Published online September 30, 2005
PEDIATRICS
Vol. 116
No. 4
October 2005, pp.
1047
(doi:10.1542/peds.2005-1298)
Why Is the Neurological Examination So Badly Neglected in Early Childhood?
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
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 Hypoxic-Ischemic 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 Accardo's 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 significant insight into the impact of cerebral injury on the neonatal neurologic examination is expected to be gained from such correlations."7
REFERENCES
- Inder TE, Warfield Sk, Wang H, Hüppi PS, Volpe JJ. Abnormal cerebral structure is present at term in premature infants.
Pediatrics. 2005;115
:286
–294[Abstract/Free Full Text]
- 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
:327
–332[Abstract/Free Full Text]
- Amiel-Tison C, Grenier A.
Évaluation Neurologique du Nouveau-né et du Nourrisson. Paris, France: Masson; 1980
- Touwen BCL. Examination of the child with minor neurological dysfunction. In:
Clinics in Developmental Medicine, No 71. London, United Kingdom: SIMP/Heinemann; 1979
- 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
- 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
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- Volpe JJ. Neurological examination: normal and abnormal features. In: Volpe JJ, ed.
Neurology of the Newborn. 4th ed. Philadelphia, PA: WB Saunders; 2001:127
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
