Prediction of cerebral palsy and cognitive delay among high-risk children in a developing nation: A successful early
Gemunu Hewawitharana1,2, Nuwan Darshana Ila3, Asha Madhushani Ui1
1Paediatric Neurology Unit, Teaching Hospital, Galle, Sri Lanka.
Insights
Combining General Movements Assessment (GMA) and Hammersmith Infant Neurological Examination (HINE) effectively predicts developmental delays in infants. This combined approach improves early detection of cerebral palsy and other developmental issues in low-resource settings.
Area of Science:
- Developmental Pediatrics
- Neurology
- Global Health
Background:
- Early detection of developmental impairments in infants is crucial for timely intervention, especially in low- and middle-income countries (LMICs).
- Standard follow-up schedules often lack comprehensive tools for predicting diverse developmental outcomes.
- The General Movements Assessment (GMA) and Hammersmith Infant Neurological Examination (HINE) are established tools, but their combined feasibility and predictive power in LMICs require investigation.
Purpose of the Study:
- To assess the feasibility of integrating the GMA and HINE into routine infant follow-up in LMICs.
- To evaluate the combined predictive accuracy of GMA and HINE for cerebral palsy (CP) and non-CP-related developmental delays.
- To determine the optimal combination of assessments for early identification of developmental risks.
Main Methods:
- Prospective study of 201 infants in Sri Lanka (LMIC).
- Infants underwent GMA (writhing and fidgeting movements) before 44 weeks and at 3-4 months, followed by HINE at 5-6 months.
- Developmental outcomes assessed using Bayley Scales (4th Ed.) and clinical evaluation after 24 months.
Main Results:
- Combined GMA and HINE achieved 100% sensitivity for predicting CP, significantly higher than individual assessments.
- The combined approach demonstrated superior sensitivity (>83%) for predicting non-CP-related motor, cognitive, and social-emotional delays compared to single assessments (<65%).
- Specificity for predicting both CP and non-CP delays was moderate (<46%).
Conclusions:
- Combining two GMA assessments with the HINE is a feasible and highly sensitive method for identifying infants with CP and non-CP developmental delays in LMICs.
- This integrated assessment strategy enables targeted early intervention in settings with limited specialist resources.
- The findings support the use of GMA and HINE in routine follow-up for improved developmental surveillance in at-risk infants.
Aim:
To determine the feasibility of combining the Hammersmith Infant Neurological Examination (HINE) and General Movements Assessment (GMA) within a standard follow-up schedule to predict developmental outcomes in infants at risk in low- and middle-income countries (LMICs).
Method:
A total of 201 Sri Lankan infants (128 male, 73 female) were prospectively assessed with the GMA before 44 weeks (writhing movements) and at 3 to 4 months (fidgeting movements), followed by the HINE at 5 to 6 months. Developmental outcomes were assessed using the Bayley Scales of Infant and Toddler Development, Fourth Edition and clinical assessment after 24 months.
Results:
The sensitivity of predicting cerebral palsy (CP) was lower with a single GMA assessment (writhing 89.5%, fidgeting 94.7%) or HINE (89.5%) compared to all three assessments combined (sensitivity 100%, 95% confidence interval [CI] = 82.4-100.0). The GMA and HINE were less predictive of non-CP-related developmental delays, particularly when single assessments were used (< 65% for all domains) compared to all three assessments combined (motor sensitivity > 86.9%, 95% CI = 66.4-97.2; cognitive sensitivity > 86.7%, 95% CI = 69.3-96.2; social-emotional sensitivity > 83.3%, 95% CI = 65.3-94.4). Specificity was lower for the prediction of CP-related (40.1%) and non-CP-related developmental delays (< 46.0% for all).
Interpretation:
In an LMIC such as Sri Lanka, with limited access to specialist care and neuroimaging, combining two GMA measures and the HINE identified most infants with CP-related and non-CP-related developmental delay, thereby allowing targeted early intervention therapies.
