Publications on the Prechtl General Movement Assessment

312. Silva N, Zhang D, Kulvicius T, Gail A, Barreiros C, Lindstaedt S, Kraft M, Bölte S, Poustka L, Nielsen-Saines K, Wörgötter F, Einspieler C, Marschik PB.
The future of General Movement Assessment: The role of computer vision and machine learning - A scoping review.
Res Dev Disabil 2021; 110: 103854. doi: 10.1016/j.ridd.2021.103854.

Background: The clinical and scientific value of Prechtl general movement assessment (GMA) has been increasingly recognised, which has extended beyond the detection of cerebral palsy throughout the years. With advancing computer science, a surging interest in developing automated GMA emerges. Aims: In this scoping review, we focused on video-based approaches, since it remains authentic to the non-intrusive principle of the classic GMA. Specifically, we aimed to provide an overview of recent video-based approaches targeting GMs; identify their techniques for movement detection and classification; examine if the technological solutions conform to the fundamental concepts of GMA; and discuss the challenges of developing automated GMA. Methods and procedures: We performed a systematic search for computer vision-based studies on GMs. Outcomes and results: We identified 40 peer-reviewed articles, most (n = 30) were published between 2017 and 2020. A wide variety of sensing, tracking, detection, and classification tools for computer vision-based GMA were found. Only a small portion of these studies applied deep learning approaches. A comprehensive comparison between data acquisition and sensing setups across the reviewed studies, highlighting limitations and advantages of each modality in performing automated GMA is provided. Conclusions and implications: A "method-of-choice" for automated GMA does not exist. Besides creating large datasets, understanding the fundamental concepts and prerequisites of GMA is necessary for developing automated solutions. Future research shall look beyond the narrow field of detecting cerebral palsy and open up to the full potential of applying GMA to enable an even broader application.

311. Caesar R, Colditz PB, Cioni G, Boyd RN.
Clinical tools used in young infants born very preterm to predict motor and cognitive delay (not cerebral palsy): a systematic review.
Dev Med Child Neurol 2021; 63(4): 387-395. doi: 10.1111/dmcn.14730.

Aim: This systematic review evaluates the accuracy of clinical tools used at a corrected age of 6 months or younger to predict motor and cognitive delay (not cerebral palsy) at 24 months' corrected age, in infants born very preterm. Method: Six databases were searched. Quality was evaluated using the Quality Assessment of Diagnostic Accuracy Studies tool. Predictive analysis included calculation of sensitivity and specificity, inspection of summary receiver operating characteristics curves, and bivariate meta-analysis. Results: Six assessments were identified in 10 studies of 992 infants. Overall prevalence of motor delay was 13.8% and cognitive delay was 11.7%. Methodological quality was variable for patient selection, reference standard, flow, and timing. All studies had a low risk of bias for the index test. General Movement Assessment (GMA) predicted motor and cognitive outcomes with good accuracy for mild, moderate, and severe delays (fidgety age: pooled diagnostic odds ratio=12.3 [5.9-29.8]; hierarchical summary receiver operating characteristics curve=0.733). The Hammersmith Infant Neurological Examination (HINE) demonstrated excellent predictive accuracy for severe motor delay (3mo and 6mo; sensitivity 93% [68-100%], specificity 100% [96-100%]) but showed limited ability to predict milder delays. Interpretation: In the population of infants born very preterm, few assessment tools used at 6 months or younger corrected age have proven predictive accuracy for cognitive and motor delay at 24 months' corrected age. Only the GMA and HINE demonstrated useful predictive validity. What this paper adds: General movements have predictive validity for both motor and cognitive dysfunction in infants born very preterm. The Hammersmith Infant Neurological Examination showed the highest predictive accuracy for severe motor delay. The General Movement Assessment was the best tool to predict mild-to-moderate motor and cognitive delays.

310. Örtqvist M, Einspieler C, Marschik PB, Ådén U.
Movements and posture in infants born extremely preterm in comparison to term-born controls
Early Hum Dev 2021; 154: 105304. doi: 10.1016/j.earlhumdev.2020.105304.

Background: Identifying altered motor development at an early stage is crucial for infants born extremely preterm (EPT), as they face a high risk of long-term neurodevelopmental impairment. The Prechtl General Movement Assessment (GMA), including the Motor Optimality Score Revised (MOS-R), can provide important insights into these infants' later neurodevelopmental function. Aims: To compare age-specific movements and postures in infants born EPT compared to term-born controls at three months corrected age. Study design: A retrospective observational study design. Subjects: 53 infants born EPT (mean gestational age 25 weeks; 23-26) were included and matched for gender and recording age with 53 term-born controls (mean gestational age 40 weeks, 37-41). Outcome measures: GMA including the MOS-R at three months corrected age (re-analysis of video-recordings). Results: Of the infants born EPT, 19% showed aberrant fidgety movements (FMs); all term-born infants had normal FMs. There was a significant difference in MOS-R (p≤0.001) between controls (median = 26, IQR 26-28) and EPT infants (median = 18, IQR 17-21), as well as in all subcategories of the MOS-R. The EPT group had a significantly higher number of infants showing atypical movement and postural patterns as well as a reduced repertoire for the age compared to the controls. All infants born EPT moved monotonously and jerky. P-values were all <0.001. Conclusion: Infants born EPT have an altered early motor development. The MOS-R may contribute to further understanding of motor performance in this group of children since it can detect neurological- and motor alterations at a very early age.

309. Barnes F, Graham L, Loganathan P, Nair V.
General Movement Assessment predicts neuro-developmental outcome in very low birth weight infants at two years - a five-year observational study.
Indian J Pediatr 2021; 88(1): 28-33. doi: 10.1007/s12098-020-03365-1.

Objective: To assess the value of general movements (GMs) in predicting the neurodevelopmental outcome using Bayley Scale of Infant Development III (BSID-III) at two years of age in very low birth weight (VLBW) infants. Methods: This is a five-year observational study (January 2012-June 2017). Two hundred twenty-seven VLBW infants were assessed in the neurodevelopmental clinic between Jan 2012 and June 2017. Of these 137 infants had GMs assessments at 3 mo post term (first visit to the clinic). Results: Absence of fidgety movements (FMs) at 3 mo post term had high specificity and negative predictive value for moderate to severe neurodevelopmental outcome in motor, cognition and language domains (composite score less than 70 in the Bayley III scales of Infant development scores). At 3 mo post term, absent FMs had high sensitivity, specificity and negative predictive value (NPV) for cerebral palsy (CP). Conclusions: GMs assessment at 3 mo post term could be considered as an important screening tool for early identification of VLBW infants who are at risk of neurodevelopmental impairment/cerebral palsy.

308. Wu Y-C, van Rijssen IM, Buurman MT, Dijkstra L-J, Hamer EG, Hadders-Algra M
Temporal and spatial localisation of general movement complexity and variation - why Gestalt assessment requires experience.
Acta Paediatr 2021; 110(1): 290-300. doi: 10.1111/apa.15300.

Aim: General movements' assessment (GMA), based on Gestalt perception, identifies infants at risk of cerebral palsy. However, the requirement of ample experience to construct the assessor's inner criteria for abnormal movement hampers its widespread clinical use. This study aims to describe details of general movements (GMs) in various body parts and to investigate their association with GMA-Gestalt. Methods: Participants were 24 typically developing infants and 22 very-high-risk infants. GMs were assessed during the writhing (0-8 weeks) and/or fidgety GM phase (2-5 months) by GMA-Gestalt and a semi-quantification of the duration of simple movements and complex movements in various body parts. Results: During both GM phases, the quality of movement often varied within a single assessment, but the degree of complexity and variation of movements in trunk, arms and legs were interrelated (ρ = 0.32-0.84). Longer durations of complex movements in arms and legs (P < .042) were further associated with a better quality in GMA-Gestalt. Head movement was associated with movements in other body parts only in the writhing phase and not associated with GMA-Gestalt during both GM phases. Conclusion: Infants did not show consistently over time and across body parts simple or complex movements. Detailed description of movement characteristics may facilitate the development of computer-based GMA.

307. Tacchino C, Impagliazzo M, Maggi E, Bertamino M, Blanchi I, Campone F, Durand P, Fato M, Giannoni P, Iandolo R, Izzo M, Morasso P, Moretti P, Ramenghi L, Shima K, Shimatani K, Tsuji T, Uccella S, Zanardi N, Casadio M.
Spontaneous movements in the newborns: a tool of quantitative video analysis of preterm babies.
Comput Methods Programs Biomed 2021; 199: 105838. doi: 10.1016/j.cmpb.2020.105838.

Background and objectives: The number of preterm babies is steadily growing world-wide and these neonates are at risk of neuro-motor-cognitive deficits. The observation of spontaneous movements in the first three months of age is known to predict such risk. However, the analysis by specifically trained physiotherapists is not suited for the clinical routine, motivating the development of simple computerized video analysis systems, integrated with a well-structured Biobank to make available for preterm babies a growing service with diagnostic, prognostic and epidemiological purposes. Methods: MIMAS (Markerless Infant Movement Analysis System) is a simple, low-cost system of video analysis of spontaneous movements of newborns in their natural environment, based on a single standard RGB camera, without markers attached to the body. The original videos are transformed into binarized sequences highlighting the silhouette of the baby, in order to minimize the illumination effects and increase the robustness of the analysis; such sequences are then coded by a large set of parameters (39) related to the spatial and spectral changes of the silhouette. The parameter vectors of each baby were stored in the Biobank together with related clinical information. Results: The preliminary test of the system was carried out at the Gaslini Pediatric Hospital in Genoa, where 46 preterm (PT) and 21 full-term (FT) babies (as controls) were recorded at birth (T0) and 8-12 weeks thereafter (T1). A simple statistical analysis of the data showed that the coded parameters are sensitive to the degree of maturation of the newborns (comparing T0 with T1, for both PT and FT babies), and to the conditions at birth (PT vs. FT at T0), whereas this difference tends to vanish at T1. Moreover, the coding method seems also able to detect the few 'abnormal' preterm babies in the PT populations that were analyzed as specific case studies. Conclusions: Preliminary results motivate the adoption of this tool in clinical practice allowing for a systematic accumulation of cases in the Biobank, thus for improving the accuracy of data analysis performed by MIMAS and ultimately allowing the adoption of data mining techniques.

306. Yardιmcι-Lokmanoğlu BN, Mutlu A, Livanelioğlu A, Haliloğlu G.
The general movements assessment and effects of an early intervention in an infant with Cri du chat syndrome: a case report.
Turk J Pediatr 2021; 63(1): 167-173. doi: 10.24953/turkjped.2021.01.021.

Background: Cri du chat syndrome (CdCS) is a rare orphan genetic disorder. Infants with CdCS have a neurodevelopmental dysfunction, but there are limited studies on their spontaneous movements or effect of the early interventions in children with CdCS. This study aimed to describe early spontaneous movements and investigate the effects of an early intervention in an infant with the CdCS. Case: We analyzed the detailed general movements assessment (GMA) of an infant with CdCS at 14 weeks, and the Bayley Scales of Infant and Toddler Development-third edition (Bayley-III) were used for the determining and the follow-up of developmental functioning at 14 weeks, 6 months and 12 months. The infant was included in an early intervention beginning from 14 weeks. Fidgety movements were absent. The motor repertoire appeared significantly reduced, and the movement character was monotonous at 14 weeks. Although the infant achieved some developmental milestones with the early intervention program, the improvements were not reflected in the Bayley-III composite score. Conclusions: As a consequence, abnormal GMA results, including fidgety movements and concurrent movement patterns, seen in CdCS can be associated with early signs of neurodevelopmental dysfunction. Early intervention programs in infants with genetic disorders could help enable the early achievement of motor milestones.

305. Alonzo CJ, Letzkus LC, Connaughton EA, Kelly NL, Michel JA, Zanelli SA.
High prevalence of abnormal general movements in hospitalized very low birth weight infants.
Am J Perinatol 2021; doi: 10.1055/s-0041-1722943.

Objective: Abnormal general movements (GMs) are predictive of later risk of motor impairments in preterm infants. The goals of this study are to (1) describe the implementation of the GM assessment (GMA) in a neonatal intensive care unit (NICU) and (2) investigate the prevalence and evolution of abnormal GMs in very low birth weight (VLBW) infants. Study design: Observational study of GMs in VLBW infants (gestational age [GA] <32 weeks and/or birth weight [BW] <1,500 g) following GMA implementation in a level-IV NICU. All VLBW infants admitted between November 2017 and April 2019 were eligible for the GMA. Infants were excluded if they required high-frequency ventilation or if they could not be unbundled for video acquisition. GMAs were scored weekly by at least 2 GMA-certified providers. Results: The GMA was performed in 121 VLBW infants with a mean (standard deviation [SD]) GA of 28.3 (2.6) and BW of 1,113 (400 g). Only 28% of infants had normal GMs on initial assessment (32.9 ± 2.7 weeks' GA), while 61 and 11% had poor repertoire and cramped-synchronized GMs, respectively. At NICU discharge (37.6 ± 3.4 weeks corrected GA), 45 and 21% of infants were classified as having poor repertoire and cramped-synchronized GMs, respectively. Most infants with cramped-synchronized GMs on initial assessment had persistent abnormal GMs at discharge. In contrast, only one infant with normal GMs on first assessment developed cramped-synchronized GMs. Conclusion: Abnormal GMs are common in VLBW infants, including a high prevalence of the more concerning cramped-synchronized movement pattern. The GMA can be successfully performed in VLBW infants. The GMA may be helpful in identifying infants at increased risk of later motor impairments, as well as assisting clinicians, in the stratification of infants who may benefit from additional brain imaging and/or an intensive hospital-based interventions.

304. Hadders-Algra M.
Early diagnostics and early intervention in neurodevelopmental disorders - age-dependent challenges and opportunities.
J Clin Med 2021; 10(4): 861. doi: 10.3390/jcm10040861.

This review discusses early diagnostics and early intervention in developmental disorders in the light of brain development. The best instruments for early detection of cerebral palsy (CP) with or without intellectual disability are neonatal magnetic resonance imaging, general movements assessment at 2-4 months and from 2-4 months onwards, the Hammersmith Infant Neurological Examination and Standardized Infant NeuroDevelopmental Assessment. Early detection of autism spectrum disorders (ASD) is difficult; its first signs emerge at the end of the first year. Prediction with the Modified Checklist for Autism in Toddlers and Infant Toddler Checklist is possible to some extent and improves during the second year, especially in children at familial risk of ASD. Thus, prediction improves substantially when transient brain structures have been replaced by permanent circuitries. At around 3 months the cortical subplate has dissolved in primary motor and sensory cortices; around 12 months the cortical subplate in prefrontal and parieto-temporal cortices and cerebellar external granular layer have disappeared. This review stresses that families are pivotal in early intervention. It summarizes evidence on the effectiveness of early intervention in medically fragile neonates, infants at low to moderate risk, infants with or at high risk of CP and with or at high risk of ASD.

303. Zhang Q, Hu Y, Dong X, Tu W.
Predictive value of electroencephalogram, event-related potential, and general movements quality assessment in neurodevelopmental outcome of high-risk infants.
Appl Neuropsychol Child 2021; 1-6. doi: 10.1080/21622965.2021.1879085.

Objective: The objective of the study is to investigate the predictive value of electroencephalogram (EEG), event-related potential (ERP), and general movements (GMs) quality assessment in the neurodevelopmental outcome of high-risk infants at one year old. Methods: EEG and ERP were performed in high-risk infants at four weeks old, and GMs quality was evaluated once at 4 weeks and once at 12 weeks. The Gesell score was used to assess neurodevelopment outcome at one year old. A comparative analysis of the effects of EEG, GMs, EEG + ERP, and EEG + ERP + GMs was used to predict high-risk neonatal neurodevelopmental outcome. Results: Of 71 high-risk infants at the age of one year, 3 (4.23%) had cerebral palsy, 14 (19.72%) had psychomotor retardation, and 54 (76.05%) were normal. The sensitivity, specificity, positive predictive value, and negative predictive value of EEG + ERP + GMs method were 90.00%, 95.08%, 75.00%, and 98.31%, respectively, and these indexes were the highest among the four methods (EEG, GMs, EEG + ERP, and EEG + ERP + GMs). The kappa statistic for the reliability of predicting neurodevelopmental outcome of high risk newborns by the EEG + ERP + GMs method was substantial at 0.785, while the other three methods obtained relatively low Kappa values (0.599, 0.586, and 0.712, respectively). Conclusions: The combination of EEG, ERP, and GMs quality assessment can greatly improve the prediction of neurodevelopmental outcome of high-risk newborns.

302. King AR, Machipisa C, Finlayson F, Fahey MC, Novak I, Malhotra A
Early detection of cerebral palsy in high-risk infants: Translation of evidence into practice in an Australian hospital.
J Paediatr Child Health 2021; 57(2): 246-250. doi: 10.1111/jpc.15191.

Aim: The early diagnosis of cerebral palsy (CP) allows children timely access to early intervention. In 2018, Monash Children's Hospital established an Early Neurodevelopment Clinic based upon evidence-based guidelines for the early diagnosis of CP in high-risk infants. In this study, we aimed to characterise the infants presenting to the clinic and determine the rate of CP diagnosis. Methods: This study analysed data from infants attending the Early Neurodevelopment Clinic between May 2019 and April 2020. Infants at high-risk for CP attended the clinic at 3 months corrected age. Neuroimaging reports were reviewed, and a Prechtl's General Movement Assessment and Hammersmith Infant Neurological Examination were performed. Infants were diagnosed as having typical development, delayed development, high-risk of CP or CP at the time of clinic attendance and referred on to the appropriate pathway. Results: Ninety-six high-risk infants attended the clinic over the 1 year study period. Sixty-eight (71%) infants were extremely preterm or extremely low birthweight, and 28 (29%) were infants at born at older gestation with evidence of moderate to severe brain injury. Nine (9.6%) infants received a CP diagnosis and 12 (12.5%) were considered high-risk of CP. All infants with CP or high-risk of CP were referred to the Victorian Paediatric Rehabilitation Service. Conclusions: It is feasible to implement the early CP diagnosis guidelines into a high-risk infant follow-up clinic. Implementation of the guidelines allows for early diagnosis of CP and appropriate referral of high-risk infants.

301. Glass HC, Li Y, Gardner M, Barkovich AJ, Novak I, McCulloch CE, Rogers EE.
Early Identification of cerebral palsy using neonatal MRI and General Movements Assessment in a cohort of high-risk term neonates.
Pediatr Neurol 2021; 118: 20-25. doi: 10.1016/j.pediatrneurol.2021.02.003.

Background: Cerebral palsy (CP) is the most common motor disability of childhood. Its early identification is an important priority for parents and is critical for access to early intervention resources, which may optimize function. Methods: A prospective cohort of term neonates at high risk for CP was assessed by neonatal magnetic resonance imaging (MRI) to determine myelination of the posterior limb of the internal capsule, General Movements Assessment to assess typical fidgety movements at age three months, and followed to at least age two years to determine diagnosis of CP based on neurological examination. Results: Seven of 58 children developed CP (12%), two with moderate/severe CP. Sensitivity and specificity for abnormal myelination of the posterior limb of the internal capsule were (PLIC) was 29% and 94%, and for absent fidgety movements, 29% and 98%, respectively. Negative predictive value of both absent myelination of the PLIC and absent fidgety movements was 90% (79% to 96%) for any CP and 98% (90% to 100%) for moderate/severe CP cerebral palsy. None of the children with both normal PLIC and normal fidgety movements had moderate/severe CP. Conclusion: Normal neonatal MRI and General Movements Assessment at age three months are reassuring that a high-risk term-born child is at low risk for moderate/severe CP. These results are important for counseling parents and individualizing therapy resources in the community.

300. McNamara L, Scott KM, Boyd RN, Novak I.
Consensus of physician behaviours to target for early diagnosis of cerebral palsy: A Delphi study
J Paediatr Child Health 2021. doi: 10.1111/jpc.15369.

Aims: Historically, the diagnosis of cerebral palsy has been made after 12 months of age, delaying access to crucial early intervention that optimises functional outcomes. This study aimed to identify and specify priority physician diagnostic behaviours to target in implementation interventions to increase the rate of diagnosis of cerebral palsy under 6 months of age in Australia. Methods: We conducted a two-round online Delphi study with a multi-professional expert panel of cerebral palsy researchers and clinicians. A reference group identified a six-item list of potential diagnostic behaviours, which were modifiable at the individual level, that could lead to an early cerebral palsy diagnosis. In the first survey, participants rated the importance of each item on a 10-point Likert scale and supplied their reasoning for this, and were able to suggest new behaviours. In the second survey, participants ranked items in order of priority. Results: All six items reached consensus for inclusion (100%). No new items were added to the list. Ranking identified the top three priorities for online physician implementation interventions: (i) refer for or conduct the General Movements Assessment; (ii) refer for or conduct the Hammersmith Infant Neurological Examination; and (iii) communication of the diagnosis. Conclusion: An online Delphi method can effectively inform tailored implementation intervention development. A consensus was achieved on the priority physician diagnostic behaviours to target in interventions to lower the age of cerebral palsy diagnosis in Australia.

299. Williams SA, Mackey A, Sorhage A, Battin M, Wilson N, Spittle A, Stott NS.
Clinical practice of health professionals working in early detection for infants with or at risk of cerebral palsy across New Zealand
J Paediatr Child Health 2021; 57(4): 541-547. doi: 10.1111/jpc.15263.

