Early ReportAn early marker for neurological deficits after perinatal brain lesions
Introduction
The human fetus and young infant have a repertoire of distinct movement patterns that are spontaneous.1 One set of these movement patterns are known as general movements.2 These movements can be observed in fetuses as young as 10 weeks postmenstrual age.3 Postmenstrual age, age of the fetus or infant calculated from the date of the mother's last period, is used as a way of compensating for premature birth. In infants at low-risk of neurological damage general movements continue in a similar pattern until about the end of the second month post term.4
After birth, general movements are commonly referred to as writhing movements.4 At the age of 6 to 9 weeks post term the form and character of general movements of normal infants changes from the writhing type into a fidgety pattern.4, 5 Fidgety movements are defined as an ongoing stream of small, circular, and elegant movements of neck, trunk, and limbs. They differ qualitatively from involuntary dyskinesias that appear to be forced. Fidgety movements of a healthy infant are a transient phenomenon; they emerge gradually at 6 weeks, come to full expression between 9 and 13 weeks post term and taper off again between the ages of 14 to 20 weeks post term.6 This is true for low-risk term as well as preterm infants whose age has been corrected.7, 8 Fidgety movements can best be observed when the infant is awake, alert, and either lying supine or sitting reclined in a baby seat. Under these conditions, normal infants aged 3 months can sustain continual fidgety movements for as long as an hour at a time. Fidgety movements will stop when the baby cries or fusses or when it is distracted by its immediate surroundings.
In previous studies9, 10 absent or abnormal quality of fidgety movements seemed to have clinical significance for predicting the later outcome of neurological impairment. To clarify this issue we did a collaborative study, using the same method of assessment and follow-up but on a large scale. We aimed to answer three questions: which abnormal writhing general movements lead to absent or abnormal fidgety movements; what is the long-term neurological outcome of infants with abnormal quality of writhing movements whose general movements normalise at an early age and who develop normal fidgety movements; and what is the long-term neurological outcome of infants who show abnormal or a total lack of fidgety movements?
Section snippets
Methods
We enrolled preterm and term newborn babies from the University Hospitals of Graz, Groningen, Heidelberg, Modena, and Pisa. We included infants for whom: mother's last menstrual dates were known, brain ultrasound scans were available, general movements at various ages had been observed, at least one assessment during the period with fidgety movements (46-60 weeks postmenstrual age) had been done, and standardised repeated neurological followup until 2-years corrected age had been done.
On the
Results
The final study sample was 130 infants: 52 girls and 78 boys. Their gestational age at birth ranged from 26 to 41 weeks (median 32 weeks, IQR: 29 to 38 weeks); 74% were born preterm. The infants' birthweight ranged from 700 to 4680 g (median 1660 g, IQR: 1245 g to 2730 g).
With ultrasound scanning 70 (54%) of the 130 infants were classified as at low risk and 60 (46%) were classified as at high risk of developing neurological deficits. Of the low-risk infants 47 had no abnormalities and 23 had
Discussion
Our method of observing the quality of fidgety movements in young infants allows valid predictions about later neurological outcome to be made long before the first signs of spasticity appear. Not only are abnormal and absent fidgety movements indicative of a poor outcome but normal fidgety movements are an excellent marker for a normal neurological outcome. The qualitative assessment of general movements before the onset of fidgety movements has an equally high sensitivity but its specificity
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