Better Prediction of Neuro-Developmental Outcome in Babies Using Combined Vojta’s Neurokinesiological Examination, Amiel Tison Angles and Head Holding Grades

Introduction: With the advances in medical technology, the survival rate has increased amongst the high-risk neonates. Changes occurring in the neuro-motor function during the first year of life are closely related to the maturation of the central nervous system of babies and the presence or absence of injury to brain. These should be detected as early as possible, so that intervention programmes can be started. Methods: A prospective study was done in NICU of a teaching hospital, to find the predictive value of combined assessment by three neuro-developmental examinations Viz. Vojta’s Neurokinesiological examination, Amiel-Tison angles and head holding grades. Total 375 babies with various high risk category were included, out of which only 114 infants completed one-year follow-up. On the first visit a detailed neurological examination was performed using Vojtas Neurokinesological postures, AmielTison angles and head holding grades based on Trivandrum Developmental Screening Chart (TDSC). At one year, the milestones attained were plotted against the BSID percentiles and babies assigned as developmentally delayed, if it was below 97% pass level. Sensitivity and specificity were calculated and propositions evaluated by chi-square test. Results: 23% babies had developmental delay at one year. The important high risk factors were maternal risk factors 39%, HIE with MAS, HIE stage-III, complications during NICU stay. Conclusions: Vojta’s Neurokinesiological examination is an effective screening test that can be applied to all high-risk neonates. The predictive value could be enhanced to 100%, by using other simple tests, like Amiel-Tison Angles and Head holding grades by TDSC.


INTRODUCTION
With the advances in medical technology and better neonatal intensive care, there has emerged an increased survival amongst the high risk neonates. Neuro-motor function changes during the first year of life are closely related to the maturation of the central nervous system of babies and the presence or absence of injury to brain. Therefore, it is i m p o r t a n t t o k e e p a c l o s e w a t c h o n neurodevelopment of high risk babies, to detect abnormalities as early as possible, and to start intervention programmes at earliest.
Although neuro-imaging is often used to predict the neurological outcome, and in fact abnormal findings on MRI in preterm infants at termequivalent age can predict neuro-motor impairment at two years of age and also stratify infants by risk. [1][2][3] Usage of MRI is limited in daily practice by its cost, accessibility and expertise requirement, especially in resource limited set ups. Cranial ultrasounds are routinely performed in some neonatal intensive care units, and there is a strong correlation which has been reported between severe lesions observed on neonatal cranial ultrasound and school-age MRI. 2 Although, neonatal cranial ultrasound is highly reliable for the detection of intraventricular haemorrhage and cystic white matter injury, its ability to accurately diagnose noncystic lesions is limited. 4 Therefore, the value o f c r a n i a l u l t r a s o u n d i n p r e d i c t i n g neurodevelopmental outcome in neonates remains controversial. [5][6] Hence, we need a clinical examination method for the neurological assessment to monitor baby's neuro-development.
This study was conducted to find the predictive value of combined assessment by three neurodevelopmental examinations viz. Vojta's Neurokinesiological examination 7 , Amiel-Tison 8 angles and head holding grades.