Aim: A diagnosis of cerebral palsy (CP) can, and should, be made as early as possible. This work describes current clinical practice around the awareness and use of diagnostic tools for the detection of CP in New Zealand (NZ). Methods: A purpose-developed survey distributed electronically to NZ clinicians working with young children with or at risk of CP. Results: A total of 159 clinicians (including paediatricians, physiotherapists and occupational therapists) participated in this cross-sectional study. Ninety-six percent were aware that a diagnosis of CP can be made by 12 months of age, with high levels of awareness of the use of magnetic resonance imaging (94%), Prechtl's qualitative assessment of general movements (GMs) (70%) and Hammersmith Infant Neurological Examination (HINE) (77%). Only 40% were aware of the HINE optimality scoring. Fifty-four clinicians provided a diagnosis of CP as part of their role: 48% never used the GMs or HINE to assess children <1 year, and 57% never used the HINE for children between 1 and 2 years. Clinicians not providing a diagnosis within their professional role (n = 104) also indicated infrequent use of assessment tools with 74% and 54% never using the GM's or HINE (respectively) in their assessment of children at risk of CP. Barriers to use included lack of time and funding, lack of clear pathways and management support. Conclusion: Despite high awareness, current use of international best practice tools in NZ clinical practice appears low. Multiple barriers are reported to the use of these tools, which need to be addressed to improve the timeliness of diagnosis.

298. Pouppirt NR, Martin V, Pagnotto-Hammitt L, Spittle AJ, Flibotte J, DeMauro SB.
The General Movements Assessment in neonates with hypoxic ischemic encephalopathy.
J Child Neurol 2021; 883073820981515. doi: 10.1177/0883073820981515.

Background: Clinical measures after birth and studies such as electroencephalogram (EEG) and brain imaging do not fully predict neurodevelopmental outcomes of infants with hypoxic-ischemic encephalopathy. Early detection of adverse neurologic outcomes, and cerebral palsy in particular, in high-risk infants is essential for ensuring timely management. The General Movements Assessment is a tool that can be used in the early detection of cerebral palsy in infants with brain injury. The majority of studies on the General Movements Assessment in the late preterm and term population were performed prior to the introduction of therapeutic hypothermia. Aims: To apply the General Movements Assessment in late preterm and term infants with hypoxic-ischemic encephalopathy (including those who received therapeutic hypothermia), to determine if clinical markers of hypoxic-ischemic encephalopathy predict abnormal General Movements Assessment findings, and to evaluate interrater reliability of the General Movements Assessment in this population. Study design: Pilot prospective cohort study Subjects: We assessed 29 late preterm and full-term infants with mild, moderate, and severe hypoxic-ischemic encephalopathy in Philadelphia, PA. Results: Most infants' general movements normalized by the fidgety age. Only infants with moderate or severe hypoxic-ischemic encephalopathy had abnormal general movements in both the writhing and the fidgety ages (n = 6). Seizure at any point during the initial hospitalization was the clinical sign most predictive of abnormal general movements in the fidgety age (sensitivity 100%, specificity 55%, positive predictive value 40%, negative predictive value 100%). Interrater reliability was greatest during the fidgety age (κ = 0.67). Conclusions: Seizures were the clinical predictor most closely associated with abnormal findings on the General Movements Assessment. However, clinical markers of hypoxic-ischemic encephalopathy are not fully predictive of abnormal General Movements Assessment findings. Larger future studies are needed to evaluate the associations between the General Movements Assessment and childhood neurologic outcomes in patients with hypoxic-ischemic encephalopathy who received therapeutic hypothermia.

297. Rodijk LH, Bos AF, Verkade HJ, de Kleine RH, Hulscher JBF, Bruggink JLM
Early motor repertoire in infants with biliary atresia: A nationwide prospective cohort study
J Pediatr Gastroenterol Nutr 2021; 72(4): 592-596. doi: 10.1097/MPG.0000000000003021.

Objectives: The aim of the study was to assess the neurological status in infants with biliary atresia (BA) at time of diagnosis, using Prechtl's validated General Movement Assessment. Methods: Infants diagnosed with BA were prospectively included in a nationwide cohort study. From birth to approximately 46 weeks of postmenstrual age (PMA), general movements (GMs) are defined as "writhing movements." At 46 to 49 weeks PMA, "'fidgety movements" emerge. The infant's early motor repertoire was recorded on video before Kasai portoenterostomy. We scored GM optimality scores (min-max 5-42) or motor optimality scores (MOS, min-max 5-28) as appropriate. We defined GM optimality scores <36 and MOS <26 as atypical, and compared the results with 2 reference groups of healthy peers. Results: We assessed GMs in 35 infants with BA (11/35 boys, gestational age 40 weeks [36-42], birth weight 3370 g [2015-4285]). At time of diagnosis (PMA 47 weeks [42-60]), 16 infants (46%) showed atypical GMs. The proportion of infants with atypical GMs was significantly higher in BA (46%) than in 2 reference groups of healthy infants (vs 10%, P < 0.001; vs 18%, P < 0.001). Total and direct bilirubin levels were 165 μmol/L (87-364) and 134 μmol/L (72-334), respectively, height z score was 0.05 (-2.90, 1.75), weight z score -0.52 ([-2.50, -0.20) and mean upper arm circumference z score -1.80 (-2.50, -0.20). We found no statistically significant relation between atypical GMs and clinical variables. Conclusions: Almost half of the infants with BA showed atypical GMs at time of diagnosis, suggesting neurological impairment. Close monitoring of these infants is warranted to determine their individual neurodevelopmental trajectories.

296. Saini L, Madaan P, Bhagwat C, Einspieler C.
Home-videos for neurodevelopmental follow-up of high-risk infants during COVID-19 pandemic: A simple and inexpensive tool.
J Trop Pediatr 2021; 67(1): fmaa088. doi: 10.1093/tropej/fmaa088.

295. Lucaccioni L, Boncompagni A, Pugliese M, Talucci G, Della Casa E, Bertoncelli N, Coscia A, Bedetti L, Berardi A, Iughetti L, Ferrari F.
Subtle impairment of neurodevelopment in infants with late fetal growth restriction
Affiliations expand.
J Matern Fetal Neonatal Med 2021; 1-8. doi: 10.1080/14767058.2021.1873267.

Introduction: Children with late fetal growth restriction (FGR) are at high risk of being born small for gestational age (SGA). These categories of newborns are at increased risk for neurodevelopment impairment. The general movements assessment, in particular at fidgety age, has been used to predict neurological dysfunctions. This study aimed to evaluate growth recovery, presence of fidgety movements at 3 months, and neurodevelopmental outcome at 2 years of age in term late FGR infants and adequate for gestational age (AGA) controls. Methods: Prospective clinical evaluation. At 3 months auxological parameters (AP) and neurological examination were evaluated while at 24 months neurodevelopment outcome by Griffiths Mental Development Scales (GMDS-R) was evaluated. Results: 38 late FGR and 20 AGA controls completed the study. Despite a significant catch up, at 3 months 13% of late FGR presented at least one auxological parameter <3° percentile. Moreover, 23.7% of late FGR infants did not show fidgety movements compared to 100% AGA controls (p < .001). Cranial circumference at birth resulted a positive predictive factor for FMs (p = .039). At 2 years of age, a difference statistically significant between late FGR and AGA was detected in GMDS-R. Conclusion: Independently from growth recovery, fidgety movements resulted less expressed in late FGR infants, and at 2 years of age the neurodevelopmental assessment revealed differences in each domain of evaluation between late FGR and AGA infants, although within normal ranges.

294. Lucaccioni L, Bertoncelli N, Comini M, Martignoni L, Coscia A, Lugli L, Righi E, Iughetti L, Berardi A, Ferrari F.
The ontogeny of limbs movements towards midline in healthy infants born at term.
Early Hum Dev 2021; 155: 05324. doi: 10.1016/j.earlhumdev.2021.105324.

Background: Movements towards midline are part of the age-adequate motor repertoire of infants. They develop contemporaneously to general movements, changing from occasional simple contact to proper midline motor patterns. Aim: The aim of this study is to describe the ontogeny of movements towards midline in full term healthy infants. Study design: Parents were asked to record their infant every second week, from term age to 22 weeks post-term. Subjects: 25 healthy full-term infants. Results: Three main epochs of development were detected: in the first one, between birth and 4 weeks post-term, movements towards midline were occasional, apparently due to the dominant flexed posture of elbow and knees and the adducted posture of shoulders and hips. In the second epoch, from 4 to 8 weeks, the limbs movements towards midline markedly decreased. In the third one, after 8 weeks, movements towards midline increased again in frequency, first appearing in lower limbs then in upper limbs, first solely as contact and thereafter as manipulation. A temporal overlapping with the occurrence of intermittent or continual fidgety movements was detected. Conclusions: Movements towards midline progressively change, through a defined timeline, in full term healthy infants. The increased knowledge about the normal age-adequate motor repertoire can help physicians in clinical assessment of high risk infants.

293. Barbosa VM, Einspieler C, Smith E, Bos AF, Cioni G, Ferrari F, Yang H, Urlesberger B, Marschik PB, Zhang D.
Clinical implications of the General Movement Optimality Score: Beyond the classes of Rasch analysis.
J Clin Med 2021; 10(5): 1069. doi: 10.3390/jcm10051069.

This article explores the clinical implications of the three different classes drawn from a Rasch analysis of the general movements optimality scores (GMOS) of 383 infants. Parametric analysis of the class membership examines four variables: age of assessment, brain injury presence, general movement patterns, and 2-year-old outcomes. GMOS separated infants with typical (class 3) from atypical development, and further separated cerebral palsy (class 2) from other neurodevelopmental disorders (class 1). Each class is unique regarding its quantitative and qualitative representations on the four variables. The GMOS has strong psychometric properties and provides a quantitative measure of early motor functions. The GMOS can be confidently used to assist with early diagnosis and predict distinct classes of developmental outcomes, grade motor behaviors, and provide a solid base to study individual general movement developmental trajectories.

292. Katušić A, Žunić Išasegi I, Radoš M, Raguž M, Grizelj R, Ferrari F, Kostović I.
Transient structural MRI patterns correlate with the motor functions in preterm infants.
Brain Dev 2021; 43(3): 363-371. doi: 10.1016/j.braindev.2020.11.002.

Aim: To explore the relationships between transient structural brain patterns on MRI at preterm and at term-equivalent age (TEA) as a predictor of general movements (GMs) and motor development at 1-year corrected age (CA) in very preterm infants. Methods: In this prospective study, 30 very preterm infants (median = 28wks; 16 males) had structural magnetic resonance imaging (MRI) at preterm (median = 31wks + 6d) and at TEA (median = 40 wks) and neuromotor assessments. The quality of GMs was assessed by Prechtl's general movements assessment and a detailed analysis of the motor repertoire was performed by calculating a motor optimality score (MOS), both at term age and at 3 months post-term. Motor development at 1-year CA was evaluated with the Infant Motor Profile (IMP). Associations between qualitative MRI findings and neuromotor scores were investigated. Results: Abnormal GMs and low motor performance at 1-year CA were associated with the poor visibility of transient structural pattern, that is with sagittal strata. Interpretation: Transient structural MRI pattern, sagittal strata, at preterm age is related to the quality of GMs and later motor development in preterm infants. This transient fetal brain compartment may be considered as a component of neurobiological basis for early neuromotor behavior, as expressed by GMs.

291. Raghuram K, Orlandi S, Church P, Chau T, Uleryk E, Pechlivanoglou P, Shah V.
Automated movement recognition to predict motor impairment in high-risk infants: a systematic review of diagnostic test accuracy and meta-analysis.
Dev Med Child Neurol 2021; doi: 10.1111/dmcn.14800.

Aim To assess the sensitivity and specificity of automated movement recognition in predicting motor impairment in high-risk infants. Method: We searched MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and Scopus databases and identified additional studies from the references of relevant studies. We included studies that evaluated automated movement recognition in high-risk infants to predict motor impairment, including cerebral palsy (CP) and non-CP motor impairments. Two authors independently assessed studies for inclusion, extracted data, and assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies-2. Meta-analyses were performed using hierarchical summary receiver operating characteristic models. Results: Of 6536 articles, 13 articles assessing 59 movement variables in 1248 infants under 5 months corrected age were included. Of these, 143 infants had CP. The overall sensitivity and specificity for motor impairment were 0.73 (95% confidence interval [CI] 0.68-0.77) and 0.70 (95% CI 0.65-0.75) respectively. Comparatively, clinical General Movements Assessment (GMA) was found to have sensitivity and specificity of 98% (95% CI 74-100) and 91% (95% CI 83-93) respectively. Sensor-based technologies had higher specificity (0.88, 95% CI 0.80-0.93). Interpretation: Automated movement recognition technology remains inferior to clinical GMA. The strength of this study is its meta-analysis to summarize performance, although generalizability of these results is limited by study heterogeneity.

290. Elliott C, Alexander C, Salt A, Spittle AJ, Boyd RN, Badawi N, Morgan C, Silva D, Geelhoed E, Ware RS, Ali A, McKenzie A, Bloom D, Sharp M, Ward R, Bora S, Prescott S, Woolfenden S, Le V, Davidson S-A, Thornton A, Finlay-Jones A, Jensen L, Amery N, Early Moves Clinical Working Group, Valentine J.
Early Moves: a protocol for a population-based prospective cohort study to establish general movements as an early biomarker of cognitive impairment in infants

BMJ Open 2021; 11(4): e041695. doi: 10.1136/bmjopen-2020-041695.

Introduction: The current diagnostic pathways for cognitive impairment rarely identify babies at risk before 2 years of age. Very early detection and timely targeted intervention has potential to improve outcomes for these children and support them to reach their full life potential. Early Moves aims to identify early biomarkers, including general movements (GMs), for babies at risk of cognitive impairment, allowing early intervention within critical developmental windows to enable these children to have the best possible start to life. Method and analysis: Early Moves is a double-masked prospective cohort study that will recruit 3000 term and preterm babies from a secondary care setting. Early Moves will determine the diagnostic value of abnormal GMs (at writhing and fidgety age) for mild, moderate and severe cognitive delay at 2 years measured by the Bayley-4. Parents will use the Baby Moves smartphone application to video their babies' GMs. Trained GMs assessors will be masked to any risk factors and assessors of the primary outcome will be masked to the GMs result. Automated scoring of GMs will be developed through applying machine-based learning to the data and the predictive value for an abnormal GM will be investigated. Screening algorithms for identification of children at risk of cognitive impairment, using the GM assessment (GMA), and routinely collected social and environmental profile data will be developed to allow more accurate prediction of cognitive outcome at 2 years. A cost evaluation for GMA implementation in preparation for national implementation will be undertaken including exploring the relationship between cognitive status and healthcare utilisation, medical costs, health-related quality of life and caregiver burden.

289. George JM, Colditz PB, Chatfield MD, Fiori S, Pannek K, Fripp J, Guzzetta A, Rose SE, Ware RS, Boyd RN.
Early clinical and MRI biomarkers of cognitive and motor outcomes in very preterm born infants
Pediatr Res 2021 Feb 24. doi: 10.1038/s41390-021-01399-5.

Background: This study aimed to identify which MRI and clinical assessments, alone or in combination, from (i) early (32 weeks postmenstrual age, PMA), (ii) term equivalent age (TEA) and (iii) 3 months corrected age (CA) are associated with motor or cognitive outcomes at 2 years CA in infants born <31 weeks gestation. Methods: Prospective cohort study of 98 infants who underwent early and TEA MRI (n = 59 males; median birth gestational age 28 + 5 weeks). Hammersmith Neonatal Neurological Examination (HNNE), NICU Neonatal Neurobehavioural Scale and General Movements Assessment (GMs) were performed early and at TEA. Premie-Neuro was performed early and GMs, Test of Infant Motor Performance and visual assessment were performed at TEA and 3 months CA. Neurodevelopmental outcomes were determined using Bayley Scales of Infant and Toddler Development 3rd edition. Results: The best combined motor outcome model included 3-month GMs (β = -11.41; 95% CI = -17.34, -5.49), TEA MRI deep grey matter score (β = -6.23; 95% CI = -9.47, -2.99) and early HNNE reflexes (β = 3.51; 95% CI = 0.86, 6.16). Combined cognitive model included 3-month GMs (β = -10.01; 95% CI = -15.90, -4.12) and TEA HNNE score (β = 1.33; 95% CI = 0.57, 2.08).

Conclusion: Early neonatal neurological assessment improves associations with motor outcomes when combined with term MRI and 3-month GMs. Term neurological assessment combined with 3-month GMs improves associations with cognitive outcomes. Impact: We present associations between 32- and 40-week MRI, comprehensive clinical assessments and later 2-year motor and cognitive outcomes for children born <31 weeks gestation. MRI and clinical assessment of motor, neurological and neurobehavioural function earlier than term equivalent age in very preterm infants is safe and becoming more available in clinical settings. Most of these children are discharged from hospital before term age and so completing assessments prior to discharge can assist with follow up. MRI and neurological assessment prior to term equivalent age while the child is still in hospital can provide earlier identification of children at highest risk of adverse outcomes and guide follow-up screening and intervention services.

288. Adde L, Brown A, Van den Broeck C, DeCoen K, Horsberg Eriksen B, Fjørtoft T, Groos D, Ihlen EAF, Osland S, Pascal A, Paulsen H, Skog OM, Sivertsen W, Støen R.
In-Motion-App for remote General Movement Assessment: a multi-site observational study.
BMJ Open 2021; 11(3): e042147. doi: 10.1136/bmjopen-2020-042147.

OBJECTIVES: To determine whether videos taken by parents of their infants' spontaneous movements were in accordance with required standards in the In-Motion-App, and whether the videos could be remotely scored by a trained General Movement Assessment (GMA) observer. Additionally, to assess the feasibility of using home-based video recordings for automated tracking of spontaneous movements, and to examine parents' perceptions and experiences of taking videos in their homes. DESIGN: The study was a multi-centre prospective observational study. SETTING: Parents/families of high-risk infants in tertiary care follow-up programmes in Norway, Denmark and Belgium. METHODS: Parents/families were asked to video record their baby in accordance with the In-Motion standards which were based on published GMA criteria and criteria covering lighting and stability of smartphone. Videos were evaluated as GMA 'scorable' or 'non-scorable' based on predefined criteria. The accuracy of a 7-point body tracker software was compared with manually annotated body key points. Parents were surveyed about the In-Motion-App information and clarity. PARTICIPANTS: The sample comprised 86 parents/families of high-risk infants. RESULTS: The 86 parent/families returned 130 videos, and 121 (96%) of them were in accordance with the requirements for GMA assessment. The 7-point body tracker software detected more than 80% of body key point positions correctly. Most families found the instructions for filming their baby easy to follow, and more than 90% reported that they did not become more worried about their child's development through using the instructions. CONCLUSIONS: This study reveals that a short instructional video enabled parents to video record their infant's spontaneous movements in compliance with the standards required for remote GMA. Further, an accurate automated body point software detecting infant body landmarks in smartphone videos will facilitate clinical and research use soon. Home-based video recordings could be performed without worrying parents about their child's development.

287. Yardιmcι-Lokmanoğlu BN, Mutlu A, Livanelioğlu A.
General Movements and developmental functioning in an individual with Rhizomelic Chondrodysplasia Punctata within the first months of the life: A case report.
Phys Occup Ther Pediatr 2021; 41(3): 326-335. doi: 10.1080/01942638.2020.1841870.

AIMS: Rhizomelic chondrodysplasia punctata (RCDP) is an autosomal recessive inherited disorder. Individuals with RCDP have a wide range of neurodevelopmental outcomes, but there are limited descriptions of their early motor development before 5 months of age. This study aimed to describe in detail the age-specific spontaneous movements and examine the developmental functioning in an individual with RCDP. METHODS: A female infant (born at 39 weeks' gestation), diagnosed with RCDP at 3 weeks of age, was assessed at 4 and 16 weeks for general movements (GMs) and concurrent motor repertoire; the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III) was also applied at the same ages. RESULTS: At 4 weeks, the infant showed poor repertoire GMs, with a detailed General Movement Optimality Score of 16/42. At 16 weeks, age-specific fidgety movements were absent, and the movement character was monotonous and stiff; the detailed Motor Optimality Score was severely reduced (7/28). All Bayley-III scores were <2 SD, that is <70 indicating severe developmental delay. CONCLUSION: Functional assessments such as the GM assessment and age-specific detailed assessment could be complementary to neuroimaging assessments to predict the neurodevelopmental outcomes in infants with RCDP.

286. Tacchino C, Impagliazzo M, Maggi E, Bertamino M, Blanchi I, Campone F, Durand P, Fato M, Giannoni P, Iandolo R, Izzo M, Morasso P, Moretti P, Ramenghi L, Shima K, Shimatani K, Tsuji T, Uccella S, Zanardi N, Casadio M.
Spontaneous movements in the newborns: a tool of quantitative video analysis of preterm babies.
Comput Methods Programs Biomed 2021; 199: 105838. doi: 10.1016/j.cmpb.2020.105838.

