Reliability of the Telehealth Hammersmith Infant Neurological Examination at 24 Months: A Prospective Counterbalanced...

The Hammersmith Infant Neurological Examination (HINE) is a standardized assessment used in high-risk infant follow-up to monitor neurodevelopmental concerns. Access barriers have accelerated telehealth use despite the absence of validation for remote HINE administration. This study evaluated reliability and clinical agreement of protocolized telehealth HINE compared with in-person assessment in term-born children aged 22-24 months.

Using a counterbalanced within-subjects design, 65 children completed two same-day HINE assessments in randomized order: in-person examination performed by a certified examiner (parents absent for blinding), and telehealth examination where a different examiner remotely guided the parent via videoconferencing while scoring in real time. Examiners were blinded to each other's scores. Agreement was assessed using intraclass correlation coefficient and Bland-Altman analysis, with a priori acceptable disagreement defined as ≤7.8 points (≤10% maximum score). Preservation of clinical classifications (total HINE ≤65; asymmetry ≥4) was evaluated.

Mean differences in total, domain, and asymmetry scores were below the prespecified threshold, with minimal bias (-0.15 points) and no difference in total score exceeding six points. Total score reliability was acceptable (intraclass correlation coefficient = 0.68) despite restricted variance (mean 75.0, S.D. 3.4; maximum 78). Both modalities preserved clinical classification, identifying the same children with total HINE ≤65 and asymmetry ≥4.

Telehealth HINE with real-time expert guidance demonstrates clinically acceptable agreement for neurologic surveillance at 24 months in term-born children when in-person follow-up is limited. Validation in younger, higher-risk cohorts with greater score variability is needed before broader diagnostic or triage use.