METHODS
It was a prospective study done at Level -II NICU of a teaching hospital in India. The babies in NICU who had high risk of poor neuro -developmental outcomes were taken into the study. These included maternal risk factors like PPROM, fever, oligohydramnios, BOH, PIH, eclampsia, polyhydramnios, Rh incompatibility, MSAF and others. Informed verbal consent was taken from the parents before including the babies into the study. The study approval was taken from the Institutional Ethics Committee. Total 375 babies with various high risk categories were given high risk cards for follow-up. However, among the 375 babies, only 114 infants completed one year follow up from April 2019 to April 2020. The babies with congenital anomalies, very sick babies hindering examination and those who could not complete one year follow up were excluded from the study. High risk babies were given a special high risk card and asked to come at three, six, nine and 12 months of age regularly for follow up.
The babies were also examined for five angles of Amiel-Tison 11 viz (1) Heel to ear (2) Dorsiflexion angle (3) Popliteal angle (4) Scarf sign (5) Adductor angle and Head holding grades based on TDSC (Trivandrum Developmental Screening Chart). 12 Each of reactions was read as normal or abnormal depending on postural signs observed and the motor handicap was graded as below. • 1 -3 abnormal: lightest central co-ordination disorder (CCD) • 4 -5 abnormal: light CCD • 6 -7 abnormal: moderate CCD • All reaction abnormal: Severe CCD The grade of head holding less than two was taken abnormal and more than two as normal.
Similarly, more than three abnormal angles were taken as abnormal and less than three as normal. At one year, the number of milestones attained was plotted against the BSID 13 -Baroda percentiles and the case was assigned delayed developmentally if it fell below the 97% pass level. The sensitivity and specificity of these tests were calculated and propositions evaluated by chi-square test. P-value of < 0.05 was taken as significant.
Va r i o u s c o m p l i c a t i o n s w e r e s t u d i e d i n developmentally delayed babies, during their hospital stay. Almost all cases required oxygen and had feeding problems. Among the babies, 88% of cases had received inotorpic support with dopamine. Significant jaundice was noted in 69% of the cases and 46% developed septicaemia. About 15% of the cases had respiratory distress syndrome. The outcome in terms of development in the various HIE groups is depicted in Table 1.
In the study, 5% of stage 1 HIE cases and 57% of stage II HIE and 87% of stage III HIE had developmental delay at one year of age. All cases of stage III HIE except one had more than six abnormal postures at three months examination. Only 26% of the stage II HIE cases and 2% of the stage I HIE cases had more than six postures abnormal at three-month examination. Table 2,  Table 3 and Table 4 depicts the results of threemonth examination and neurodevelopment outcome at one year for the various tests.
The analysis of three simple tests used, was done in terms of negative predictive value (NPV), positive predicative value (PPV), specificity, sensitivity, false positive value, false negative value, P value, and accuracy was done.

DISCUSSION
Increased survival of many high risk babies presents as a formidable challenge to health professionals because of the fact that these babies carry high risk of developing neurological abnormalities, and therefore follow-up of these babies is very crucial. Early diagnosis and commencing appropriate therapy to address even the small deviation from the normal neurology leads to better long-term neuro-developmental outcome in babies. Therefore, it is of utmost importance to closely monitor the neurological development of babies esp. high risk babies with appropriate examination tools which have good predictive value.
The present study included a variety of high-risk babies as compared to earlier studies conducted by Choudhary et al., 14,15 which included five high risk groups viz. HIE, preterm, IUGR, jaundice, septicaemia. Maiya PP et al. 16 studied prediction of neuro-developmental outcome only in HIE babies, out of which 3.6% of the infants had HIE II and 77% had HIE III. Paro-Panjan et al. 8 studied neurodevelopmental outcome in HIE, MAS, septicaemia, genetic syndromes.
We found that final developmental outcome was delayed in 26 babies out of 114 (23%) compared to 39% in Maiya PP et al. 10 and 11% in Choudhary et al. 9 None of the patients in Maiya PP et al. 16 study had abnormal reactions at three months who turned out to be normal, thus having a nil false positive rate and 100% negative predictive value. In our study four babies who were normal at one year had more than four postures abnormal bringing down the negative predictive value of 83% and a false positive rate of 6%. Accordingly, the specificity of the test in our study was 93% compared to 100% in the study done by Maiya PP et al. 16   system early in life and high correlation was found between cerebral palsy and asymmetry of the body, but not of the head. Imamura S et al 20 did a followup study where babies with motor development delay were classified as very light, light, moderate and severe Cerebral Coordination Disturbance (CCD) according to Vojta and they concluded that the severity of CCD correlates well with the neurodevelopmental prognosis.
In the present study, we attempted to combine three simple neurological examinations at three months and boost up the predictive value. On statistical analysis this was proved that combining the three tests a specificity, sensitivity, of 100% with nil false positive and negative rates and negative predictive value and positive predictive value of 100% can be obtained with accuracy close to hundred. Such screening tests are the valuable tools that tell the paediatricians and the parents to be vigilant about child's development and help for early introduction of intervention. This modality can help reduce the future disability and perhaps help the compromised babies a chance of fully functional future life. Limitations of our study are that ours is a single centre study with relatively less number of babies and relatively shorter period of follow up; therefore, this combination of tests needs further evaluations in multi-centre, larger study population with longer follow up.

CONCLUSIONS
The Vojta's Neurokinesiological examination is a very effective screening test with a sensitivity of 100% and a positive predictive value of 100%. The results can be further enhanced by using other simple tests, like Amiel Tison Angles and Head holding grades by TDSC.