BACKROUND AND OBJECTIVES: The number of preterm babies is steadily growing world-wide and these neonates are at risk of neuro-motor-cognitive deficits. The observation of spontaneous movements in the first three months of age is known to predict such risk. However, the analysis by specifically trained physiotherapists is not suited for the clinical routine, motivating the development of simple computerized video analysis systems, integrated with a well-structured Biobank to make available for preterm babies a growing service with diagnostic, prognostic and epidemiological purposes. METHODS: MIMAS (Markerless Infant Movement Analysis System) is a simple, low-cost system of video analysis of spontaneous movements of newborns in their natural environment, based on a single standard RGB camera, without markers attached to the body. The original videos are transformed into binarized sequences highlighting the silhouette of the baby, in order to minimize the illumination effects and increase the robustness of the analysis; such sequences are then coded by a large set of parameters (39) related to the spatial and spectral changes of the silhouette. The parameter vectors of each baby were stored in the Biobank together with related clinical information. RESULTS: The preliminary test of the system was carried out at the Gaslini Pediatric Hospital in Genoa, where 46 preterm (PT) and 21 full-term (FT) babies (as controls) were recorded at birth (T0) and 8-12 weeks thereafter (T1). A simple statistical analysis of the data showed that the coded parameters are sensitive to the degree of maturation of the newborns (comparing T0 with T1, for both PT and FT babies), and to the conditions at birth (PT vs. FT at T0), whereas this difference tends to vanish at T1. Moreover, the coding method seems also able to detect the few 'abnormal' preterm babies in the PT populations that were analyzed as specific case studies. CONCLUSIONS: Preliminary results motivate the adoption of this tool in clinical practice allowing for a systematic accumulation of cases in the Biobank, thus for improving the accuracy of data analysis performed by MIMAS and ultimately allowing the adoption of data mining techniques.

285. Alkan H, Kahraman A, Mutlu A.
Early spontaneous movements of infants with hypoxic-ischemic encephalopathy.
Pediatr Phys Ther 2021; 33(1): 18-22. doi: 10.1097/PEP.0000000000000759.

OBJECTIVE: The aim of this study was to determine motor repertoire at 3 to 5 months of age in infants with hypoxic-ischemic encephalopathy (HIE) and to examine changes according to HIE severity. METHODS: Participants were 38 infants aged 3 to 5 months with HIE and 38 infants in the comparison group. The general movement assessment and the Motor Optimality Score (MOS) were used. RESULTS: Infants in the HIE group had a significantly lower total MOS and scores for fidgety movements, age adequacy of motor repertoire, and quality of movement patterns compared with the comparison group. Infants with grade III HIE compared with grade I had a significantly lower MOS. CONCLUSIONS: Infants with HIE had poorer motor repertoire at age 3 to 5 months when compared with peers. Motor repertoire deteriorated as HIE severity increased. Detecting potential developmental delays as early as possible allows for early intervention and rehabilitation in this population.

284. Harpster K, Merhar S, Illapani VSP, Peyton C, Kline-Fath B, Parikh NA.
Associations between early structural MRI, Hammersmith Infant Neurological Exam, and General Movements Assessment in very preterm infants.
J Pediatr 2021; 13: S0022-3476(20)31566-3. doi: 10.1016/j.jpeds.2020.12.056.

OBJECTIVE: To evaluate the prevalence and associations between structural MRI (sMRI) injury/abnormality at term equivalent age and absent fidgety General Movements Assessment (GMA) and abnormal Hammersmith Infant Neurological Examination (HINE) scores among very preterm infants at 3-4 months corrected age. STUDY DESIGN: This prospective cohort study enrolled 392 infants born ≤32 weeks' gestation from five neonatal intensive care units in the greater Cincinnati area between September 2016 and October 2019. Infants completed sMRI at term-equivalent age and GMA and HINE at 3-4 months corrected age. All assessors were blinded. RESULTS: Of 392 infants, 375 (96%) had complete data. Of these, 44 (12%) exhibited moderate or severe brain abnormalities, 17 (4.5%) had abnormal GMA, and 77 (20.3%) had abnormal HINE. Global and regional abnormality scores on sMRI were significantly correlated with GMA (R² range: 0.05-0.17) and HINE at 3-4 months corrected age (R² range: 0.01-0.17). These associations remained significant in multivariable analyses after adjusting for gestational age and sex. There was a significant but low correlation (R² 0.14) between GMA and HINE. CONCLUSION: We observed a low prevalence of moderate or severe brain abnormalities in very preterm survivors in this geographically-defined cohort. The much higher prevalence of abnormal motor exam on the HINE compared with GMA and their low correlation suggests that these tests evaluate different constructs, and thus, should be used in combination with sMRI rather than interchangeably.

283. Toldo M, Varishthananda S, Einspieler C, Tripathi N, Singh A, Verma SK, Vishwakarma K, Zhang D, Dwivedi A, Gupta R, Karn S, Kerketta N, Narayan R, Nikam Singh K, Rani S, Singh A, Singh D, Singh KP, Singh N, Singh N, Singh R, Singh SP, Srivastava R, Srivastava S, Srivastava S, Yadav G, Yadav P, Yadav S, Yadav S, Marschik PB.
Enhancing early detection of neurological and developmental disorders and provision of intervention in low-resource settings in Uttar Pradesh, India: study protocol of the G.A.N.E.S.H. programme
BMJ Open 2020; 10(11): e037335. doi: 10.1136/bmjopen-2020-037335.

Introduction: Around 9% of India's children under six are diagnosed with neurodevelopmental disorders. Low-resource, rural communities often lack programmes for early identification and intervention. The Prechtl General Movement Assessment (GMA) is regarded as the best clinical tool to predict cerebral palsy in infants <5 months. In addition, children with developmental delay, intellectual disabilities, late detected genetic disorders or autism spectrum disorder show abnormal general movements (GMs) during infancy. General Movement Assessment in Neonates for Early Identification and Intervention, Social Support and Health Awareness (G.A.N.E.S.H.) aims to (1) provide evidence as to whether community health workers can support the identification of infants at high-risk for neurological and developmental disorders and disabilities, (2) monitor further development in those infants and (3) initiate early and targeted intervention procedures. Methods: This 3-year observational cohort study will comprise at least 2000 infants born across four districts of Uttar Pradesh, India. Community health workers, certified for GMA, video record and assess the infants' GMs twice, that is, within 2 months after birth and at 3-5 months. In case of abnormal GMs and/or reduced MOSs, infants are further examined by a paediatrician and a neurologist. If necessary, early intervention strategies (treatment as usual) are introduced. After paediatric and neurodevelopmental assessments at 12-24 months, outcomes are categorised as normal or neurological/developmental disorders. Research objective (1): to relate the GMA to the outcome at 12-24 months. Research objective (2): to investigate the impact of predefined exposures. Research objective (3): to evaluate the interscorer agreement of GMA.

282. Wu Y-C, Bouwstra H, Heineman KR, Hadders-Algra M.
Atypical general movements in the general population: Prevalence over the last 15 years and associated factors
Acta Paediatr 2020, 109(12): 2762-2769. doi: 10.1111/apa.15329.

Aim: To determine the prevalence of atypical general movements (GMs) in the general population, to examine its time trend and associated factors. Methods: Participants consisted of 300 infants born in 2016-2018 (current cohort; gestational age 39.4 weeks (27-42); 162 boys), representative of the Dutch population. GMs were assessed at 2-4 months corrected age in terms of GM-complexity (definitely abnormal (DA) or not) and fidgety movements (present or absent). GM-complexity data from a cohort of 455 Dutch infants born in 2001-2002 were used to investigate the time trend. Results: In the current cohort, 10 infants (3%) showed DA GM-complexity and 8 (3%) absent fidgety movements. Only one infant had both GM-impairments (0.3%). The prevalence of DA GM-complexity did not differ from that in the 2001-2002 cohort (adjusted odds ratio (OR) = 1.47 [0.53, 4.06]). DA GM-complexity was associated with maternal smoking (adjusted OR = 3.59 [1.56, 8.28]) and marginally with prematurity (adjusted OR = 2.78 [1.00, 7.74]); absence of fidgety movements was curvilinearly associated with assessment age only (OR = 1.06 [1.01, 1.12]). Conclusion: In the general population, the prevalence of DA GM-complexity and absent fidgety movements is 3%. The finding that they rarely co-occur and are associated with different factors indicates that GM-assessment needs to address both aspects.

281. Goyen T-A, Morgan C, Crowle C, Hardman C, Day R, Novak I, Badawi N.
Sensitivity and specificity of general movements assessment for detecting cerebral palsy in an Australian context: 2-year outcomes
J Paediatr Child Health 2020; 56(9): 1414-1418. doi: 10.1111/jpc.14953

Aim: We previously reported sensitivity and specificity levels of the general movements assessment (GMA) to detect cerebral palsy (CP) at 1 year within a clinical setting and with the assistance of the New South Wales (NSW) Rater Network. The aim of this study was to determine whether similarly high levels of validity could be maintained in the same group at 2 years. Methods: A prospective longitudinal cross-sectional study was conducted. GMA was blind-rated from conventional video by two independent certified raters, blinded to medical history. A third rater resolved disagreements. High-risk population screening for CP using the GMA during the fidgety period (12-20 weeks) was carried out in four neonatal intensive care units and one CP service over a 30-month period. Participants were 259 high-risk infants for the initial study. Multidisciplinary follow-up at 2-3 years included Bayley Scales of Infant Development and confirmed diagnosis of CP. Sensitivity and specificity values were calculated with true positives defined as a confirmed diagnosis of CP. Results: At 2-3 years, 184 (71%) completed the follow-up assessment. GMA was normal for 134 (73%, low risk for CP), absent fidgety for 48 (26%, high risk for CP) and abnormal fidgety for 2 (1%, high risk for abnormal neurological disorder). Sensitivity for detecting CP was 97.6% (40/41) and specificity 95.7% (133/139). Sensitivity for detecting any abnormal outcome with absent/abnormal fidgety general movements (GMs) was 57.9% (44/76) and specificity 94.4% (101/107). Conclusion: Excellent levels of sensitivity and specificity of the GMA for detecting CP in the clinical setting were maintained at 2 years and were similar to our previously reported findings.

280. Marchi V, Belmonti V, Cecchi F, Coluccini M, Ghirri P, Grassi A, Sabatini AM, Guzzetta A.
Movement analysis in early infancy: Towards a motion biomarker of age.
Early Hum Dev 2020; 142: 104942. doi: 10.1016/j.earlhumdev.2019.104942. 

Background: Early motor development is characterized by progressive changes in general movements paralleled by a gradual organization of the four limbs' repertoire towards the midline, as shown by computerised movement analysis. Aims: Our aim was to test the performance of quantitative computerised kinematic indexes as predictors of post-term age in an independent cohort of typically developing subjects at fidgety age, tested cross-sectionally. Subjects: We selected twelve low risk term infants, who were video recorded between 9 and 20 weeks (fidgety age) during one spontaneous movements session. Study design: We correlated post-term age with I)indexes of coordination including interlimb correlation of velocity and position, II)indexes of distance, including interlimb and limb-to- ground, both expressed as linear distance and as probability of midline limbs position III)indexes of global movement quality by calculating Hjorth's activity, mobility and complexity parameters. All indexes were calculated for both upper and lower limbs. Results: Significant positive correlations were found between post-term age and indexes of distance, and probability of occurrence of upper-limb antigravity patterns, and with both indexes of global movement quality. By combining linear and non-linear parameters related to the upper limb kinematics, we determined individual post-term age with a mean error of <1 week (5.2 days). No correlations were found between age and indexes of coordination. Conclusions: Quantitative computerised analysis of upper-limb movements is a promising predictor of post-term age in typically developing subjects at fidgety age.

279. Athanasiadou A, Buitelaar JK, Brovedani P, Chorna O, Fulceri F, Guzzetta A, Scattoni ML.
Early motor signs of attention-deficit hyperactivity disorder: a systematic review
Eur Child Adolesc Psychiatry 2020; 29(7): 903-916. doi: 10.1007/s00787-019-01298-5.

ADHD is a common neurodevelopmental disorder with onset of symptoms typically in early childhood. First signs of the disorder, including language delay, motor delay and temperament characteristics, may be evident as early as infancy. The present review describes published evidence about early motor signs of either children with later symptoms of ADHD or a later diagnosis of the disorder. Nine published cohort studies were included after a systematic search of related terms in PubMed and PsycInfo databases. Study eligibility criteria included: (1) report on early motor function or any motor-related signs; (2) the presence of a participants' assessment by/at 12 months of age; (3) report of a later presence of ADHD symptoms. The limited number of reports included suggests an association between mild early neurological markers and later developmental coordination disorder and motor overflow movements. Unfortunately, due to their small sample sizes and focus on group reports rather than individuals, they have limited power to find strong associations. Early motor indicators of ADHD, if present, appear to be non-specific, and therefore not yet useful in clinical screening. Spontaneous motility seems to be a promising measure for early ADHD detection, although further studies with large cohorts are recommended to determine its clinical role in children at risk for ADHD.

278. Mebius MJ, Bilardo CM, Kneyber MC, Modestini M, Ebels T, Bereger RM, Bos AF, Kooi EMW.
Onset of brain injury in infants with prenatally diagnosed congenital heart disease
PLoS One 2020; 15(3): e0230414. doi: 10.1371/journal.pone.0230414.

Background: The exact onset of brain injury in infants with congenital heart disease (CHD) is unknown. Our aim was, therefore, to assess the association between prenatal Doppler flow patterns, postnatal cerebral oxygenation and short-term neurological outcome. Methods: Prenatally, we measured pulsatility indices of the middle cerebral (MCA-PI) and umbilical artery (UA-PI) and calculated cerebroplacental ratio (CPR). After birth, cerebral oxygen saturation (rcSO2) and fractional tissue oxygen extraction (FTOE) were assessed during the first 3 days after birth, and during and for 24 hours after every surgical procedure within the first 3 months after birth. Neurological outcome was determined preoperatively and at 3 months of age by assessing general movements and calculating the Motor Optimality Score (MOS). Results: Thirty-six infants were included. MOS at 3 months was associated with MCA-PI (rho 0.41, P = 0.04), UA-PI (rho -0.39, P = 0.047, and CPR (rho 0.50, P = 0.01). Infants with abnormal MOS had lower MCA-PI (P = 0.02) and CPR (P = 0.01) and higher UA-PI at the last measurement (P = 0.03) before birth. In infants with abnormal MOS, rcSO2 tended to be lower during the first 3 days after birth, and FTOE was significantly higher on the second day after birth (P = 0.04). Intraoperative and postoperative rcSO2 and FTOE were not associated with short-term neurological outcome. Conclusion: In infants with prenatally diagnosed CHD, the prenatal period may play an important role in developmental outcome. Additional research is needed to clarify the relationship between preoperative, intra-operative and postoperative cerebral oxygenation and developmental outcome in infants with prenatally diagnosed CHD.

277. Panvequio Aizawa CY, Einspieler C, Genovesi FF, Ibidi SM, Hydee Hasue R.
The general movement checklist: A guide to the assessment of general movements during preterm and term age.
J Pediatr (Rio J) 2020; S0021-7557(20)30217-5. doi: 10.1016/j.jped.2020.09.006.

Objectives: To develop a checklist describing features of normal and abnormal general movements (GMs) in order to guide General Movement Assessment (GMA) novices through the assessment procedure, to provide a quantification of GMA; and to demonstrate that normal and abnormal GMs can be distinguished on the basis of a metric checklist score. Methods: Three examiners used GMA and the newly developed GM checklist to assess 20 videos of 16 infants (seven males) recorded at 31-45 weeks postmenstrual age (writhing GMs). Inter- and intra-scorer agreement was determined for GMA (nominal data; Kappa values) and the checklist score (metric scale ranging from 0 to 26; Intraclass Correlation - ICC - values). The scorers' satisfaction with the usefulness of the checklist was assessed by means of a short questionnaire (score 10 for maximum satisfaction). Results: The scorers' satisfaction ranged from 8.44 to 9.14, which indicates high satisfaction. The median checklist score of the nine videos showing normal GMs was significantly higher than that of the eleven videos showing abnormal GMs (26 vs. 11, p<0.001). The checklist score also differentiated between poor-repertoire (median=13) and cramped-synchronized GMs (median=7; p=0.002). Inter- and intra-scorer agreement on (i) normal vs. abnormal GMs was good to excellent (Kappa=0.68-1.00); (ii) the distinction between the four GM categories was considerable to excellent (Kappa=0.56-0.93); (iii) the checklist was good to excellent (ICC=0.77-0.96). Conclusion: The GM checklist proved an important tool for the evaluation of normal and abnormal GMs; its score may potentially document individual trajectories and the effect of therapeutic intervention.

276. SokoƖłw M, Adde L, Klimont L, Pilarska E, Einspieler C.
Early intervention and its short-term effect on the temporal organization of fidgety movements.
Early Hum Dev 2020; 151: 105197. doi: 10.1016/j.earlhumdev.2020.105197.

Background: The Prechtl General Movement Assessment (GMA) predicts various neurological and developmental disorders while also documenting therapeutic effects. Aims: To describe the temporal organization of fidgety general movements in infants with mild to moderate postural asymmetries and/or tonus regulation problems, and to analyze to what extent the temporal organization of fidgety movements will change after physiotherapy. Study design: Repeated measure design. Participants: Twelve infants (five females) with mild to moderate postural asymmetries and/or tonus regulation problems were admitted for an early intervention program. The gestational age ranged from 27 to 40 weeks (Median, 36 weeks; nine infants born preterm) with birth weights ranging from 740 g to 3500 g (Median, 2590 g). Measures: Fidgety movements and their temporal organization were measured using the Prechtl GMA at 9 to 19 weeks post term age (Median, 14 weeks) before and after an early motor training procedure. The movements of one of the infants were analysed using a computer-based approach, measuring the mean and standard deviation of quantity of motion, height of motion and width of motion. Results: Seven infants had sporadic fidgety movements, and five had intermittent fidgety movements. None had continual fidgety movements before the intervention was initiated. After intervention, the temporal organization of fidgety movements increased in all infants. The observations of these movements were supported by computer-based analysis. Conclusion: The study indicates that early intervention increases the temporal organization of fidgety movements in infants with postural asymmetries and/or tonus regulation problems. The clinical significance of this finding needs to be further evaluated.

275. Soloveichick M, Marschik PB, Gover A, Molad M, Kessel I, Einspieler C.
Movement Imitation Therapy for Preterm Babies (MIT-PB): a Novel Approach to Improve the Neurodevelopmental Outcome of Infants at High-Risk for Cerebral Palsy.
J Dev Phys Disabil 2020; 32(4): 587-598. doi: 10.1007/s10882-019-09707-y.

To improve the neurodevelopmental outcome in infants with high grade intraventricular haemorrhage and cramped-synchronised (CS) general movements (GMs). Four very preterm infants with intraventricular haemorrhage grade III (n = 3) or intraventricular haemorrhage with apparent periventricular haemorrhagic infarction (n = 1) were diagnosed with CS GMs at 33 to 35 weeks postmenstrual age. A few days later MIT-PB [Movement Imitation Therapy for Preterm Babies], an early intervention programme, was commenced: the instant an infant showed CS movements, the therapist intervened by gently guiding the infant's limbs so as to manoeuvre and smoothen the movements, thereby imitating normal GM sequences as closely as possible (at least for 10 min, 5 times a day, with increasing frequency over a period of 10 to 12 weeks). After a period of consistent CS GMs, the movements improved. At 14 weeks postterm age, the age specific GM pattern, fidgety movements, were normal in three infants, one infant had abnormal fidgety movements. At preschool age, all participants had a normal neurodevelopmental outcome. This report on four cases demonstrates that mimicking normal and variable GM sequences might have a positive cascading effect on neurodevelopment. The results need to be interpreted with caution and replication studies on larger samples are warranted. Nonetheless, this innovative approach may represent a first step into a new intervention strategy.

274. Salavati S, Salavati M, Coenen MA, Ter Horst JH, Bos AF.
A Parechovirus type 3 infection with a presumed intrauterine onset: A poor neurodevelopmental outcome.
Neonatology 2020; 117(5): 658-662. doi: 10.1159/000509571.

Parechovirus type 3 (HPeV-3) infection is an important cause of illness in neonates. We present the first case of an infant with a HPeV-3 meningoencephalitis which presumably commenced in utero. Severe developmental delay was seen. In the case of inexplicable neonatal meningoencephalitis, an intrauterine onset of HPeV-3 infection might be the cause.

273. Olsen JE, Cheong JLY, Eeles AL, FitzGerald TL, Cameron KL, Albesher RA, Anderson PJ, Doyle LW, Spittle AJ.
Early general movements are associated with developmental outcomes at 4.5-5 years.
Early Hum Dev 2020; 148: 105115. doi: 10.1016/j.earlhumdev.2020.105115.

Background: Prechtl's general movements assessment (GMA) post-term has high predictive validity for cerebral palsy, but less is known about whether earlier GMA, including before term, are associated with other developmental problems. Aims: To examine the relationships between GMA prior to term and at term-equivalent, with developmental outcomes at 4.5-5 years' corrected age. Study design: Prospective cohort study. Subjects: 122 very preterm infants born <30 weeks' gestation and 91 healthy term controls. Outcome measures: GMA (categorised as 'normal' or 'abnormal') were assessed at <32, 32-33 and 34-36 weeks' postmenstrual age for the preterm infants, and at term-equivalent for both groups. Children were assessed at 4.5-5 years' corrected age using the Movement Assessment Battery for Children-2nd edition (MABC-2), Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT), Pediatric Quality of Life Inventory (PedsQL), Little Developmental Coordination Disorder Questionnaire (Little DCD-Q) and Wechsler Preschool and Primary Scale of Intelligence-IV (WPPSI-IV). Results: Prior to term, abnormal GMA at the first two timepoints were associated with lower scores on the Little DCD-Q, and abnormal GMA at the second and third timepoints with lower quality of life scores and PEDI-CAT mobility domain scores. Abnormal GMA at term-equivalent were associated with lower MABC-2, mobility and quality of life scores for preterm infants, and worse social/cognitive domain scores for both groups. Conclusions: Abnormal GMA prior to term and at term-equivalent are associated with worse motor, functional and cognitive outcomes at 4.5-5 years' corrected age, and may be useful to identify infants for developmental surveillance/early intervention.

