akman İ. General movements assessment and Alberta infant motor Scale in neurodevelopmental outcome of preterm infants.Peditar Neonatol. 2022; 63: 535-541Google Scholar compared different tools of motor function assessments, i.e., GMA as infants’ stay in the neonatal intensive care unit and Alberta Infant Motor Scale (AIMS) at 6–12 months of corrected age, to predict neurodevelopmental outcomes including CP and neurodevelopmental delay. Then, the general movement optimality score (GMOS) at 0–4 weeks of corrected age and the motor optimality score (MOS) at 3–5 months of corrected age, both of which were derived from GMA, were examined. This study reported good correlations between GMOS and AIMS and between MOS and AIMS, and all these three indicators corresponded to neurodevelopmental outcomes. The finding that these tools showed good prognostications is not surprising, as these assessments were validated in several studies. However, as GMOS, MOS, and AIMS were scored at different time points, GMOS, which was assessed at 0–4 weeks of corrected age, showed a good prediction ability. Furthermore, all infants classified as normal by GMOS and MOS had normal neurodevelopmental outcomes, but four patients who had AIMS in the normal range were diagnosed of CP or neurodevelopmental delay. GMOS and MOS might show better sensitivity and thus could serve as early screening tools. The awareness of the neurodevelopmental sequelae at term-equivalent age is still a dilemma in preterm infants. Nuysink et al. revealed a poor prediction of motor development using gross motor assessments before 6 months of corrected age.6Nuysink J. van Haastert I.C. Eijsermans M.J. Koopman-Esseboom C. Helders P.J. de Vries L.S. et al.Prediction of gross motor development and independent walking in infants born very preterm using the Test of Infant Motor Performance and the Alberta Infant Motor Scale.Early Hum Dev. 2013; 89: 693-697Google Scholar Moreover, the motor development trajectories in preterm infants are different from those in term babies even after being adjusted by gestational age, which further complicates the distinction between normal and abnormal in the preterm population.7van Haastert I.C. de Vries L.S. Helders P.J. Jongmans M.J. Early gross motor development of preterm infants according to the Alberta Infant Motor Scale.J Pediatr. 2006; 149: 617-622Google Scholar According to Yildirim et al.,5Yildirim C. Asalioğlu A. Coşkun Y. Acar G. Akman İ. General movements assessment and Alberta infant motor Scale in neurodevelopmental outcome of preterm infants.Peditar Neonatol. 2022; 63: 535-541Google Scholar although 40% of infants with abnormal GMOS had normal neurodevelopmental outcomes, GMOS could still highlight high-risk infants, requiring an intense follow-up program and possibly the early initiation of intervention. This study has limitations to consider when interpreting its results. First, the effect of gestational age was not considered in the outcome prediction. This study analyzed 75 preterm infants, who were further classified into extremely preterm, very preterm, and late preterm. The gestational age showed a positive correlation to GMOS, MOS, and AIMS scores. Infants in the higher gestational age group had higher scores. However, as preterm infants may have different motor development trajectories,7van Haastert I.C. de Vries L.S. Helders P.J. Jongmans M.J. Early gross motor development of preterm infants according to the Alberta Infant Motor Scale.J Pediatr. 2006; 149: 617-622Google Scholar the effect of gestational age was not adjusted, and the analysis for outcome prediction was not stratified according to different gestational age groups. Second, the infants studied had a high proportion of brain injuries. Of the 22 extremely preterm infants, 6 (27%) had a high-grade intraventricular hemorrhage, and low-grade intraventricular hemorrhage occurred in 10 (45%). The good prediction of GMOS at 0–4 weeks of corrected age might be due to the high prevalence of severe brain injuries, indicating a greater severity of neurological sequelae among infants involved in this study. Given the decreasing trend of severe CP in several large cohorts,1Adams-Chapman I. Heyne R.J. DeMauro S.B. Duncan A.F. Hintz S.R. Pappas A. et al.Neurodevelopmental impairment among extremely preterm infants in the neonatal research network.Pediatrics. 2018; 141e20173091Google Scholar the study subjects may not be representative and the generalization of results could be limited. Early markers for neurodevelopmental impairments, not only for CP but also for all neurodevelopmental disorders, could facilitate clinical decisions. Detecting neurodevelopmental sequelae as early as at term-equivalent age by gross motor function assessments might reveal an opportunity to improve the overall neurodevelopmental outcomes in preterm infants.

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