Why Is the Neurological Examination So Badly Neglected in Early Childhood?

Claudine Amiel-Tison, Julie Gosselin and Sheila Gahagan Pediatrics 2005;116;1047 DOI: 10.1542/peds.2005-1298

The online version of this article, along with updated information and services, is located on the World Wide Web at:
http://pediatrics.aappublications.org/content/116/4/1047.1.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2005 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on May 31, 2013

Letters to the Editor

Letters to the Editor reflect the viewpoints of the writers and do not represent the official position of the journal or of the American Academy of Pediatrics. Letters on any topic, including the contents of Pediatrics, are welcome from all members of the profession. For instructions on submitting Letters to the Editor, please see the Instructions for Authors in this issue or visit the journals Web site.

Why Is the Neurological Examination So Badly Neglected in Early Childhood?

To the Editor.
We read with interest 2 articles concerning neonatal neuropathophysiology in the February issue of Pediatrics. The first article, Abnormal Cerebral Structure Is Present at Term in Premature Infants by Inder et al1 (co-authored by Joseph J. Volpe), presents important new findings by the authors, who used advanced MRI techniques to document impaired cerebral development present at term equivalent in very low birth weight premature infants. They correlated advanced 3-dimensional reconstruction MRI images with physical examination by an experienced neurologist or neonatologist and/or a developmental examination based on observational data from parent report and examination with the Denver Developmental Screening tool.1 This shocking lack of rigor for the clinical assessment contrasts sharply with the extreme sophistication on the technical side. The second article, Sleep-Wake Cycling on Amplitude-Integrated Electroencephalography in Term Newborns With HypoxicIschemic Encephalopathy by Osredkar et al2 (co-authored by Linda S. de Vries), also uses vague methodology to categorize neurodevelopmental status. The follow-up consisted of Griffiths Developmental Scale and items from Amiel-Tison and Grenier3 and Touwen.4 Outcome of patients was categorized as good in the absence of cerebral palsy, epilepsy, bilateral blindness, and hearing loss and a Griffiths developmental quotient of 85 and poor in the presence of cerebral palsy (diagnosed at a minimum age of 18 months), epilepsy, bilateral blindness, and hearing loss requiring bilateral amplification, and/or a Griffiths developmental quotient of 85. While the Griffiths Developmental Scales allow standardized assessment in 6 different domains of development, there is no standardized neurologic assessment but a mixture of a few items selected in 2 different neurologic examinations. It is unlikely that reviewers would accept psychological assessment based on a few selected items from the Bayley Scales of Infant Development and the Griffiths Scales; yet, it seems acceptable when neurologic assessment is concerned. Moreover, the categorization of children into 2 categories opposing major sequelae to any other any other outcome (therefore clustering mild and moderate impairments with normal outcome) reflects a reductionist approach that is not acceptable anymore. A telephone call to the parents could have provided equally valid information. In the context of research that mainly focuses on brain imaging or electrophysiological techniques, long-term follow-up may seem almost impossible to achieve. In fact, it may not be strictly indispensable in every study if valid short-term outcome is defined. In this respect, we deeply regret the loss of information concerning (1) the neurologic status at 40 weeks corrected age,5 optimal or not, mainly based on the integrity of upper motor control as well as fix-and-track ability and (2) the categorization at 2 years based on the spectrum of motor disorders. Why did we focus our frustration on these 2 studies? Because they appeared in the same issue of Pediatrics at the time we were completing a chapter concerning neurologic assessment in the third edition of Capute and Accardos Developmental Disabilities in Infancy and Childhood,6 in which we analyzed a few pitfalls in the use of a neurologic assessment during childhood. These 2 studies1,2 are not unique with regard to the clinical methodology. In fact, they reflect a general tendency to use neurodevelopmental outcomes that are not grounded on valid and evidence-based assessment. In many studies, the neurodevelopmental assessment seems to be added onto research as an afterthought. This general attitude is not fitting with the following statement: Perhaps of greatest importance is the realization that careful clinico-anatomic correlations are only beginning to be made in neonatal neurology, especially since the advent of high resolution brain imaging techniques. Further sig-

nificant insight into the impact of cerebral injury on the neonatal neurologic examination is expected to be gained from such correlations.7