272. Fjørtoft T, Brandal M, Brubakk AM, Adde L, Ustad T, Vågen R, Evensen KAI.
Maternal alcohol and drug use during pregnancy affects the motor behaviour and general movements of infants aged 3-4 months.
Early Hum Dev 2020; 151: 105171. doi: 10.1016/j.earlhumdev.2020.105171.

Background: Exposure of alcohol and/or other addictive drugs in pregnancy is a documented risk factor for later neurological impairment. Aims: The aim of the study was to determine whether infants suffering from prenatal exposure to addictive drugs and alcohol develop an abnormal motor behaviour at three to four months of age. Study design: Controlled cohort study of infants exposed to alcohol and/or other addictive drugs in pregnancy who were recruited from a hospital follow-up programme. The control group consisted of healthy, unexposed infants. Subjects: The study group of 108 infants exposed to alcohol and/or addictive drugs in pregnancy were enrolled based on referrals from primary health care. The control group included 106 infants who had not been exposed to the aforementioned substances. Outcome measures: We assessed the general movements (Prechtl's General-Movement-Assessment, GMA), the motor repertoire (Assessment-of-Motor-Repertoire, AMR), and the Alberta-Infant Motor-Scale (AIMS) in all infants at three to four months of age. Results: None of the infants in either group had absent fidgety movements (FMs). In the study group 5(5%) had exaggerated FMs and 5(5%) had sporadic FMs; and 68(63%) infants in the study group displayed an abnormal movement character, compared to 23(22%) in the control group (p<0.001). On the AIMS, 46(44%) infants in the study group scored below the 10th percentile, compared to 2(3%) controls (p< 0.001). Conclusion: The study describes an abnormal movement character of infants exposed to alcohol and/or addictive drugs in pregnancy when their motor repertoire was assessed at three to four months of age. The AIMS also showed negative effects on their motor behaviour.

271. Doroniewicz I, Ledwoń DJ, Affanasowicz A, Kieszczyńska K, Latos D, Matyja M, Mitas AW, Myśliwiec A.
Writhing movement detection in newborns on the second and third day of life using pose-based feature machine learning classification.
Sensors (Basel) 2020; 20(21): 5986. doi: 10.3390/s20215986.

Observation of neuromotor development at an early stage of an infant's life allows for early diagnosis of deficits and the beginning of the therapeutic process. General movement assessment is a method of spontaneous movement observation, which is the foundation for contemporary attempts at objectification and computer-aided diagnosis based on video recordings' analysis. The present study attempts to automatically detect writhing movements, one of the normal general movement categories presented by newborns in the first weeks of life. A set of 31 recordings of newborns on the second and third day of life was divided by five experts into videos containing writhing movements (with occurrence time) and poor repertoire, characterized by a lower quality of movement in relation to the norm. Novel, objective pose-based features describing the scope, nature, and location of each limb's movement are proposed. Three machine learning algorithms are evaluated in writhing movements' detection in leave-one-out cross-validation for different feature extraction time windows and overlapping time. The experimental results make it possible to indicate the optimal parameters for which 80% accuracy was achieved. Based on automatically detected writhing movement percent in the video, infant movements are classified as writhing movements or poor repertoire with an area under the ROC (receiver operating characteristics) curve of 0.83.

270. da Fonseca Filho GG, Lopes AC, Bezerra RB, de Candido A, Arrais N, Pereira SA, Lindquist AR.
Assessment of child development in premature babies based on the ICF biopsychosocial model
Eur J Phys Rehabil Med 2020; doi: 10.23736/S1973-9087.20.06543-0.

Background: The International Classification of Functionality (ICF) has been recommended to enable a broader and more holistic view of an individual's health condition. In addition, it works as an important reference for multiprofessional teams. Noneth, in low-income countries, like Brazil, the attempts to systematize and incorporate the ICF model in health services has been a challenge. Aim: Analyze the development of premature babies considering the biopsychosocial model of the ICF. Design: A longitudinal study. Setting: Maternity in the northeast Brazil. Population: 35 premature babies were evaluated in the first stage and 20 in the second. Methods: Pre, perinatal, socioeconomic data and environmental factors were collected and general movements assessed during the 38th (±1.79) week of corrected gestational age. The Age and Stages Questionnaire (ASQ-3) was used to assess child development, in the 13th (±1.50) month of life. The instruments were chosen with the objective of evaluating information necessary for the follow-up of premature infants and to represent the five domains of the ICF. Results: Of the 35 newborns initially evaluated, 20 were reassessed at 1 year of age and 70% were boys. In the function and structure domain, 55% exhibited altered general movements and 35% grade 1 intraventricular hemorrhage; in activity and participation, 15% displayed delayed communication, 20% delayed ample motor coordination, 40% fine motor coordination and problem resolution and 35% personal/social delay in the ASQ-3. Only one item of the personal factors (male sex) and function and structure domain (intraventricular hemorrhage) exhibited an association with atypical child development. Conclusions: Given the susceptibility of premature newborn neurodevelopment and the magnitude of the biopsychosocial model of the ICF, even at this early stage of life, it was possible to observe the influence of personal factors, body function and structure domains on atypical child development.

269. Pascal A, Govaert P, Ortibus E, Naulaers G, Adde L, Fjørtoft T, Oostra A, Zecic A, Cools F, Cloet E, Casaer A, Cornette L, Laroche S, Samijn B, Van den Broeck C.
Motor outcome after perinatal stroke and early prediction of unilateral spastic cerebral palsy.
Eur J Paediatr Neurol 2020; 29: 54-61. doi: 10.1016/j.ejpn.2020.09.002.

Background: Unilateral spastic cerebral palsy (USCP) occurs in 30%-68% of infants with perinatal stroke. Early detection of USCP is essential for referring infants to early intervention. The aims of this study were to report motor outcomes after perinatal stroke, and to determine the predictive value of the General Movements Assessment (GMA) and Hand Assessment for Infants (HAI) for detection of USCP. Materials and methods: This was a prospective observational study involving infants with perinatal stroke. GMA was conducted between 10 and 15 weeks post term-age (PTA). The HAI was performed between 3 and 5 months PTA. Motor outcome was collected between 12 and 36 months PTA. Results: The sample consisted of 46 infants. Fifteen children (32.6%) were diagnosed with CP, two children with bilateral CP and 13 with USCP. Abnormal GMA had a sensitivity of 85% (95% confidence interval [CI] 55-98%) and a specificity of 52% (95% CI 33-71%) to predict USCP. When asymmetrically presented FMs were also considered as abnormal, sensitivity increased to 100%, hence the specificity declined to 43%. A HAI asymmetry index cut-off of 23, had both a sensitivity and a specificity of 100% to detect USCP. Conclusion: Using GMA and HAI can enable prediction of USCP before the age of 5 months in infants with perinatal stroke. Nevertheless, GMA must be interpreted with caution in this particular population. The HAI was found to be a very accurate screening tool for early detection of asymmetry and prediction of USCP.

268. Peinado-Gorlat P, Gómez de Valcárcel-Sabater M, Gorlat-Sánchez B.
[General movement assessment as a tool for determining the prognosis in infantile cerebral palsy in preterm infants: a systematic review]. [Article in Spanish]
Rev Neurol 2020; 71(4): 134-142. doi: 10.33588/rn.7104.2019460.

Introduction: Cerebral palsy is considered to be the main cause of physical disability in childhood. General movements are an assessment tool in order to predict the neurological and long-term outcome of the newborn. Aim: To analyze the current evidence on the general movements assessment in preterm infants as cerebral palsy prognostic tool. Subjects and methods: Systematic review following PRISMA statements. Databases consulted were: PubMed/Medline, Lilacs, IBECS, Cochrane, PEDro, Cinhal, Sport Discuss, Phyinfo, Academic Search Complete, Web of Science, and SciELO. We included studies that evaluated general movements in the first 20 weeks premature newborns. We excluded studies where the sample submit other pathologies or medication was administered. Newcastle-Ottawa Scale was used to assessment the risk of bias. Results: Ten cohort studies form this review. 2243 premature, with an average of 30.9 weeks of gestation, were analyzed. General movements recording was carried out between 5 and 30 minutes. When there are abnormal general movements, the chances of neurological involvement increase during development, whereas when normal general movements are evaluated, there will rarely be a subsequent cerebral palsy diagnosis. Conclusions: The predictive validity of the preterm general movements assessment is confirmed as a tool to predict cerebral palsy early. Since preterm infants are more likely to trigger abnormal general movements, it is interesting to promote this type of assessment.

267. Porro M, Fontana C, Giannì ML, Pesenti N, Boggini T, De Carli A, De Bon G, Lucco G, Mosca F, Fumagalli M, Picciolini O.
Early detection of general movements trajectories in very low birth weight infants.
Sci Rep 2020; 10(1):13290. doi: 10.1038/s41598-020-70003-3.

The aim of the study was to investigate General Movements'(GMs) neonatal trajectories and their association with neurodevelopment at three months corrected age (CA) in preterm infants. We conducted an observational, longitudinal study in 216 very low birth weight infants. GMs were recorded at 31 ± 1, 35 ± 1, 40 ± 1 weeks of postmenstrual age and at three months of corrected age (CA). More than 90% of infants showing neonatal trajectories with persistent Normal (N-N) or initial Poor Repertoire to Normal (PR-N) movements presented fidgety pattern at three months CA. On the contrary, fidgety movements were not detected in any infant with a trajectory of persistent Cramped-Synchronized (CS-CS) or an initial Poor-Repertoire to Cramped-Synchronized (PR-CS) movements. Trajectories with initial Normal to Poor-Repertoire (N-PR) or persistent Poor-Repertoire (PR-PR) movements showed an increased risk of having a non-normal Fidgety pattern compared with the N-N group (OR = 8.43, 95% CI: 2.26-31.45 and OR = 15.02, 95% CI: 6.40-35.26, respectively). These results highlight the importance to evaluate neonatal GMs' trajectory to predict infants' neurodevelopment. N-N or PR-N trajectories suggest normal short-term neurodevelopment, especially a lower risk of Cerebral Palsy; whereas findings of N-PR and PR-PR trajectories indicate the need for closer follow up to avoid delay in programming intervention strategies.

266. Tekerlek H, Mutlu A, Inal-Ince D, Livanelioglu A, Kahraman A, Eryilmaz-Polat S, Karakaya J, Ozcelik U.
Motor repertoire is age-inadequate in infants with cystic fibrosis.
Pediatr Res 2020. doi: 10.1038/s41390-020-1082-4.

Background: General movements (GMs) in infants occur as fidgety movements (FMs) between postterm 9 and 20 weeks. We aimed to evaluate FMs and motor repertoire in infants with cystic fibrosis (CF) and their relation with clinical findings. Methods: Demographic and clinical characteristics were recorded. FMs and motor repertoire were analyzed from a 5-min video recording of each infant. Videos were rated based on the Prechtl General Movement Assessment and motor optimality score (MOS) was calculated. Results: The analysis included 18 infants with CF and 20 healthy infants at postterm age of 3-5 months. MOS was significantly lower in the infants with CF compared to controls (p < 0.05). Fifty percent of the infants with CF had abnormal or absent/sporadic FMs. MOS was negatively associated with hospitalization duration (r = -0.378, p = 0.036); and positively associated with vitamin A level in CF infants (r = 0.665, p = 0.026). Conclusions: Infants with genetically anticipated severe CF phenotype tended to have lower MOS. MOS may be used in addition to genetic testing to predict disease severity in infants with CF. Infants with CF, absent/sporadic FMs, and lower MOS could be considered for planning specific age-adequate early intervention programs. Impact: Motor repertoire was age-inadequate in infants with cystic fibrosis (CF).50% of infants with CF had abnormal or absent/sporadic fidgety movements (FMs).Motor optimality score (MOS) was positively associated with vitamin A level and negatively correlated with hospitalization duration in infants with CF.MOS tended to decrease as genetically anticipated disease severity increased; thus, MOS might enable us to predict disease severity in CF. The relationship between motor repertoire and phenotype and genotype is unclear and warrants further study.CF infants with absent/sporadic FMs, and lower MOS could be considered for planning early intervention.

265. Seesahai J, Luther M, Rhoden CC, Church PT, Asztalos E, Banihani R.
The general movements assessment in term and late-preterm infants diagnosed with neonatal encephalopathy, as a predictive tool of cerebral palsy by 2 years of age: a scoping review protocol.
Syst Rev 2020; 9(1): 154. doi: 10.1186/s13643-020-01358-x.

Background: Prediction of long-term neurodevelopmental outcomes remains an elusive goal for neonatology. Clinical and socioeconomic markers have not proven to be adequately reliable. The limitation in prognostication includes those term and late-preterm infants born with neonatal encephalopathy. The General Movements Assessment tool by Prechtl has demonstrated reliability for identifying infants at risk for neuromotor impairment. This tool is non-invasive and cost-effective. The purpose of this study is to identify the published literature on how this tool applies to the prediction of cerebral palsy in term and late-preterm infants diagnosed with neonatal encephalopathy and so detect the research gaps. Methods: We will conduct a systematic scoping review for data on sensitivity, specificity, positive, and negative predictive value and describe the strengths and limitations of the results. This review will consider studies that included infants more than or equal to 34 + 0 weeks gestational age, diagnosed with neonatal encephalopathy, with a General Movements Assessment done between birth to six months of life and an assessment for cerebral palsy by at least 2 years of age. Experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies, interrupted time-series studies and systematic reviews will be considered. Case reports, case series, case control, and cross-sectional studies will be included. Text, opinion papers, and animal studies will not be considered for inclusion in this scoping review as this is a highly specific and medical topic. Studies in the English language only will be considered. Studies published from at least 1970 will be included as this is around the time when the General Movements Assessment was first introduced in neonatology as a potential predictor of neuromotor outcomes. We will search five databases (MEDLINE, Embase, PsychINFO, Scopus, and CINAHL). Two reviewers will conduct all screening and data extraction independently. The articles will be categorized according to key findings and a critical appraisal performed. Discussion: The results of this review will guide future research to improve early identification and timely intervention in infants with neonatal encephalopathy at risk of neuromotor impairment.

264. Skworc A, Marciniak S, Sławska H.
Influence of infections on the quality of general movements in premature infants.
Early Hum Dev 2020;148: 105118. doi: 10.1016/j.earlhumdev.2020.105118.

Introduction: The task of contemporary neonatology is not only to save the lives of children born prematurely, but also to provide them with the highest possible quality of life. The Prechtl method, one of several methods of assessing the quality of general movement patterns, enables early identification of immaturity or damage to the central nervous system. Aim: Dynamic assessment of the type and quality of general movement (GMs) in preterm infants to determine indications for early neurodevelopmental support and to identify the relationship between the occurrence of maternal and neonatal perinatal risk factors and the type and quality of general movements. Material and method: 90 infants were assessed between 28 0/7 and 36 6/7 weeks gestational age. Dominant cases (57 cases) were infants born between 32 and 36 weeks GE. Most cases (48) received low Apgar score at 1 min (≤7), including two born in very severe condition. Neonatal infections were diagnosed in 26 infants. The study included three GM assessments: I - up to 14th day post-partum, II at term and III between 12 and 15 weeks corrected age. The analysis included gestational age, general condition of the newborn as per Apgar score as well as early and late infections. Results: Neonatal infections were found to show a close correlation with the occurrence of abnormal general movements. It was confirmed that gestational age and congenital infections are important variables affecting the occurrence of abnormal general movements.

263. Kahraman A, Mutlu A, Livanelioğlu A.
Assessment of motor repertoire in 3- to 5-month-old infants with obstetric brachial plexus lesion.
Pediatr Phys Ther 2020; 32(2): 114-119. doi: 10.1097/PEP.0000000000000688.

Purpose: The aim of this study was to define the movement characteristics and postures of infants with obstetric brachial plexus lesion. Methods: The study group included 20 infants with obstetric brachial plexus lesion and a control group of 20 infants with normal neurological outcome, aged 9 to 17 weeks postterm. Infants were evaluated by global and detailed general movements assessment. Results: There were no significant differences between the motor optimality scores of the 2 groups. However, there were some differences in terms of concurrent movements and the posture. Infants with obstetric brachial plexus lesion demonstrated more excitement bursts, head rotation, hand-knee contact, rolling, and few finger posture and postural asymmetry, and performed jerky movements when compared with the control group. Conclusions: Obstetric brachial plexus lesion did not affect the quality of fidgety movements of the infants but leads to compensatory movements in concurrent movements on the unaffected sides.

262. da Silva Pires C, Martins Marba ST, de Siqueira Caldas JP, de Carvalho Sanchez Stopiglia M.
Predictive value of the general movements assessment in preterm infants: a meta-analysis [in Portuguese].
Rev Paul Pediatr 2020; 38: e2018286. doi: 10.1590/1984-0462/2020/38/2018286.

Objective: To discuss the predictive value of the General Movements Assessment for the diagnosis of neurodevelopment disorders in preterm newborns. Data source: We conducted a systematic literature review using the following databases: Scientific Electronic Library Online (SciELO), National Library of Medicine, National Institutes of Health (PubMed), and Excerpta Medica Database (EMBASE). The articles were filtered by language, year of publication, population of interest, use of Prechtl's Method on the Qualitative Assessment of General Movements, and presence of variables related to the predictive value. The Quality Assessment of Diagnostic Accuracy Studies 2 was used to assess the methodology of the included studies. Sensitivity, specificity, Diagnostic Odds Ratio, positive and negative likelihood ratio, and parameter of accuracy were calculated. Data synthesis: Six of 342 articles were included. The evaluation of Writhing Movements is a good indicator for recognizing cerebral palsy, as it has high values for the sensitivity and accuracy parameters. The evaluation of Fidgety Movements has the strongest predictive validity for cerebral palsy, as it has high values in all measures of diagnostic accuracy. The quality assessment shows high risk of bias for patient selection and flow and timing of the evaluation. Therefore, the scale has potential to detect individuals with neurodevelopment disorders. However, the studies presented limitations regarding the selection of subjects and the assessment of neurological outcomes. Conclusions: Despite the high predictive values of the tool to identify neurological disorders, research on the subject is required due to the heterogeneity of the current studies.

261. Kahraman A, Livanelioğlu A, Kara ÖK, Yurdakök M.
Are general movements at 3-5 months correlated and compatible with the Bayley-III at 1,5-2 years age?
Turk J Pediatr 2020; 62(1): 89-93. doi: 10.24953/turkjped.2020.01.012.

Since early intervention is important in risky infants, it is also important to identify developmental problem as early as possible. There are various assessment methods for this. One of them is the General movements assessment (GMs), and the other one is the Bayley Scales of Infants and Toddler Developmental, third edition (Bayley-III). The present study aimed to compare the neurodevelopmental outcomes and Bayley-III scores at the age of 1.5-2 years with fidgety GMs. One hundred and twenty-six infants (57 females, 69 males) were assessed by the GMs at the corrected 3-5 months and also by the Bayley-III at the age of 1.5-2 years. According to the GMs, 21 infants exhibited the absence of fidgety movements, six infants exhibited abnormal fidgety movements, and 99 infants exhibited normal fidgety movements. According to the Bayley-III, 19 infants` motor scores, 13 infants` language scores, and 18 infants` cognitive scores were low (-2SD). Various neurodevelopmental problems were identified in 25.4% of the infants. As a result, although in the present study the Bayley-III underestimates the rates of motor impairment, it was found to be moderately compatible with the GMs at 3-5 months (r= 0.4, p < 0.001). However, the GMs were better than the Bayley-III in predicting neurodevelopmental outcomes at the age of 1.5-2. Although the Bayley-III and GMs may be valuable tools for estimating the later outcomes of infants, care should be taken while interpreting their results.

260. Goel D, Luig M, Maheshwari R, D'Cruz D, Goyen T-A.
General Movement assessment and neurodevelopmental trajectory in extremely preterm infants with hypothyroxinaemia of prematurity (THOP)
Early Hum Dev 2020; 144: 104886. doi: 10.1016/j.earlhumdev.2019.104886.

Background: Transient hypothyroxinaemia of prematurity (THOP) has been associated with neurodevelopmental deficits with a paucity of literature leading to variable practice. Aim: Evaluation of the relationship between free T4 (fT4) levels at 2 weeks after birth and early markers of neurodevelopmental outcome. Study design: A retrospective study of prospectively collected data from infants born <29 weeks' gestation, admitted to NICU between January 2012 and December 2014. The primary outcomes were the relationship between fT4 levels at 2 weeks, Prechtl General Movement Assessment (GMA) at 36 weeks and 3 months postterm age, and Bayley Scales of Infant Development (BSID-III) at 2 years postterm age. Secondary outcomes were survival free of disability and other neonatal morbidities. Results: Of 122 infants, 101 infants had normal fT4 levels (No-THOP) and 21 had fT4 levels >1SD below the mean (THOP group). There was increased frequency of abnormal GMA in the No-THOP group compared with the THOP group at 36 weeks (abnormal writhing GMs: 43% vs 21%, p = 0.15) and 3 months corrected age (absent fidgety GMs: 7.6% vs 0%, p = 0.36), though not statistically significant. The neurodevelopmental outcome was worse in the No-THOP group compared with the THOP group with significantly lower mean cognitive and motor scores at 2 year of corrected age (90 ± 13.8 vs 100 ± 8.3, p = 0.01 and 91 ± 15.2 vs 100 ± 13.2, p = 0.04 respectively). Conclusions: This is the first report describing General Movements (GMs) in preterm infants with THOP. We found worse neurodevelopmental outcome in No-THOP infants reflected by significantly worse cognitive and motor outcomes at 2 years corrected age.

259. Peyton C, Einspieler C, Fjørtoft T, Adde L, Schreiber MD, Drobyshevsky A, Marks JD.
Correlates of normal and abnormal general movements in infancy and long-term neurodevelopment of preterm infants: Insights from functional connectivity studies at term equivalence.
J Clin Med 2020; 9(3): 834. doi: 10.3390/jcm9030834.

Preterm infants born before 32 weeks gestation have increased risks for neurodevelopmental impairment at two years of age. How brain function differs between preterm infants with normal or impaired development is unknown. However, abnormal spontaneous motor behavior at 12-15 weeks post-term age is associated with neurodevelopmental impairment. We imaged brain blood oxygen level-dependent signals at term-equivalent age in 62 infants born at <32 weeks gestation and explored whether resting state functional connectivity (rsFC) differed with performances on the General Movement Assessment (GMA) at 12-15 weeks, and Bayley III scores at two years of corrected age. Infants with aberrant general movements exhibited decreased rsFC between the basal ganglia and regions in parietal and frontotemporal lobes. Infants with normal Bayley III cognitive scores exhibited increased rsFC between the basal ganglia and association cortices in parietal and occipital lobes compared with cognitively impaired children. Infants with normal motor scores exhibited increased rsFC between the basal ganglia and visual cortices, compared with children with motor impairment. Thus, the presence of abnormal general movements is associated with region-specific differences in rsFC at term. The association of abnormal long-term neurodevelopmental outcomes with decreased rsFC between basal ganglia and sub-score specific cortical regions may provide biomarkers of neurodevelopmental trajectory and outcome.

258. Irshad MT, Nisar MA, Gouverneur P, Rapp M, Grzegorzek M.
AI approaches towards Prechtl's assessment of general movements: A systematic literature review.
Sensors (Basel) 2020; Sep 17;20(18):5321. doi: 10.3390/s20185321.

General movements (GMs) are spontaneous movements of infants up to five months post-term involving the whole body varying in sequence, speed, and amplitude. The assessment of GMs has shown its importance for identifying infants at risk for neuromotor deficits, especially for the detection of cerebral palsy. As the assessment is based on videos of the infant that are rated by trained professionals, the method is time-consuming and expensive. Therefore, approaches based on Artificial Intelligence have gained significantly increased attention in the last years. In this article, we systematically analyze and discuss the main design features of all existing technological approaches seeking to transfer the Prechtl's assessment of general movements from an individual visual perception to computer-based analysis. After identifying their shared shortcomings, we explain the methodological reasons for their limited practical performance and classification rates. As a conclusion of our literature study, we conceptually propose a methodological solution to the defined problem based on the groundbreaking innovation in the area of Deep Learning.

257. Sandle M, Sheppard A, Fletcher AA, Berry M, De Vries N.
Early identification of infants at risk of cerebral palsy: developing the use of general movement assessment in routine clinical practice in a tertiary neonatal unit in New Zealand.
N Z Med J 2020; 133(1514): 63-70.

BACKROUND: Preterm infants have a high risk of neurodevelopmental disability, including cerebral palsy (CP). Often, CP is not diagnosed until after 12 months, leading to delay in targeted interventions. The General Movements assessment (GM) evaluates the spontaneous movements of high-risk infants from birth to 20 weeks corrected postnatal age (CPA), and accurately predicts the risk of CP. This allows for earlier diagnosis and intervention, potentially changing the trajectory of disability, yet routine use of GM is not well established in New Zealand. AIM: To describe the process of setting up GM in a tertiary neonatal unit. METHODS: We reviewed the process and progress made to date setting up GM in our service. RESULTS: Challenges and potential solutions for the implementation of GM were identified. Key areas of development included staff training and support, IT services, resources, medical documentation, inter-departmental communication and establishing clinical pathways. CONCLUSION: GM has become successfully integrated into the assessment of high-risk infants in our neonatal unit, with the aim to provide valuable information to health professionals and families to optimise intervention and improve outcomes. Efforts will continue to ensure there is robust and sustainable system for using GM in our service.

256. Wang Y, Zhu P, Yang Z, Gu G.
Establishing an early identification score system for cerebral palsy based on detailed assessment of general movements.
J Int Med Res 2020; Apr;48(4):300060520902579. doi: 10.1177/0300060520902579.

OBJECTIVE: This retrospective study aimed to establish an early identification score system of cerebral palsy (CP) in the writhing movement period of high-risk infants by detailed assessment of general movements (GMs). METHODS: High-risk infants from our hospital during January 2016 to January 2017 were included. GMs were assessed and a detailed score was calculated. The 52-neuromotor examination for 0- to 1-year-olds was performed and follow-up outcome was determined at the 12th month according to CP diagnostic criteria. An early identification score of detailed assessment was established in the writhing movement period of infants. RESULTS: The detailed score during the writhing movement period was significantly different among the normal, poor repertoire, and cramped-synchronized groups of GMs (F = 208.186). Detailed scores were positively related to 52-neuromotor examination scores, with a correlation coefficient of 0.218. The predictive validity of the early identification score was 92.11%, sensitivity was 100%, specificity was 90.00%, the positive predictive value was 72.73%, the negative predictive value was 100%, the false positive rate was 10, and the false negative rate was 0. CONCLUSION: The detailed GM score in the writhing movement period is correlated with 52-neuromotor examination results. The CP early identification score could be useful in clinical practice.

255. Barbosa VM, Smith EV, Bos A, Cioni G, Ferrari F, Guzzetta A, Marschik PB, Pansy J, Urlesberger B, Yang H, Einspieler C.
Psychometric Properties of the General Movement Optimality Score using Rasch Measurement.
J Appl Meas 2020; 21(1): 17-37.

AIM: To explore the psychometric properties of the general movements optimality score (GMOS) by examining its dimensionality, rating scale functioning, and item hierarchies using Rasch measurement. METHODS: Secondary data analysis of the GMOS data for video-recording of 383 infants with uni-, multidimensional, and mixed Rasch partial credit models. Videos were scored based on the global General Movement Assessment categories, and on the amplitude, speed, spatial range, proximal and distal rotations, onset and offset, tremulous and cramped components of the upper and lower extremities (21 items), resulting in the GMOS. RESULTS: The GMOS data fits best to a unidimensional mixed Rasch model with three different classes of infants, with all but two items contributing to the infants' separation. Rating scales functioned well for 19 items. Item difficulty hierarchies varied depending on infants' class. No floor effect and no substantive gaps between item difficulty estimates were found. CONCLUSION: The GMOS has strong psychometric properties to distinguish infants with different functional motor performance and provides a quantitative measure of quality of movement. INTERPRETATION: The GMOS can be confidently used to assist with early diagnosis, grade motor performance, and provide a solid base to study individual general movement developmental trajectories.

254. Yeh KK, Liu WY, Wong AM, Lein R.
Validity of general movement assessment based on clinical and home videos.
Pediatr Phys Ther 2020; 32(1): 35-43. doi: 10.1097/PEP.0000000000000664.

INTRODUCTION: The purposes of this study were to develop an instructional leaflet on home video recording for the General Movement Assessment (GMA) and to examine the concurrent and predictive validity of the GMA completed by physical therapists (PTs) and completed by parents. METHODS: The GMA and the Alberta Infant Motor Scale (AIMS) were completed by PTs in the clinic. Parents completed the GMA following the instructional leaflet. RESULTS: The content validity of the leaflet was 0.83. The consistency of the GMA results between sources was κ = 0.869. The concurrent validity of the GMA at a corrected age of 3 months was κ = 0.266 (PT) versus 0.525 (parent) using the 10th-percentile cutoffs of the AIMS. The positive likelihood ratio was 26 (PT) versus 25 (parents) at a corrected age of 12 months based on 5th-percentile cutoffs of the AIMS. CONCLUSIONS: Home GMA videos are valid for clinical assessment following the instructional leaflet.

253. Tsuji T, Nakashima S, Hayashi H, Soh Z, Furui A, Shibanoki T, Shima K, Shimatani K.
Markerless measurement and evaluation of general movements in infants.
Sci Rep 2020; 10(1): 1422. doi: 10.1038/s41598-020-57580-z.

General movements (GMs), a type of spontaneous movement, have been used for the early diagnosis of infant disorders. In clinical practice, GMs are visually assessed by qualified licensees; however, this presents a difficulty in terms of quantitative evaluation. Various measurement systems for the quantitative evaluation of GMs track target markers attached to infants; however, these markers may disturb infants' spontaneous movements. This paper proposes a markerless movement measurement and evaluation system for GMs in infants. The proposed system calculates 25 indices related to GMs, including the magnitude and rhythm of movements, by video analysis, that is, by calculating background subtractions and frame differences. Movement classification is performed based on the clinical definition of GMs by using an artificial neural network with a stochastic structure. This supports the assessment of GMs and early diagnoses of disabilities in infants. In a series of experiments, the proposed system is applied to movement evaluation and classification in full-term infants and low-birth-weight infants. The experimental results confirm that the average agreement between four GMs classified by the proposed system and those identified by a licensee reaches up to 83.1 ± 1.84%. In addition, the classification accuracy of normal and abnormal movements reaches 90.2 ± 0.94%.

252. Saini L, Madaan P, Naik MRR.
General movements: Longitudinal assessment better than cross-sectional.
Brain Dev 2019; 41(6): 563-564. doi: 10.1016/j.braindev.2019.03.001.

251. Einspieler C, Marschik PB.
Regression in Rett syndrome: Developmental pathways to its onset.
Neurosci Biobehav Rev 2019; 98: 320-332. doi: 10.1016/j.neubiorev.2019.01.028.

Rett syndrome (RTT) is an X-linked genetic disorder that occurs predominantly in females. The clinical picture associated with RTT is defined by core and supportive consensus criteria, with a period of behavioural regression being a conditio sine qua non. This review sheds light on atypical neurofunctions and potential behavioural biomarkers before the onset of regression. The main focus lies on (a) motor development, especially on purposeful hand movements and the occurrence of stereotypies; and (b) speech-language and socio-communicative development. We outline potentially specific atypical behavioural patterns in these domains (e.g., vocalisations on inspiratory airstream) and different developmental traits of regression: (i) non-achievement of certain milestones: 'regression', here, might point to the fact that the lack of respective behavioural patterns appeared more and more worrisome with increasing age; and (ii) developmental milestones were achieved and functions deteriorate or even get lost during regression. To conclude, we are not quite there yet, but seem to be on the right track towards defining new and reliable neurofunctional markers for early detection of RTT.

250. Einspieler C, Utsch F, Brasil P, Panvequio Aizawa CY, Peyton C, Hydee Hasue R, Genovesi FF, Damasceno L, Moreira ME, Adachi K, Marschik PB, Nielsen-Saines K, GM Zika Working Group.
Association of infants exposed to prenatal Zika virus infection with their clinical, neurologic, and developmental status evaluated via the General Movement Assessment tool.
JAMA Netw Open 2019; 2(1): e187235. doi: 10.1001/jamanetworkopen.2018.7235.

Importance: There is an urgent need to assess neurodevelopment in Zika virus (ZIKV)-exposed infants. Objectives: To perform general movement assessment (GMA) at 9 to 20 weeks' postterm age and to evaluate whether the findings are associated with neurodevelopmental outcomes at age 12 months in infants prenatally exposed to acute maternal illness with rash in Brazil during the ZIKV outbreak and in age-matched controls. Design, setting, and participants: In this cohort study, infants prenatally exposed to acute maternal illness with rash were recruited at medical institutions in Rio de Janeiro and Belo Horizonte, Brazil, from February 1, 2016, to April 30, 2017, while infants without any exposure to maternal illness originated from the Graz University Audiovisual Research Database for the Interdisciplinary Analysis of Neurodevelopment. Participants were 444 infants, including 76 infants without congenital microcephaly, 35 infants with microcephaly, and 333 neurotypical children matched for sex, gestational age at birth, and age at GMA. Main outcomes and measures: General movement assessment performed at 9 to 20 weeks' postterm age, with negative predictive value, positive predictive value, sensitivity, and specificity generated, as well as clinical, neurologic, and developmental status (Bayley Scales of Infant and Toddler Development, Third Edition [Bayley-III] scores) at age 12 months. Motor Optimality Scores were generated based on the overall quality of the motor repertoire. Adverse outcomes were defined as a Bayley-III score less than 2 SD in at least 1 domain, a score less than 1 SD in at least 2 domains, and/or atypical neurologic findings. Results: A total of 444 infants were enrolled, including 111 children prenatally exposed to a maternal illness with rash and 333 children without any prenatal exposure to maternal illness (57.7% male and mean [SD] age, 14 [2] weeks for both groups); 82.1% (46 of 56) of ZIKV-exposed infants without congenital microcephaly were healthy at age 12 months. Forty-four of 46 infants were correctly identified by GMA at 3 months, with a negative predictive value of 94% (95% CI, 85%-97%). Seven of 10 ZIKV-exposed children without microcephaly with adverse neurodevelopmental outcomes were identified by GMA. The GMA positive predictive value was 78% (95% CI, 46%-94%), sensitivity was 70% (95% CI, 35%-93%), specificity was 96% (95% CI, 85%-99%), and accuracy was 91% (95% CI, 80%-97%). Children with microcephaly had bilateral spastic cerebral palsy; none had normal movements. The Motor Optimality Score differentiated outcomes: the median Motor Optimality Score was 23 (interquartile range [IQR], 21-26) in children with normal development, 12 (IQR, 8-19) in children with adverse outcomes, and 5 (IQR, 5-6) in children with microcephaly, a significant difference (P = .001). Conclusions and relevance: This study suggests that although a large proportion of ZIKV-exposed infants without microcephaly develop normally, many do not. The GMA should be incorporated into routine infant assessments to enable early entry into targeted treatment programs.

249. Støen R, Boswell L, de Regnier R-A, Fjørtoft T, Deborah Gaebler-Spira D, Ihlen E, Labori C, Loennecken M, Msall M, Möinichen UI, Peyton C, Russow A, Schreiber MD, Silberg IE, Songstad NT, Vågen R, Øberg GK, Adde L.
The predictive accuracy of the general movement assessment for cerebral palsy: A prospective, observational study of high-risk infants in a clinical follow-up setting.
J Clin Med 2019 Oct 25;8(11):1790. doi: 10.3390/jcm8111790.

Background: Early prediction of cerebral palsy (CP) using the General Movement Assessment (GMA) during the fidgety movements (FM) period has been recommended as standard of care in high-risk infants. The aim of this study was to determine the accuracy of GMA, alone or in combination with neonatal imaging, in predicting cerebral palsy (CP). Methods: Infants with increased risk of perinatal brain injury were prospectively enrolled from 2009-2014 in this multi-center, observational study. FM were classified by two certified GMA observers blinded to the clinical history. Abnormal GMA was defined as absent or sporadic FM. CP-status was determined by clinicians unaware of GMA results. Results: Of 450 infants enrolled, 405 had scorable video and follow-up data until at least 18-24 months. CP was confirmed in 42 (10.4%) children at mean age 3 years 1 month. Sensitivity, specificity, positive and negative predictive values, and accuracy of absent/sporadic FM for CP were 76.2, 82.4, 33.3, 96.8, and 81.7%, respectively. Only three (8.1%) of 37 infants with sporadic FM developed CP. The highest accuracy (95.3%) was achieved by a combination of absent FM and abnormal neonatal imaging. Conclusion: In infants with a broad range of neonatal risk factors, accuracy of early CP prediction was lower for GMA than previously reported but increased when combined with neonatal imaging. Sporadic FM did not predict CP in this study.

248. Nemanich ST, Chen C-Y, Chen M, Zorn E, Mueller B, Peyton C, Elison JT, Stinear J, Rao R, Georgieff M, Menk J, Rudser K, Gillick B.
Safety and feasibility of transcranial magnetic stimulation as an exploratory assessment of corticospinal connectivity in infants after perinatal brain injury: An observational study.
Phys Ther 2019; 99(6): 689-700. doi: 10.1093/ptj/pzz028.

Background: Perinatal brain injuries often impact the corticospinal system, leading to motor impairment and cerebral palsy. Although transcranial magnetic stimulation (TMS) has been widely used to study corticospinal connectivity in adults and older children, similar studies of young infants are limited. Objectives: The objective was to establish the safety and feasibility of advanced TMS assessments of the corticospinal connectivity of young infants with perinatal brain injury. Design: This was a pilot, cross-sectional study of 3- to 12-month-old (corrected age) infants with perinatal stroke or intracranial hemorrhage. Methods: Six participants (2 term, 4 preterm) were assessed with stereotactic neuronavigation-guided TMS. Single-pulse TMS was applied to each hemisphere and responses were recorded simultaneously from both upper limbs. During data collection, vital signs and stress responses were measured to assess safety. Developmental motor outcomes were evaluated using the General Movements Assessment and Bayley Scales of Infant and Toddler Development (3rd edition). A clinical diagnosis of cerebral palsy was recorded, if available. Results: No adverse events occurred during TMS testing. All sessions were well tolerated. Contralateral motor evoked responses were detected in 4 of 6 participants. Both contralateral and ipsilateral responses were observed in 2 of 6 participants. Limitations: TMS responses were not obtained in all participants. This could be related to the location of brain injury or developmental stage of the corticospinal system controlling the wrist flexor muscle group from which responses were recorded. Conclusions: This study provides a summary of the framework for performing novel TMS assessments in infants with perinatal brain injury. Implementing this approach to measure corticospinal connectivity in hypothesis-driven studies in young infants appears to be justified. Such studies could inform the characterization of corticospinal development and the neural mechanisms driving recovery following early interventions.

247. Ferrari F, Plessi C, Lucaccioni L, Bertoncelli N, Bedetti L, Ori L, Berardi A, Della Casa E, Lughetti L, D'Amico R.
Motor and postural patterns concomitant with general movements are associated with cerebral palsy at term and fidgety age in preterm infants.
J Clin Med 2019 Aug 8;8(8):1189. doi: 10.3390/jcm8081189.

General movements (GMs) in combination with neurological examination and magnetic resonance imaging at term age can accurately determine the risk of cerebral palsy. The present study aimed to assess whether 11 motor and postural patterns concomitant with GMs were associated with cerebral palsy. Video recordings performed after birth in 79 preterm infants were reviewed retrospectively. Thirty-seven infants developed cerebral palsy at 2 years corrected age and the remaining 42 showed typical development. GMs were assessed from preterm to fidgety age and GM trajectories were defined. The 11 motor and postural patterns were evaluated at each age and longitudinally, alone and in combination with GM trajectories. A logistic regression model was used to assess the association between GMs, concomitant motor and postural patterns, and cerebral palsy. We confirmed that high-risk GM trajectories were associated with cerebral palsy (odds ratio = 44.40, 95% confidence interval = 11.74-167.85). An association between concomitant motor and postural patterns and cerebral palsy was found for some of the patterns at term age and for all of them at fidgety age. Therefore, at term age, concomitant motor and postural patterns can support GMs for the early diagnosis of cerebral palsy.

246. Maeda T, Iwata H, Sekiguchi K, Takahashi M, Ihara K.
The association between brain morphological development and the quality of general movements.
Brain Dev 2019; 41(6): 490-500. doi: 10.1016/j.braindev.2019.01.007.

Aim: To clarify the morphologic characteristics of the brain, which are the foundation of the emergence of general movements (GMs) in very-low-birth-weight infants. Study design: Prospective cohort study. GMs were scored according to a semiquantitative scoring system: the GMs optimality score (GMOS) at preterm and term ages. Brain magnetic resonance imaging (MRI) at term-equivalent age was scored using a validated scoring system (MRI score). We examined the relationship between the two scores by multiple regression analysis with relevant clinical background. Subjects: We included 50 very-low-birth-weight infants cared for at Oita University Hospital from August 2012 to August 2018 who underwent MRI and GMs assessment. Their median gestational age and birth weight were 29w2d and 1145 g, respectively. Results: The MRI score and systemic steroid administration were related to preterm GMOS, and the MRI score was related to term GMOS. The component cerebellum score and cortical grey matter score of the MRI score were associated with preterm GMOS, and the cerebellum and the cerebral white matter scores were associated with term GMOS. Conclusion: The quality of GMs was associated with brain morphological development. The co-evaluation of GMs and brain morphology leads to accurate developmental prediction.

245. Campbell MJ, Ziviani JM, Stocker CF, Khan A, Sakzewski L.
Neuromotor performance in infants before and after early open-heart surgery and risk factors for delayed development at 6 months of age.
Cardiol Young 2019; 29(2): 100-109. doi: 10.1017/S1047951118001622.

Background: Early identification of infants with CHD at heightened risk of developmental delays can inform surveillance priorities. This study investigated pre-operative and post-operative neuromotor performance in infants undergoing open-heart surgery, and their developmental status at 6 months of age, to identify risk factors and inform care pathways. Methods: Infants undergoing open-heart surgery before 4 months of age were recruited into a prospective cohort study. Neuromotor performance was assessed pre-operatively and post-operatively using the Test of Infant Motor Performance and Prechtl's Assessment of General Movements. Development was assessed at 6 months of age using the Ages and Stages Questionnaire third edition. Pre-operative and post-operative General Movements performance was compared using McNemar's test and test of infant motor performance z-scores using Wilcoxon's signed rank test. Risk factors for delayed development at 6 months were explored using logistic regression.