Claudine Amiel-Tison, MD Port-Royal-Baudelocque University of Paris V 75014 Paris, France Julie Gosselin, OT, PhD School of Rehabilitation Faculty of Medicine University of Montreal Montreal, Quebec, Canada H3C 3J7 Sheila Gahagan, MD, MPH Center for Human Growth and Development Medical School University of Michigan Ann Harbor, MI 48109 REFERENCES
1. Inder TE, Warfield Sk, Wang H, Hu ppi PS, Volpe JJ. Abnormal cerebral structure is present at term in premature infants. Pediatrics. 2005;115: 286 294 2. Osredkar D, Toet MC, van Rooij LGM, van Huffelen AC, Groenendaal F, de Vries LS. Sleep-wake cycling on amplitude-integrated electroencephalography in term newborns with hypoxic-ischemic encephalopathy. Pediatrics. 2005;115:327332 valuation Neurologique du Nouveau-ne 3. Amiel-Tison C, Grenier A. E et du Nourrisson. Paris, France: Masson; 1980 4. Touwen BCL. Examination of the child with minor neurological dysfunction. In: Clinics in Developmental Medicine, No 71. London, United Kingdom: SIMP/Heinemann; 1979 5. Amiel-Tison C, Gosselin J. The Amiel-Tison and Gosselin neurological assessment and its correlations with disorders of higher cerebral function. In: Accardo PJ, ed. Developmental Disabilities in Infancy and Childhood. 3rd ed. Baltimore, MD: Paul H Brookes; 2005: In press 6. Gosselin J, Gahagan S, Amiel-Tison C. The Amiel-Tison neurological assessment at term: conceptual and methodological continuity in the course of follow-up. Ment Retard Dev Disabil Res Rev. 2005;11:34 51 7. Volpe JJ. Neurological examination: normal and abnormal features. In: Volpe JJ, ed. Neurology of the Newborn. 4th ed. Philadelphia, PA: WB Saunders; 2001:127 doi:10.1542/peds.2005-1298

In Reply.
I am grateful for the letter from Amiel-Tison et al, which highlights the importance of functional correlates to neurologic investigations, including our volumetric MRI techniques, in understanding the pathway to neurodevelopmental disability in the preterm infant. We have always considered this to be essential in our research and wish to reassure the authors of this letter that we have gathered the following: extensive perinatal and neonatal information including maternal and infant factors; neurobehavioral assessments including the NICU Network Neurobehavioral Scale1 and the Revised Hammersmith Neonatal Neurologic Examination2 at term equivalent; surveys of development and behavior at 1 year of age; and an extensive evaluation including the Bayley II Scales of Infant Development, pediatric neurologic examination, parent-infant interactional scales, behavioral checklist, and executive functioning tasks at 2 years of age. We also recently enhanced our image-analysis techniques to define regional cerebral development across 16 regions, which improves our ability to carry out

PEDIATRICS Vol. 116 No. 4 October 2005 Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on May 31, 2013

1047

Why Is the Neurological Examination So Badly Neglected in Early Childhood? Claudine Amiel-Tison, Julie Gosselin and Sheila Gahagan Pediatrics 2005;116;1047 DOI: 10.1542/peds.2005-1298
Updated Information & Services References including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/116/4/1047.1.full .html This article cites 3 articles, 2 of which can be accessed free at: http://pediatrics.aappublications.org/content/116/4/1047.1.full .html#ref-list-1 This article has been cited by 2 HighWire-hosted articles: http://pediatrics.aappublications.org/content/116/4/1047.1.full .html#related-urls This article, along with others on similar topics, appears in the following collection(s): Premature & Newborn http://pediatrics.aappublications.org/cgi/collection/premature _and_newborn Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/site/misc/Permissions.xht ml Information about ordering reprints can be found online: http://pediatrics.aappublications.org/site/misc/reprints.xhtml

Citations

Subspecialty Collections

Permissions & Licensing

Reprints

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2005 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on May 31, 2013