Results: Sixty infants were included in this study. In the 23 (38%) infants. A total of 60 infants were recruited. In the 23 (38%) infants assessed pre-operatively, there was no significant difference between pre- and post-operative performance on the GMs (p=0.63) or TIMP (p=0.28). At discharge, 15 (26%) infants presented with abnormal GMs, and the median TIMP z-score was -0.93 (IQR: -1.4 to -0.69). At 6 months, 28 (52.8%) infants presented with gross motor delay on the ASQ-3, significantly negatively associated with gestational age (p=0.03), length of hospital stay (p=0.04) and discharge TIMP score (p=0.01). Conclusions: Post-operative assessment using the GMs and TIMP may be useful to identify infants requiring individualised care and targeted developmental follow-up. Long-term developmental surveillance beyond 6 months of age is recommended.

244. Morgan C, Romeo DM, Chorna O, Novak I, Galea C, Del Secco S, Guzzetta A.
The pooled diagnostic accuracy of neuroimaging, general movements, and neurological examination for diagnosing cerebral palsy early in high-risk infants: A case control study.
J Clin Med 2019; 8(11): 1879. doi: 10.3390/jcm8111879.

Introduction: Clinical guidelines recommend using neuroimaging, Prechtls' General Movements Assessment (GMA), and Hammersmith Infant Neurological Examination (HINE) to diagnose cerebral palsy (CP) in infancy. Previous studies provided excellent sensitivity and specificity for each test in isolation, but no study has examined the pooled predictive power for early diagnosis. Methods: We performed a retrospective case-control study of 441 high-risk infants born between 2003 and 2014, from three Italian hospitals. Infants with either a normal outcome, mild disability, or CP at two years, were matched for birth year, gender, and gestational age. Three-month HINE, GMA, and neuroimaging were retrieved from medical records. Logistic regression was conducted with log-likelihood and used to determine the model fit and Area Under the Curve (AUC) for accuracy. Results: Sensitivity and specificity for detecting CP were 88% and 62% for three-month HINE, 95% and 97% for absent fidgety GMs, and 79% and 99% for neuroimaging. The combined predictive power of all three assessments gave sensitivity and specificity values of 97.86% and 99.22% (PPV 98.56%, NPV 98.84%). Conclusion: CP can be accurately detected in high-risk infants when these test findings triangulate. Clinical implementation of these tools is likely to reduce the average age when CP is diagnosed, and intervention is started.

243. Einspieler C, Bos AF, Krieber-Tomantschger M, Alvarado E, Barbosa VM, Bertoncelli N, Burger M, Chorna O, Del Secco S, DeRegnier R-A, Hüning B, Ko J, Lucaccioni L, Maeda T, Marchi V, Martin E, Morgan C, Mutlu A, Nogolová A, Pansy J, Peyton C, J, Pokorny FB, Prinsloo LR, Ricci E, Saini L, Scheuchenegger A, Silva CRD, Soloveichick M, Spittle AJ, Toldo M, Utsch F, van Zyl J, Viñals C, Wang J, Yang H, Yardιmcι-Lokmanoglu BN, Cioni G, Ferrari F, Guzzetta A, Marschik PB.
Cerebral palsy: Early markers of clinical phenotype and functional outcome.
J Clin Med 2019; 8(10): 1616. doi: 10.3390/jcm8101616.

The Prechtl General Movement Assessment (GMA) has become a cornerstone assessment in early identification of cerebral palsy (CP), particularly during the fidgety movement period at 3-5 months of age. Additionally, assessment of motor repertoire, such as antigravity movements and postural patterns, which form the Motor Optimality Score (MOS), may provide insight into an infant's later motor function. This study aimed to identify early specific markers for ambulation, gross motor function (using the Gross Motor Function Classification System, GMFCS), topography (unilateral, bilateral), and type (spastic, dyskinetic, ataxic, and hypotonic) of CP in a large worldwide cohort of 468 infants. We found that 95% of children with CP did not have fidgety movements, with 100% having non-optimal MOS. GMFCS level was strongly correlated to MOS. An MOS > 14 was most likely associated with GMFCS outcomes I or II, whereas GMFCS outcomes IV or V were hardly ever associated with an MOS > 8. A number of different movement patterns were associated with more severe functional impairment (GMFCS III-V), including atypical arching and persistent cramped-synchronized movements. Asymmetrical segmental movements were strongly associated with unilateral CP. Circular arm movements were associated with dyskinetic CP. This study demonstrated that use of the MOS contributes to understanding later CP prognosis, including early markers for type and severity.

242. Marchi V, Hakala A, Knight A, D'Acunto F, Scattoni ML, Guzzetta A, Vanhatalo S.
Automated pose estimation captures key aspects of General Movements at eight to 17 weeks from conventional videos.
Acta Paediatr 2019; 108(10): 1817-1824. doi: 10.1111/apa.14781.

Aim: General movement assessment requires substantial expertise for accurate visual interpretation. Our aim was to evaluate an automated pose estimation method, using conventional video records, to see if it could capture infant movements using objective biomarkers. Methods: We selected archived videos from 21 infants aged eight to 17 weeks who had taken part in studies at the IRCCS Fondazione Stella Maris (Italy), from 2011 to 2017. Of these, 14 presented with typical low-risk movements, while seven presented with atypical movements and were later diagnosed with cerebral palsy. Skeleton videos were produced using a computational pose estimation model adapted for infants and these were blindly assessed to see whether they contained the information needed for classification by human experts. Movements of skeletal key points were analysed using kinematic metrics to provide a biomarker to distinguish between groups. Results: The visual assessments of the skeleton videos were very accurate, with Cohen's K of 0.90 when compared with the classification of conventional videos. Quantitative analysis showed that arm movements were more variable in infants with typical movements. Conclusion: It was possible to extract automated estimation of movement patterns from conventional video records and convert them to skeleton footage. This could allow quantitative analysis of existing footage.

241. Ihlen EAF, Støen R, Boswell L, Regnier RA, Fjørtoft T, Gaebler-Spira D, Labori C, Loennecken MC, Msall ME, Möinichen UI, Peyton C, Schreiber MD, Silberg IE, Songstad NT, Vågen RT, Øberg GK, Adde L.
Machine learning of infant spontaneous movements for the early prediction of cerebral palsy: A multi-site cohort study.
J Clin Med 2019; 9(1): 5. doi: 10.3390/jcm9010005.

BACKROUND: Early identification of cerebral palsy (CP) during infancy will provide opportunities for early therapies and treatments. The aim of the present study was to present a novel machine-learning model, the Computer-based Infant Movement Assessment (CIMA) model, for clinically feasible early CP prediction based on infant video recordings. METHODS: The CIMA model was designed to assess the proportion (%) of CP risk-related movements using a time-frequency decomposition of the movement trajectories of the infant's body parts. The CIMA model was developed and tested on video recordings from a cohort of 377 high-risk infants at 9-15 weeks corrected age to predict CP status and motor function (ambulatory vs. non-ambulatory) at mean 3.7 years age. The performance of the model was compared with results of the general movement assessment (GMA) and neonatal imaging. RESULTS: The CIMA model had sensitivity (92.7%) and specificity (81.6%), which was comparable to observational GMA or neonatal cerebral imaging for the prediction of CP. Infants later found to have non-ambulatory CP had significantly more CP risk-related movements (median: 92.8%, p = 0.02) compared with those with ambulatory CP (median: 72.7%). CONCLUSION: The CIMA model may be a clinically feasible alternative to observational GMA.

240. Kwong AKL, Olsen JE, Eeles AL, Einspieler C, Lee KJ, Doyle LW, Cheong JLY, Spittle AJ.
Occurrence of and temporal trends in fidgety general movements in infants born extremely preterm/extremely low birthweight and term-born controls.
Early Hum Dev 2019; 135: 11-15.doi: 10.1016/j.earlhumdev.2019.05.018.

BACKROUND: Fidgety general movements have high predictive validity for later cerebral palsy (CP) but their temporal organisation requires further understanding for assessment accuracy. AIMS: To describe the occurrence of and temporal trends in fidgety movements, and whether they differ between infants born preterm and at term. SUBJECTS: We assessed 155 EP/ELBW infants and 185 term-born infants born extremely preterm (EP; <28 weeks' gestation) and/or extremely low birthweight (ELBW; <1000 g birthweight) or at term (37-42 weeks' gestation) in the state of Victoria, Australia. OUTCOME MEASURES: Parents of infants submitted up to two videos at 12-13⁺⁶ and/or 14-16⁺⁶weeks' corrected age of infants' general movements. Videos were scored using the Prechtl General Movements Assessment (GMA) (fidgety) and classified as normal or absent/abnormal. Infants with at least one normal GMA were classified as normal. Individual GMA trajectories were analysed over time using logistic regression. RESULTS: Overall, infants born EP/ELBW were more likely to have absent/abnormal fidgety movements than term-born infants (23% versus 3%, odds ratio [OR] 8.50 (95% confidence interval (CI) 3.48-20.8, p < 0.001). Fewer EP/ELBW and term-born infants showed absent/abnormal fidgety movements with each week of increasing age (EP/ELBW OR 0.46, 95% CI 0.25-0.84, p = 0.01; term-born OR 0.35, 95% CI 0.16-0.8, p = 0.01; interaction, p = 0.53). CONCLUSION: Absent/abnormal fidgety movements are more prevalent in infants born EP/ELBW than at term. Fidgety movements normalise with older age in both infants born EP/ELBW and at term between 12 and 16⁺⁶ weeks' corrected age.

239. Kelly CE, Thompson DK, Cheong JL, Chen J, Olsen JE, Eeles AL, Walsh JM, Seal ML, Anderson PJ, Doyle LW, Spittle AJ.
Brain structure and neurological and behavioural functioning in infants born preterm.
Dev Med Child Neurol 2019; 61(7): 820-831. doi: 10.1111/dmcn.14084.

AIM: To examine: (1) relationships between brain structure, and concurrently assessed neurological and behavioural functioning, in infants born preterm at term-equivalent age (TEA; approximately 38-44wks); and (2) whether brain structure-function relationships differ between infants born very (24-29wks) and moderate-late (32-36wks) preterm. METHOD: A total of 257 infants (91 very preterm, 166 moderate-late preterm; 120 males, 137 females) had structural magnetic resonance imaging (MRI) and neurological and behavioural assessments (Prechtl's general movements assessment, Neonatal Intensive Care Unit Network Neurobehavioral Scale [NNNS] and Hammersmith Neonatal Neurological Examination [HNNE]). Two hundred and sixty-three infants (90 very preterm, 173 moderate-late preterm; 131 males, 132 females) had diffusion MRI and assessments. Associations were investigated between assessment scores and global brain volumes using linear regressions, regional brain volumes using Voxel-Based Morphometry, and white matter microstructure using Tract-Based Spatial Statistics. RESULTS: Suboptimal scores on some assessments were associated with lower fractional anisotropy and/or higher axial, radial, and mean diffusivities in some tracts: NNNS attention and reflexes, and HNNE total score and tone, were associated with the corpus callosum and optic radiation; NNNS quality of movement with the corona radiata; HNNE abnormal signs with several major tracts. Brain structure-function associations generally did not differ between the very and moderate-late preterm groups. INTERPRETATION: White matter microstructural alterations may be associated with suboptimal neurological and behavioural performance in some domains at TEA in infants born preterm. Brain structure-function relationships are similar for infants born very preterm and moderate-late preterm. WHAT THIS PAPER ADDS: Brain volume is not related to neurological/behavioural function in infants born preterm at term. White matter microstructure is related to some neurological/behavioural domains at term. Brain-behaviour relationships are generally similar for infants born very preterm and moderate-late preterm.

237. Redd CB, Barber LA, Boyd RN, Varnfield M, Karunanithi MK.
Development of a wearable sensor network for quantification of infant general movements for the diagnosis of cerebral palsy.
Annu Int Conf IEEE Eng Med Biol Soc 2019; 2019: 7134-7139. doi: 10.1109/EMBC.2019.8857377.

Qualitative assessments of infant spontaneous movements can be performed to measure neurodevelopmental status and provide early insight into the presence of any abnormalities. Clinical assessments of infant movements at 12 weeks post term age are up to 98% predictive of the eventual development of Cerebral Palsy, but their reach is often limited to infants already identified as high-risk within the traditional healthcare system. We present the development of a network of wearable sensors designed to noninvasively measure spontaneous movements in infants from 12-20 weeks post-term- age both within the clinic and for future home use. Pilot data on a single healthy term infant is presented to demonstrate clinical functionality towards future validation studies in infants at high-risk of Cerebral Palsy. Using this system for tele- delivered assessments in the home could enhance screening of neurodevelopmental disorders for infants and families in rural and remote areas, a population with reduced health services.

236. McCay KD, Ho ESL, Marcroft C, Embleton ND.
Establishing pose based features using histograms for the detection of abnormal infant movements.
Annu Int Conf IEEE Eng Med Biol Soc 2019; 2019: 5469-5472. doi: 10.1109/EMBC.2019.8857680.

The pursuit of early diagnosis of cerebral palsy has been an active research area with some very promising results using tools such as the General Movements Assessment (GMA). In this paper, we conducted a pilot study on extracting important information from video sequences to classify the body movement into two categories, normal and abnormal, and compared the results provided by an independent expert reviewer based on GMA. We present two new pose-based features, Histograms of Joint Orientation 2D (HOJO2D) and Histograms of Joint Displacement 2D (HOJD2D), for the pose-based analysis and classification of infant body movement from video footage. We extract the 2D skeletal joint locations from 2D RGB images using Cao et al.'s method [1]. Using the MINI-RGBD dataset [2], we further segment the body into local regions to extract part specific features. As a result, the pose and the degree of displacement are represented by histograms of normalised data. To demonstrate the effectiveness of the proposed features, we trained several classifiers using combinations of HOJO2D and HOJD2D features and conducted a series of experiments to classify the body movement into categories. The classification algorithms used included k-Nearest Neighbor (kNN, k=1 and k=3), Linear Discriminant Analysis (LDA) and the Ensemble classifier. Encouraging results were attained, with high accuracy (91.67%) obtained using the Ensemble classifier.

235. Zorzenon RFM, Takaara LK, Linhares MBM.
General spontaneous movements in preterm infants differentiated by post-conceptional ages.
Early Hum Dev 2019; 134: 1-6. doi: 10.1016/j.earlhumdev.2019.04.011.

AIM: The aim of the study was to assess general spontaneous motor development in the neonatal phase in groups of neonatal high-risk preterm infants who were differentiated by post-conceptional (PCo) age until term age. METHOD: The sample included 54 preterm infants (<32 weeks of gestational age) with low birthweight and neurological injuries of both sexes. The General Movements Assessment (GMA) was used to evaluate motor development from 30 to 40 weeks of PCo age, using the General Movements Optimality Score (GMOS). Between-group and within-group comparisons were performed. RESULTS: Significant differences in GMOS scores and the upper extremities score, specifically in the neck and trunk, were found between 30 and 33 weeks, 34 and 36 weeks, and 38 and 40 weeks of PCo age. Preterm infants had gradually higher GMOSs from 30 weeks of PCo age to term age (38-40 weeks of PCo age). No significant differences in general movements were found between 30 and 33 and 34 and 36 weeks of PCo age. CONCLUSION: The preterm infants presented poor spontaneous motor movements, assessed by the GMOS, but gradual improvement was observed from 30 weeks of PCo age until term age.

234. Gima H, Shimatani K, Nakano H, Watanabe H, Taga G.
Evaluation of fidgety movements of infants based on Gestalt perception reflects differences in limb movement trajectory curvature.
Phys Ther 2019; 99(6): 701-710. doi: 10.1093/ptj/pzz034.

BACKROUND: Infants aged 2 to 5 months show spontaneous general movements (GMs) of the whole body, which are referred to as fidgety movements (FMs). Although previous studies have shown that evaluation of GMs by the General Movement Assessment (GMA) has predictive value about later neurological impairments, it remains unknown whether raters consistently perceive and rate such complex kinematic information. OBJECTIVE: The purpose of this study was to construct a method to reveal which movement features are associated with each rater's evaluation of FMs based on the GMA. DESIGN: GMA scores of 163 healthy infants aged 11 to 16 weeks postterm were matched with data obtained from a 3-dimensional motion analysis system. METHODS: Three physical therapists performed the GMA and classified GMs into 9 types, from which we focused on 3 subtypes differing in the temporal organization of FMs (continual, intermittent, and sporadic FMs). We also calculated 6 movement indices (average velocity of limb movements, number of movement units, kurtosis of acceleration, jerk index, average curvature, and correlation between limb velocities) for arms and legs for each infant and analyzed which movement indices were associated with the ratings of the 3 FM subtypes by each rater. RESULTS: Only the average curvature differed significantly among the ratings of the 3 FM subtypes for all 3 raters. Each rater showed significant differences in the average curvature in either arms or legs. LIMITATIONS: It is difficult to generalize the present results to raters with various levels of expertise and experience in using the GMA. This issue calls for further research. CONCLUSIONS: The method used revealed commonality and individuality about the perceived movement features that can be associated with the rating of FMs.

233. Pansy J, Barones C, Urlesberger B, Pokorny FB, Bartl-Pokorny KD, Verheyen S, Marschik PB, Einspieler C.
Early motor and pre-linguistic verbal development in Prader-Willi syndrome - A case report.
Res Dev Disabil 2019; 88: 16-21. doi: 10.1016/j.ridd.2019.01.012.

BACKROUND: Prader-Willi syndrome (PWS) is a rare genetic disorder. Infants with PWS show a neurodevelopmental dysfunction which entails a delayed motor and language development, but studies on their spontaneous movements (i.e. general movements) or pre-linguistic speech-language development before 6 months of age are missing so far. AIM: To describe early motor and pre-linguistic verbal development in an infant with PWS. METHODS AND PROCEDURES: Prospective case report; in addition to the assessment of general movements and the concurrent movement repertoire, we report on early verbal forms, applying the Stark Assessment of Early Vocal Development-Revised. OUTCOMES AND RESULTS: General movements were abnormal on days 8 and 15. No fidgety movements were observed at 11 weeks; they only emerged at 17 weeks and lasted until at least 27 weeks post-term. The movement character was monotonous, and early motor milestones were only achieved with a delay. At 27 weeks the infant produced age-adequate types of vocalisations. However, none of the canonical-syllable vocalisations that typically emerge at that age were observed. Early vocalisations appeared monotonous and with a peculiarly harmonic structure. CONCLUSION AND IMPLICATIONS: Early motor and pre-linguistic verbal behaviours were monotonous in an infant with PWS throughout his first 6 months of life. This suggests that early signs of neurodevelopmental dysfunction (i.e. abnormal general movements) might already be diagnosed in infants with PWS during their first weeks of life, potentially enabling us to diagnose and intervene at an early stage.

232. Kwong AK, Eeles AL, Olsen JE, Cheong JL, Doyle LW, Spittle AJ.
The Baby Moves smartphone app for General Movements Assessment: Engagement amongst extremely preterm and term-born infants in a state-wide geographical study.
J Paediatr Child Health 2019; 55(5): 548-554. doi: 10.1111/jpc.14240.

AIM: The Baby Moves smartphone application is designed for parents to video their infants' spontaneous movement for remote General Movements Assessment (GMA). We aimed to assess the engagement with Baby Moves amongst high- and low-risk infants' families and the socio-demographic variables related to engagement. METHODS: Families of extremely preterm (EP; <28 weeks' gestational age) or extremely low-birthweight (ELBW; <1000 g) infants and term-born controls from a state-wide geographical cohort study were asked to download Baby Moves. Baby Moves provided reminders and instructions to capture videos of their infants' general movements. Parents were surveyed about Baby Moves' usability. RESULTS: The parents of 451 infants (226 EP/ELBW; 225 control) were recruited; 416 (204 EP/ELBW; 212 control) downloaded Baby Moves, and 346 (158 EP/ELBW; 188 control) returned at least one scorable video for remote GMA. Fewer EP/ELBW families submitted a scorable video than controls (70 vs. 83%, respectively; odds ratio (OR) 0.48, 95% confidence interval (CI) 0.3-0.79, P = 0.003), but the difference diminished when adjusted for socio-demographic variables (OR 1.09, 95% CI 0.59-2.0, P = 0.79). Families who received government financial support (OR 0.28, 95% CI 0.1-0.78, P = 0.015), who spoke limited English at home (OR 0.39, 95% CI 0.22-0.69, P = 0.001) or with lower maternal education (OR 0.38, 95% CI 0.21-0.68, P = 0.001) were less likely to return a scorable video. Surveyed parents responded mostly positively to Baby Moves' usability. CONCLUSIONS: Most parents in this study successfully used Baby Moves to capture infant movements for remote GMA. Families of lower socio-demographic status used Baby Moves less.

231. Kuiper MJ, Brandsma R, Lunsing RJ, Eggink H, Ter Horst HJ, Bos AF, Sival DA.
The neurological phenotype of developmental motor patterns during early childhood.
Brain Behav 2019; 9(1): e01153. doi: 10.1002/brb3.1153.

INTRODUCTION: During early childhood, typical human motor behavior reveals a gradual transition from automatic motor patterns to acquired motor skills, by the continuous interplay between nature and nurture. During the wiring and shaping of the underlying motor networks, insight into the neurological phenotype of developmental motor patterns is incomplete. In healthy, typically developing children (0-3 years of age), we therefore aimed to investigate the neurological phenotype of developmental motor patterns. METHODS: In 32 healthy, typically developing children (0-3 years), we video-recorded spontaneous motor behavior, general movements (GMs), and standardized motor tasks. We classified the motor patterns by: (a) the traditional neurodevelopmental approach, by Gestalt perception and (b) the classical neurological approach, by the clinical phenotypic determination of movement disorder features. We associated outcomes by Cramer's V. RESULTS: Developmental motor patterns revealed (a) choreatic-like features (≤3 months; associated with fidgety GMs (r = 0.732) and startles (r = 0.687)), (b) myoclonic-like features (≤3 months; associated with fidgety GMs (r = 0.878) and startles (r = 0.808)), (c) dystonic-like features (0-3 years; associated with asymmetrical tonic neck reflex (r = 0.641) and voluntary movements (r = 0.517)), and (d) ataxic-like features (>3 months; associated with voluntary movements (r = 0.928)). CONCLUSIONS: In healthy infants and toddlers (0-3 years), typical developmental motor patterns reveal choreatic-, myoclonic-, dystonic- and ataxic-like features. The transient character of these neurological phenotypes is placed in perspective of the physiological shaping of the underlying motor centers. Neurological phenotypic insight into developmental motor patterns can contribute to adequate discrimination between ontogenetic and initiating pathological movement features and to adequate interpretation of therapeutic interactions.

230. Kepenek-Varol B, Tanr ιverdi M, Ιscan A, Alemdaroglu-Gürbüz Ι.
The acute effects of physiotherapy on general movement patterns in preterm infants: A single-blind study.
Early Hum Dev 2019; 131: 15-20. doi: 10.1016/j.earlhumdev.2019.02.004.

BACKROUND: The General Movement Assessment (GMA) is a video analysis method developed by Heinz Prechtl that examines the infant's spontaneous movements. In recent years, although many studies have been performed in preterm infants by applying GMA, few studies have shown the effects of early intervention on GMA. AIMS: Current study was planned to determine the acute effects of a single-session early physiotherapy approach on preterm infants' general spontaneous movements, and to reveal the change in Motor Optimality Scale (MOS) score including FMs. STUDY DESIGN: Prospective, single-blind study. SUBJECTS: Current study was carried out with 32 preterm infants at postterm 12-16 weeks. OUTCOME MEASURES: The infants included in the study were videotaped by a physiotherapist during 10-15 min before the physiotherapy session at postterm 12-16 weeks for GMA. After a single physiotherapy session, the same physiotherapist performed the same video footage second time. A blind evaluator assessed the videos taken before and after session and scored Motor Optimality Scale (MOS). RESULTS AND CONCLUSIONS: There was no statistically significant difference between MOS sub-category and total score of the infants before and after the session (p > 0.05). According to the results of present study, a single-session early physiotherapy intervention did not have an acute effect on the spontaneous movements of preterm infants at postterm 12-16 weeks. Future studies are needed to demonstrate the short and long-term effects of early physiotherapy approaches to risky infants.

229. Marschik PB, Einspieler C.
Of pioneers and advancements related to general movement assessment.
Eur J Paediatr Neurol 2018; 22(4): 584-585. doi: 10.1016/j.ejpn.2018.05.013.

228. Hempenius MA, Verhagen EA, Tanis JC, Einspieler C, Bos AF.
Early neonatal morbidities and neurological functioning of preterm infants 2 weeks after birth.
J Perinatol 2018; 38(11):1518-1525. doi: 10.1038/s41372-018-0211-y.

Objective: To determine the association between potential neonatal risk factors and the quality of general movements (GMs) in preterm infants. Study design: Prospective cohort study in 67 preterm infants. From video recordings made on Days 8 and 15, we scored the GMs as normal/abnormal and detailed aspects using the general movement optimality score (GMOS). Risk factors included respiratory insufficiency requiring mechanical ventilation, patent ductus arteriosus (PDA), and abnormal blood glucose levels. We used multiple regression analyses. Result: On Day 8 after birth, the presence of a PDA remained in the multivariable model, explaining 17.1% of the variance in GMOS (beta, -0.414). On Day 15, duration of mechanical ventilation and frequency of hypoglycemic episodes explained 38.8% of the variance (betas, -0.382 and -0.466, respectively). Conclusion: In preterm infants, PDA, duration of mechanical ventilation, and frequency of hypoglycemic episodes were associated with poorer neurological functioning during the first 2 weeks after birth.

227. Sharp M, Coenen A, Amery N.
General movement assessment and motor optimality score in extremely preterm infants.
Early Hum Dev 2018; 124: 38-41. doi: 10.1016/j.earlhumdev.2018.08.006.

Studies on general movement assessments (GMs) have included small numbers of extremely preterm (EP) infants. We determined the GMs and motor optimality score (MOS) of 40 EP infants. Poor repertoire at writhing age normalising to fidgety movements was the most common finding. MOS was lower than for published term infants.

226. van Dyk J, Church P, Dell S, To T, Luther M, Shah V.
Prediction of long-term neurodevelopmental outcome in preterm infants using trajectories of general movement assessments.
J Perinatol 2018; 38(10):1398-1406. doi: 10.1038/s41372-018-0173-0.

Objective: To assess the predictive value of trajectories and individual assessment of quality of general movements (AQGM) for identification of neurodevelopmental impairment (NDI) at 18-24 months corrected age (CA) in infants <30 weeks gestational age and/or birth weight <1500 g. Methods: In this retrospective cohort study, AQGM at 6 weeks and 3 months CA were scored and categorized as normal (N) or abnormal (A). AQGM measures were compared with degree of NDI and Bayley Scales of Infant Development, Third Edition (BSID-III) composite motor and cognitive scores. 'Persistently abnormal' AQGM included both mildly abnormal (MA) and definitely abnormal (DA) assessments. A "modified AQGM" where MA assessments were considered normal variant/transient injury was used to conduct post-hoc analysis. Results: Across 244 cases, persistently abnormal AQGM trajectory predicted the level of NDI (OR 2.5, 95% CI 1.2, 5.1) compared to AQGM trajectory that normalized. However, using the "modified AQGM", persistently DA trajectories were associated with significantly lower BSID-III composite motor and cognitive scores (p < 0.001 and p = 0.039, respectively). Conclusion: Categorizing MA assessments as transient injury increased the predictive value of AQGM trajectories and significantly predicted lower cognitive and motor scores at 18-24 months CA.

225. Orlandi S, Raghuram K, Smith CR, Mansueto D, Church P, Shah V, Luther M, Chau T.
Detection of atypical and typical Infant Movements using Computer-based Video Analysis.
Annu Int Conf IEEE Eng Med Biol Soc 2018; 2018: 3598-3601. doi: 10.1109/EMBC.2018.8513078.

The diagnosis of cerebral palsy (CP) is difficult before 2 years of age. The general movements assessment (GMA) is a method for predicting CP from the spontaneous movements of infants in the first months of life. This assessment has shown high accuracy in predicting CP, but its use is limited by a lack of trained clinicians and its subjective nature. An objective and cost-effective alternative is the automatic videobased assessment of infant movements. Retrospective videos with clinical GMA outcomes were evaluated against eligibility criteria for the automatic analysis consisting of a skin model for segmentation and large displacement optical flow (LDOF) for motion tracking. Kinematic features were extracted to classify the movements as typical or atypical using different classification algorithms. Preliminary classification results obtained from the analysis of 127 videos of preterm infants showed up to 92% of accuracy in predicting CP. A computerbased assessment would provide clinicians with an objective tool for early diagnosis of CP, to facilitate early intervention and improve functional outcomes.

224. Benfer KA, Novak I, Morgan C, Whittingham K, Khan NZ, Ware RS, Bell KL, Bandaranayake S, Salt A, Ghosh AK, Bhattacharya A, Samanta S, Moula G, Bose D, Tripathi S, Boyd RN.
Community-based parent-delivered early detection and intervention programme for infants at high risk of cerebral palsy in a low-resource country (Learning through Everyday Activities with Parents (LEAP-CP): protocol for a randomised controlled trial.
BMJ Open 2018; 8(6): e021186. doi: 10.1136/bmjopen-2017-021186.

Introduction: Cerebral palsy (CP) is the most common childhood physical disability, with 80% estimated to be in low-middle-income countries. This study aims to (1) determine the accuracy of General Movements (GMs)/Hammersmith Infant Neurological Examination (HINE) for detecting CP at 18 months corrected age (CA); (2) determine the effectiveness of a community-based parent-delivered early intervention for infants at high risk of CP in West Bengal, India (Learning through Everyday Activities with Parents for infants with CP; LEAP-CP). Methods: This study comprises two substudies: (1) a study of the predictive validity of the GMs and HINE for detecting CP; (2) randomised, double-blinded controlled trial of a novel intervention delivered through peer trainers (Community Disability Workers, CDW) compared with health advice (15 fortnightly visits). 142 infants at high risk of CP ('absent fidgety' GMs; 'high risk score' on HINE) aged 12-40 weeks CA will be recruited to the intervention substudy, with infants randomised based on a computer-generated sequence. Researchers will be masked to group allocation, and caregivers and CDWs naïve to intervention status. Visits will include therapeutic modules (goal-directed active motor/cognitive strategies and LEAP-CP games) and parent education. Health advice is based on the Integrated Management of Childhood Illness, WHO. Infants will be evaluated at baseline, post intervention and 18 months CA. The primary hypothesis is that infants receiving LEAP-CP will have greater scaled scores on the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (mobility domain) at 18 months compared with health advice. Secondary outcomes include infant functional motor, cognitive, visual and communication development; infant growth; maternal mental health.

223. Shepherd E, Salam RA, Middleton P, Han S, Makrides M, McIntyre S, Badawi N, Crowther CA.
Neonatal interventions for preventing cerebral palsy: an overview of Cochrane Systematic Reviews
Cochrane Database Syst Rev 2018; 6: CD012409. doi: 10.1002/14651858.CD012409.pub2.

Background: Cerebral palsy is an umbrella term that encompasses disorders of movement and posture attributed to non-progressive disturbances occurring in the developing foetal or infant brain. As there are diverse risk factors and aetiologies, no one strategy will prevent cerebral palsy. Therefore, there is a need to systematically consider all potentially relevant interventions for prevention. Objectives: Primary: To summarise the evidence from Cochrane Systematic Reviews regarding effects of neonatal interventions for preventing cerebral palsy (reducing cerebral palsy risk). Secondary: To summarise the evidence from Cochrane Systematic Reviews regarding effects of neonatal interventions that may increase cerebral palsy risk. Methods: We searched the Cochrane Database of Systematic Reviews (27 November 2016) for reviews of neonatal interventions reporting on cerebral palsy. Two review authors assessed reviews for inclusion, extracted data, and assessed review quality (using AMSTAR and ROBIS) and quality of the evidence (using the GRADE approach). Reviews were organised by topic; findings were summarised in text and were tabulated. Interventions were categorised as effective (high-quality evidence of effectiveness); possibly effective (moderate-quality evidence of effectiveness); ineffective (high-quality evidence of harm); probably ineffective (moderate-quality evidence of harm or lack of effectiveness); and no conclusions possible (low- to very low-quality evidence). Main results: Forty-three Cochrane Reviews were included. A further 102 reviews pre-specified the outcome cerebral palsy, but none of the included randomised controlled trials (RCTs) reported this outcome. Included reviews were generally of high quality and had low risk of bias, as determined by AMSTAR and ROBIS. These reviews involved 454 RCTs; data for cerebral palsy were available from 96 (21%) RCTs involving 15,885 children. Review authors considered interventions for neonates with perinatal asphyxia or with evidence of neonatal encephalopathy (3); interventions for neonates born preterm and/or at low or very low birthweight (33); and interventions for other specific groups of 'at risk' neonates (7). Quality of evidence (GRADE) ranged from very low to high. Interventions for neonates with perinatal asphyxia or with evidence of neonatal encephalopathy. Effective interventions: high-quality evidence of effectiveness. Researchers found a reduction in cerebral palsy following therapeutic hypothermia versus standard care for newborns with hypoxic ischaemic encephalopathy (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.54 to 0.82; seven trials; 881 children).No conclusions possible: very low-quality evidence. One review observed no clear differences in cerebral palsy following therapeutic hypothermia versus standard care. Interventions for neonates born preterm and/or at low or very low birthweight. Possibly effective interventions: moderate-quality evidence of effectiveness. Researchers found a reduction in cerebral palsy with prophylactic methylxanthines (caffeine) versus placebo for endotracheal extubation in preterm infants (RR 0.54, 95% CI 0.32 to 0.92; one trial; 644 children). Probably ineffective interventions: moderate-quality evidence of harm. Researchers reported an increase in cerebral palsy (RR 1.45, 95% CI 1.06 to 1.98; 12 trials; 1452 children) and cerebral palsy in assessed survivors (RR 1.50, 95% CI 1.13 to 2.00; 12 trials; 959 children) following early (at less than eight days of age) postnatal corticosteroids versus placebo or no treatment for preventing chronic lung disease in preterm infants. Probably ineffective interventions: moderate-quality evidence of lack of effectiveness. Trial results showed no clear differences in cerebral palsy following ethamsylate versus placebo for prevention of morbidity and mortality in preterm or very low birthweight infants (RR 1.13, 95% CI 0.64 to 2.00; three trials, 532 children); volume expansion versus no treatment (RR 0.76, 95% CI 0.48 to 1.20; one trial; 604 children); gelatin versus fresh frozen plasma (RR 0.94, 95% CI 0.52 to 1.69; one trial, 399 children) for prevention of morbidity and mortality in very preterm infants; prophylactic indomethacin versus placebo for preventing mortality and morbidity in preterm infants (RR 1.04, 95% CI 0.77 to 1.40; four trials; 1372 children); synthetic surfactant versus placebo for respiratory distress syndrome in preterm infants (RR 0.76, 95% CI 0.55 to 1.05; five trials; 1557 children); or prophylactic phototherapy versus standard care (starting phototherapy when serum bilirubin reached a pre-specified level) for preventing jaundice in preterm or low birthweight infants (RR 0.96, 95% CI 0.50 to 1.85; two trials; 756 children).No conclusions possible: low- to very low-quality evidence. No clear differences in cerebral palsy were observed with interventions assessed in 21 reviews. Interventions for other specific groups of 'at risk' neonates. No conclusions possible: low- to very low-quality evidence. Review authors observed no clear differences in cerebral palsy with interventions assessed in five reviews. Authors' conclusions: This overview summarises evidence from Cochrane Systematic Reviews regarding effects of neonatal interventions on cerebral palsy, and can be used by researchers, funding bodies, policy makers, clinicians, and consumers to aid decision-making and evidence translation. To formally assess other benefits and/or harms of included interventions, including impact on risk factors for cerebral palsy, review of the included Reviews is recommended. Therapeutic hypothermia versus standard care for newborns with hypoxic ischaemic encephalopathy can prevent cerebral palsy, and prophylactic methylxanthines (caffeine) versus placebo for endotracheal extubation in preterm infants may reduce cerebral palsy risk. Early (at less than eight days of age) postnatal corticosteroids versus placebo or no treatment for preventing chronic lung disease in preterm infants may increase cerebral palsy risk. Cerebral palsy is rarely identified at birth, has diverse risk factors and aetiologies, and is diagnosed in approximately one in 500 children. To date, only a small proportion of Cochrane Systematic Reviews assessing neonatal interventions have been able to report on this outcome. There is an urgent need for long-term follow-up of RCTs of such interventions addressing risk factors for cerebral palsy (through strategies such as data linkage with registries) and for consideration of the use of relatively new interim assessments (including the General Movements Assessment). Such RCTs must be rigorous in their design and must aim for consistency in cerebral palsy outcome measurement and reporting to facilitate pooling of data and thus to maximise research efforts focused on prevention.

222. Hadders-Algra M.
Early human motor development: From variation to the ability to vary and adapt.
Neurosci Biobehav Rev 2018; 90: 411-427. doi: 10.1016/j.neubiorev.2018.05.009.

This review summarizes early human motor development. From early fetal age motor behavior is based on spontaneous neural activity: activity of networks in the brainstem and spinal cord that is modulated by supraspinal activity. The supraspinal activity, first primarily brought about by the cortical subplate, later by the cortical plate, induces movement variation. Initially, movement variation especially serves exploration; its associated afferent information is primarily used to sculpt the developing nervous system, and less to adapt motor behavior. In the next phase, beginning at function-specific ages, movement variation starts to serve adaptation. In sucking and swallowing, this phase emerges shortly before term age. In speech, gross and fine motor development, it emerges from 3 to 4 months post-term onwards, i.e., when developmental focus in the primary sensory and motor cortices has shifted to the permanent cortical circuitries. With increasing age and increasing trial-and-error exploration, the infant improves its ability to use adaptive and efficicient forms of upright gross motor behavior, manual activities and vocalizations belonging to the native language.

221. Dostanic T, Sustercic B, Paro-Panjan D.
Developmental outcome in a group of twins: Relation to perinatal factors and general movements.
Eur J Paediatr Neurol 2018; 22(4): 682-689. doi: 10.1016/j.ejpn.2018.04.006.

Background: The quality of general movements (GMs) has proven to have predictive value for the developmental outcome, but this has not yet been studied in twins. Aims: Our aim was to analyse the quality of GMs and neurological and developmental outcome in relation to the gestational age (GA), mode of conception and other perinatal risk factors in a group of twins. Study design: The documentation of twins referred for follow-up in the period from 1998 to 2016 was studied retrospectively. Data concerning the quality of GMs, perinatal risk factors and developmental outcome were analysed. Subjects: Eighty-nine twin pairs, GA from 24 to 38 weeks (median 35.0; IQR 3), birth weight 670 g-3820 g (median 2323; IQR 645) were included. Outcome measures: Results of neurological, psychological and speech/language development and school outcome were analysed. Results: GMs at term age and at three to four months postterm age did not differ with regard to the mode of conception. Preterm birth was significantly related to GMs at three to four months postterm age. At term age, GMs were significantly related to neurological outcome, while at three to four months postterm age, GMs were related to both the neurological and psychological outcome. Difficulties in speech/language development were diagnosed in almost half of the children, more frequently in boys and children with lower Apgar scores. Conclusion: The study highlights the value of GMs for predicting the developmental outcome in twins and indicates the importance of developmental, especially speech/language, follow-up in twins.

220. Song YS, Chang HJ, Shin YB, Park YS, Park YH, Cho ES.
The validity of two neuromotor assessments for predicting motor performance at 12 months in preterm infants.
Ann Rehabil Med 2018; 42 296-304. doi: 10.5535/arm.2018.42.2.296.

Objective: To evaluate the validity of the Test of Infant Motor Performance (TIMP) and general movements (GMs) assessment for predicting Alberta Infant Motor Scale (AIMS) score at 12 months in preterm infants. Methods: A total of 44 preterm infants who underwent the GMs and TIMP at 1 month and 3 months of corrected age (CA) and whose motor performance was evaluated using AIMS at 12 months CA were included. GMs were judged as abnormal on basis of poor repertoire or cramped-synchronized movements at 1 month CA and abnormal or absent fidgety movement at 3 months CA. TIMP and AIMS scores were categorized as normal (average and low average and >5th percentile, respectively) or abnormal (below average and far below average or <5th percentile, respectively). Correlations between GMs and TIMP scores at 1 month and 3 months CA and the AIMS classification at 12 months CA were examined. Results: The TIMP score at 3 months CA and GMs at 1 month and 3 months CA were significantly correlated with the motor performance at 12 months CA. However, the TIMP score at 1 month CA did not correlate with the AIMS classification at 12 months CA. For infants with normal GMs at 3 months CA, the TIMP score at 3 months CA correlated significantly with the AIMS classification at 12 months CA. Conclusion: Our findings suggest that neuromotor assessment using GMs and TIMP could be useful to identify preterm infants who are likely to benefit from intervention.

219. Novak I, Morgan C.
Are Structural Magnetic Resonance Imaging and General Movements Assessment Sufficient for Early, Accurate Diagnosis of Cerebral Palsy?-Reply.
JAMA Pediatr 2018; 172(2): 199. doi: 10.1001/jamapediatrics.2017.4815.

218. Parikh NA.
Are Structural Magnetic Resonance Imaging and General Movements Assessment Sufficient for Early, Accurate Diagnosis of Cerebral Palsy? Comment.
JAMA Pediatr 2018; 172(2):198-199. doi: 10.1001/jamapediatrics.2017.4812.

217. Peyton C, Einspieler C.
General movements: A behavioral biomarker of later motor and cognitive dysfunction in NICU graduates.
Pediatr Ann 2018; 47(4): e159-e164. doi: 10.3928/19382359-20180325-01.

Infants who have graduated from a neonatal intensive care unit require close follow-up because they have a greater chance of experiencing later motor and cognitive difficulties; however, these difficulties are often challenging to identify at an early age. The General Movement Assessment is a low-cost and highly reliable tool that can indicate abnormal neurological development in young high-risk infants, but it has not yet been widely implemented in the United States. In this review, we discuss the literature about the use of the General Movement Assessment in high-risk infants and how to implement the tool in a clinical setting.

216. Rosenbloom L.
What is the role of the General Movements Assessment in clinical practice?
Dev Med Child Neurol 2018; 60(1): 6. doi: 10.1111/dmcn.13605.

215. Olsen J, Marschik P, Spittle A.
Do fidgety general movements predict cerebral palsy and cognitive outcome in clinical follow-up of very preterm infants?
Acta Paediatr 2018; 107: 361-362.

214. Tomantschger I, Herrero D, Einspieler C, Hamamura C, Voos MC, Marschik PB.
The general movement assessment in non-European low- and middle-income countries.
Rev Saude Publica 2018; 52: 6-6.

BACKGROUND: Abnormal general movements are among the most reliable markers for cerebral palsy. General movements are part of the spontaneous motor repertoire and are present from early fetal life until the end of the first half year after term. In addition to its high sensitivity (98%) and specificity (91%), the assessment of general movements is non-invasive and time- and cost-efficient. It is therefore ideal for assessing the integrity of the young nervous system, most notably in lowresource settings. Studies on the general movements assessment in low- and middle-income countries such as China, India, Iran, or South Africa are still rare but increasing. In Brazil, too, researchers have demonstrated that the evaluation of general movements adds to the functional assessment of the young nervous system. Applying general movements assessment in vulnerable populations in Brazil is therefore highly recommended.

213. Crowle C, Galea C, Walker K, Novak I, Badawi N.
Prediction of neurodevelopment at one year of age using the General Movements assessment in the neonatal surgical population.
Early Hum Dev 2018; 118: 42-47.

BACKGROUND: Recent evidence indicates neonatal surgery is associated with an increased risk of neurodevelopmental disability, including cerebral palsy (CP). Despite evidence for prediction of CP there is limited information on use of the General Movements Assessment (GMA) with this population. AIM: To investigate the utility of the GMA for prediction of neurodevelopment in an infant surgical population. STUDY DESIGN: Prospective cohort study Subjects: 278 infants following cardiac surgery (n = 149), non-cardiac surgery (n = 123) or both surgeries (n = 6). OUTCOME MEASURES: GMA at three months of age (mean 12 weeks, SD 1.6) rated by three assessors, two blinded to clinical details. Follow-up at one year of age (mean 372 days, SD 13) using Bayley Scales of Infant and Toddler Development III (BSID-III), clinical and neurological examination. RESULTS: At one year, none of the 248 (89%) infants with normal fidgety movements had a diagnosis of CP, however a large proportion (n = 118, 48%) demonstrated delayed development. Infants who had absent fidgety movements (n = 25, 9%) showed a significant difference on all subtests of the BSID-III (p > 0.05). For prediction of CP there was 100% sensitivity and 96% specificity. CONCLUSIONS: The GMA is a valid complementary assessment tool to enhance prediction of neurodevelopment, specifically CP, following early neonatal surgery and should be incorporated into routine follow-up for this population.

212. Kwong AKL, Fitzgerald TL, Doyle LW, Cheong JLY, Spittle AJ.
Predictive validity of spontaneous early infant movement for later cerebral palsy: a systematic review.
Dev Med Child Neurol 2018; Feb 22, doi: 10.1111/dmcn.13697.

AIM: To systematically review the predictive validity of spontaneous early infant movements for later cerebral palsy (CP). METHOD: Cohort studies with published data to calculate predictive validity of early spontaneous movements for later CP were searched in four electronic databases: CINAHL, Embase, MEDLINE, and PsycINFO. RESULTS: Forty-seven studies met inclusion criteria. The Prechtl General Movements Assessment (GMA) during the fidgety period (10-20wks corrected age) had the strongest sensitivity: 97 per cent (95% confidence interval [CI] 93-99) and specificity: 89% (95% CI 83-93). The sensitivity and specificity of the Prechtl GMA during the writhing period (birth-6wks) was 93% (95% CI 86-96) and 59% (95% CI 45-71) respectively. Cramped-synchronized movements in the writhing period according to Prechtl had the best specificity (sensitivity: 70% [95% CI 54-82]; specificity: 97% [95% CI 74-100]). Hadders-Algra's method of assessing general movements had a pooled sensitivity and specificity of 89% (95% CI 66-97) and 81% (95% CI 64-91) respectively. Presence of asymmetric postures and movement quality/quantity were reported under the Hammersmith Infant Neurological Examination, Hammersmith Neonatal Neurological Examination, and Movement Assessment of Infants but had weak associations with later CP. INTERPRETATION: Fidgety movements assessed by the Prechtl GMA have the strongest predictive validity for later CP, but cannot be considered in isolation because of the presence of false positive results. WHAT THIS PAPER ADDS: Fidgety general movements (Prechtl) are most predictive for later cerebral palsy compared with other spontaneous movements. False positive results are high among all spontaneous movement assessments.

211. Soares-Marangoni DA, Tedesco NM, Nascimento AL, Almeida PR, Santos Pereira CND.
General movements and motor outcomes in two infants exposed to Zika virus: brief report.
Dev Neurorehabil 2018; 16: 1-4.

OBJECTIVE: We described the general movements (GMs) in the fidgety period and the motor performance of two infants who were exposed to Zika virus (ZIKV) during distinct trimesters of gestation. METHODS: Infants were assessed at 4 and 12 months of age. Prechtl's GM assessment and the Alberta Infant Motor Scale were used. RESULTS: In Case 1, the mother presented confirmed ZIKV infection in the 10th week of gestation and the infant was born full-term with brain abnormalities and microcephaly. Fidgety movements were absent at 16 weeks after term and motor development was severely impaired at 12 months of age. In Case 2, the mother presented confirmed ZIKV infection in the 34th week of gestation and the infant was born full-term with no signs of brain changes or microcephaly. Fidgety movements at 13 weeks were normal in presentation and motor outcome was typical at 12 months. CONCLUSION: GM assessment can be useful for ZIKV-exposed infants. These findings represent the first information on GMs and long-term motor outcomes in ZIKV-exposed infants.

210. George JM, Fiori S, Fripp J, Pannek K, Guzzetta A, David M, Ware RS, Rose SE, Colditz PB, Boyd RN.
Relationship between very early brain structure and neuromotor, neurological and neurobehavioral function in infants born <31 weeks gestational age.
Early Hum Dev 2018; 117: 74-82.

AIM: This study aimed to examine associations between structural MRI and concurrent motor, neurological and neurobehavioral measures at 30-32 weeks postmenstrual age (PMA; 'Early'), and at term equivalent age ('Term'). METHOD: In this prospective cohort study, infants underwent Early MRI (n = 119; 73 male; median 32 weeks 1 day PMA) and Term MRI (n = 102; 61 male; median 40 weeks 4 days PMA) at 3 T. Structural images were scored generating white matter (WM), cortical gray matter, deep gray matter, cerebellar and global brain abnormality scores. Clinical measures were General Movements Assessment (GMs), Hammersmith Neonatal Neurological Examination (HNNE) and NICU Neonatal Neurobehavioral Scale (NNNS). The Premie-Neuro was administered Early and the Test of Infant Motor Performance (TIMP) and a visual assessment at Term. RESULTS: Early MRI cerebellar scores were strongly associated with neurological components of HNNE (reflexes), NNNS (Hypertonicity), the Premie-Neuro neurological subscale (regression coefficient β = -0.06; 95% confidence interval CI = -0.09, -0.04; p < .001) and cramped-synchronized GMs (β = 1.10; 95%CI = 0.57, 1.63; p < .001). Term MRI WM and global scores were strongly associated with the TIMP (WM β = -1.02; 95%CI = -1.67, -0.36; p = .002; global β = -1.59; 95%CI = -2.62, -0.56; p = .001). INTERPRETATION: Brain structure on Early and Term MRI was associated with concurrent motor, neurological and neurobehavioral function in very preterm infants.

209. McLean G, Hough C, Sehgal A, Ditchfield M, Polglase GR, Miller SL.
Three-dimensional ultrasound cranial imaging and early neurodevelopment in preterm growth-restricted infants.
J Paediatr Child Health 2018; 54: 420-425.

AIM: Fetal growth restriction (FGR) is associated with increased perinatal morbidity, mortality and long-term neurodevelopmental sequelae. The objective of this study was to examine whether information about early neurodevelopmental deficits was evident using three-dimensional head ultrasound and developmental assessments in preterm infants with FGR, compared with appropriate for gestational age (AGA) infants in the early post-natal period. METHODS: Twenty preterm FGR infants weighing <10th centile and born between 28 and 32 weeks were compared with age-matched AGA infants. In the second post-natal week after birth, we used three-dimensional ultrasound to assess cerebral ventricular volumes. Prechtl General Movement Assessments were performed at 4-6 weeks after birth. Test of Infant Motor Performance (TIMP) to measure functional motor behaviour was performed at 4-6 and 12-14 weeks corrected age. RESULTS: There was no statistically significant difference in the combined cerebral ventricular volume between the two groups (FGR, 0.81 ± 0.42 vs. AGA 0.72 ± 0.38 cm3 , P = 0.4). The TIMP assessment at 12-14 week term corrected demonstrated lower scores (worse performance) in FGR infants compared with the AGA cohort (regression coefficient: -7.74 (95% CI -16.06, 0.57); P = 0.07). We observed a significant correlation between greater ventricular volume and lower TIMP scores in the cohorts separately and also overall (FGR, r = -0.5, P = 0.06 vs. AGA, r = -0.62, P = 0.007 and overall, r = -0.53, P = 0.001). CONCLUSION: Ultrasound in the early weeks may be useful to detect the neuropathology which could then mediate functional consequences.

208. Ricci E, Einspieler C, Craig AK.
Feasibility of Using the General Movements Assessment of Infants in the United States.
Phys Occup Ther Pediatr 2018, 38(3): 269-279.

AIMS: To pilot the practicality of administering the Prechtl General Movements Assessment of infants (GMA) in the Neonatal Intensive Care Unit (NICU) setting and at home to infants at risk for developing cerebral palsy (CP). Additional aims included assessing inter-rater reliability and comparing GMA predictions to AIMS motor assessment at 12 months. METHODS: 12 "at risk" infants were recruited by convenience sample. Video recordings were obtained in the NICU and provided by parents after discharge. These recordings were analyzed by two trained examiners to assess infants in the writhing and fidgety movement periods (birth to 16 weeks). Infants were assessed at 12 months corrected age using the Alberta Infant Motor Scale (AIMS) with scores lower than 5th centile considered a motor delay. RESULTS: 33 of 42 videos (79%) were of sufficient quality to permit interpretation and there was 97% inter-examiner subcategory agreement and 100% overall developmental trajectory (abnormal/normal) agreement. The GMA demonstrated a sensitivity of 60% and a specificity of 100% in predicting AIMS score (age appropriate or delayed). CONCLUSIONS: Clinical feasibility of GMA obtained in the NICU was demonstrated however feasibility of parents providing video samples after discharge was not demonstrated, indicating a need for a parent-friendly method.

207. Adde L, Yang H, Sæther R, Jensenius AR, Ihlen E, Cao JY, Støen R.
Characteristics of general movements in preterm infants assessed by computer-based video analysis.
Physiother Theory Pract 2018; 34: 286-292.

BACKGROUND: Previous evidence suggests that the variability of the spatial center of infant movements, calculated by computer-based video analysis software, can identify fidgety general movements (GMs) and predict cerebral palsy. AIM: To evaluate whether computer-based video analysis quantifies specific characteristics of normal fidgety movements as opposed to writhing general movements. METHODS: A longitudinal study design was applied. Twenty-seven low-to moderate-risk preterm infants (20 boys, 7 girls; mean gestational age 32 [SD 2.7, range 27-36] weeks, mean birth weight 1790 grams [SD 430g, range 1185-2700g]) were videotaped at the ages of 3-5 weeks (period of writhing GMs) and 10-15 weeks (period of fidgety GMs) post term. GMs were classified according to Prechtl's general movement assessment method (GMA) and by computer-based video analysis. The variability of the centroid of motion (CSD), derived from differences between subsequent video frames, was calculated by means of computer-based video analysis software; group mean differences between GM periods were reported. RESULTS: The mean variability of the centroid of motion (CSD) determined by computer-based video analysis was 7.5% lower during the period of fidgety GMs than during the period of writhing GMs (p = 0.004). CONCLUSION: Our findings support that the variability of the centroid of motion reflects small and variable movements evenly distributed across the body, and hence shows that computer-based video analysis qualifies for assessment of direction and amplitude of FMs in young infants.

206. Olsen JE, Allinson LG, Doyle LW, Brown NC, Lee KJ, Eeles AL, Cheong JLY, Spittle AJ.
Preterm and term-equivalent age general movements and 1-year neurodevelopmental outcomes for infants born before 30 weeks' gestation.
Dev Med Child Neurol 2018; 60: 47-53.

AIM: To examine the associations between Prechtl's General Movements Assessment (GMA), conducted from birth to term-equivalent age, and neurodevelopmental outcomes at 12 months corrected age, in infants born very preterm. METHOD: One hundred and thirty-seven infants born before 30 weeks' gestation had serial GMA (categorized as 'normal' or 'abnormal') before term and at term-equivalent age. At 12 months corrected age, neurodevelopment was assessed using the Alberta Infant Motor Scale (AIMS); Neurological, Sensory, Motor, Developmental Assessment (NSMDA); and Touwen Infant Neurological Examination (TINE). The relationships between GMA at four time points and 12-month neurodevelopmental assessments were examined using regression models. RESULTS: Abnormal GMA at all time points were associated with worse continuous scores on the AIMS, NSMDA, and TINE (p<0.05). Abnormal GMA before term and at term-equivalent age were associated with increased odds of mild-severe dysfunction on the NSMDA (odds ratio [OR] 4.26, 95% confidence interval [CI] 1.55-11.71, p<0.01; and OR 4.16, 95% CI 1.55-11.17, p<0.01 respectively) and abnormal GMA before term with increased odds of suboptimal-abnormal motor function on the TINE (OR 2.75, 95% CI 1.10-6.85, p=0.03). INTERPRETATION: Abnormal GMA before term and at term-equivalent age were associated with worse neurodevelopment at 12 months corrected age in children born very preterm. WHAT THIS PAPER ADDS: Abnormal general movements before term predict developmental deficits at 1 year in infants born very preterm. General Movements Assessment before term identifies at-risk infants born very preterm.

205. Hadders-Algra M.
Neural substrate and clinical significance of general movements: an update.
Dev Med Child Neurol 2018; 60: 39-46.

General movements are present from early fetal life to 3 to 5 months corrected age. Atypical general movements, especially in the last, so-called fidgety general movement phase, are predictive of cerebral palsy (CP). This review updates knowledge on the neural substrate and clinical significance of typical and atypical general movements. Typical general movements are primarily characterized by complexity and variation. Presumably these core characteristics are initially induced by modulating activity of the cortical subplate. When the subplate gradually dissolves between 3 months before term and 3 months corrected age the cortical plate takes over. This coincides with the fidgety general movement phase. Conceivably, fidgety activity reflects 'sparsification', i.e. fragmentation of cortical network activity. The quintessential feature of atypical general movements is reduced complexity and variation. This is attributed to impaired integrity of extensive cortical-subcortical networks, in which the subplate and periventricular white matter play a prominent role. The most serious forms of network impairment are associated with absent fidgety movements. WHAT THIS PAPER ADDS: The emergence of fidgety movements reflects a developmental transition from widespread to fragmented cortical network activity. Atypical general movements characterized by reduced complexity and variation are attributed to impaired integrity of extensive cortical-subcortical networks.

204. Marschik PB, Pokorny FB, Peharz R, Zhang D, O'Muircheartaigh J, Roeyers H, Bölte S, Spittle AJ, Urlesberger B, Schuller B, Poustka L, Ozonoff S, Pernkopf F, Pock T, Tammimies K, Enzinger C, Krieber M, Tomantschger I, Bartl-Pokorny KD, Sigafoos J, Roche L, Esposito G, Gugatschka M, Nielsen-Saines K, Einspieler C, Kaufmann WE, BEE-PRI Study Group. A Novel Way to Measure and Predict Development: A Heuristic Approach to Facilitate the Early Detection of Neurodevelopmental Disorders.
Curr Neurol Neurosci Rep 2017; 17: 43.

BACKGROUND: Substantial research exists focusing on the various aspects and domains of early human development. However, there is a clear blind spot in early postnatal development when dealing with neurodevelopmental disorders, especially those that manifest themselves clinically only in late infancy or even in childhood. This early developmental period may represent an important timeframe to study these disorders but has historically received far less research attention. We believe that only a comprehensive interdisciplinary approach will enable us to detect and delineate specific parameters for specific neurodevelopmental disorders at a very early age to improve early detection/diagnosis, enable prospective studies and eventually facilitate randomised trials of early intervention. In this article, we propose a dynamic framework for characterising neurofunctional biomarkers associated with specific disorders in the development of infants and children. We have named this automated detection 'Fingerprint Model', suggesting one possible approach to accurately and early identify neurodevelopmental disorders.

203. Salavati S, Einspieler C, Vagelli G, Zhang D, Pansy J, Burgerhof JGM, Marschik PB, Bos AF.
The association between the early motor repertoire and language development in term children born after normal pregnancy.
Early Hum Dev 2017; 111: 30-35.

BACKGROUND: The assessment of the early motor repertoire is a widely used method for assessing the infant's neurological status. AIM: To determine the association between the early motor repertoire and language development. STUDY DESIGN: Prospective cohort study. SUBJECTS: 22 term children born after normal pregnancy; video recorded for the assessment of the early motor repertoire including their motor optimality score (MOS), according to Prechtl, at 3 and 5months post term. OUTCOME MEASURES: At 4years 7months and 10years 5months, we tested the children's language performance by administering three tests for expressive language and two for receptive language. RESULTS: Smooth and fluent movements at 3months of age was associated with better expressive language outcome at both 4years 7months and 10years 5months (betas 0.363 and 0.628). A higher MOS at 5months was associated with better expressive language at both ages (betas 0.486 and 0.628). The item postural patterns at 5months was the only aspect associated with poorer expressive language outcome (beta -0.677). CONCLUSION: Predominantly, qualitative aspects of the early motor repertoire at the age of 3 and 5months are associated with language development.

202. Li HH, Shan L, Wang B, Jia FY.
[Application of movement recognition technology in assessing spontaneous general movements in preterm infants].
Zhongguo Dang Dai Er Ke Za Zhi. 2017 Dec;19(12):1306-1310.

Preterm birth is a major factor which induces neurological and motor impairments, particularly cerebral palsy, in high-risk infants. Early identification of potential neurodevelopmental impairments provides the opportunity to improve neurodevelopmental outcomes in preterm infants through early rehabilitation interventions. Clinically, the general movement assessment is a pivotal tool to predict neurodevelopmental outcomes, especially motor developmental outcomes, in high-risk infants. Movement recognition can continuously capture relevant limb movements and perform objective and quantitative assessment using computerized approaches. Various methods of recording and analyzing spontaneous general movements for infants at a risk of cerebral palsy have been extensively explored. This article summarizes the general movement assessment method and reviews the translational research on using movement recognition technology for the assessment of spontaneous general movements of preterm infants.

201. Novak I, Morgan C, Adde L, Blackman J, Boyd RN, Brunstrom-Hernandez J, Cioni G, Damiano D, Darrah J, Eliasson AC, de Vries LS, Einspieler C, Fahey M, Fehlings D, Ferriero DM, Fetters L, Fiori S, Forssberg H, Gordon AM, Greaves S, Guzzetta A, Hadders-Algra M, Harbourne R, Kakooza-Mwesige A, Karlsson P, Krumlinde-Sundholm L, Latal B, Loughran-Fowlds A, Maitre N, McIntyre S, Noritz G, Pennington L, Romeo DM, Shepherd R, Spittle AJ, Thornton M, Valentine J, Walker K, White R, Badawi N.
Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy: Advances in Diagnosis and Treatment.
JAMA Pediatr 2017; 171: 897-907.

IMPORTANCE: Cerebral palsy describes the most common physical disability in childhood and occurs in 1 in 500 live births. Historically, the diagnosis has been made between age 12 and 24 months but now can be made before 6 months' corrected age. OBJECTIVES: To systematically review best available evidence for early, accurate diagnosis of cerebral palsy and to summarize best available evidence about cerebral palsy-specific early intervention that should follow early diagnosis to optimize neuroplasticity and function. EVIDENCE REVIEW: This study systematically searched the literature about early diagnosis of cerebral palsy in MEDLINE (1956-2016), EMBASE (1980-2016), CINAHL (1983-2016), and the Cochrane Library (1988-2016) and by hand searching. Search terms included cerebral palsy, diagnosis, detection, prediction, identification, predictive validity, accuracy, sensitivity, and specificity. The study included systematic reviews with or without meta-analyses, criteria of diagnostic accuracy, and evidence-based clinical guidelines. Findings are reported according to the PRISMA statement, and recommendations are reported according to the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument. FINDINGS: Six systematic reviews and 2 evidence-based clinical guidelines met inclusion criteria. All included articles had high methodological Quality Assessment of Diagnostic Accuracy Studies (QUADAS) ratings. In infants, clinical signs and symptoms of cerebral palsy emerge and evolve before age 2 years; therefore, a combination of standardized tools should be used to predict risk in conjunction with clinical history. Before 5 months' corrected age, the most predictive tools for detecting risk are term-age magnetic resonance imaging (86%-89% sensitivity), the Prechtl Qualitative Assessment of General Movements (98% sensitivity), and the Hammersmith Infant Neurological Examination (90% sensitivity). After 5 months' corrected age, the most predictive tools for detecting risk are magnetic resonance imaging (86%-89% sensitivity) (where safe and feasible), the Hammersmith Infant Neurological Examination (90% sensitivity), and the Developmental Assessment of Young Children (83% C index). Topography and severity of cerebral palsy are more difficult to ascertain in infancy, and magnetic resonance imaging and the Hammersmith Infant Neurological Examination may be helpful in assisting clinical decisions. In high-income countries, 2 in 3 individuals with cerebral palsy will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence. CONCLUSIONS AND RELEVANCE: Early diagnosis begins with a medical history and involves using neuroimaging, standardized neurological, and standardized motor assessments that indicate congruent abnormal findings indicative of cerebral palsy. Clinicians should understand the importance of prompt referral to diagnostic-specific early intervention to optimize infant motor and cognitive plasticity, prevent secondary complications, and enhance caregiver well-being.

200. Crowle C, Walker K, Galea C, Novak I, Badawi N.
General movement trajectories and neurodevelopment at 3months of age following neonatal surgery.
Early Hum Dev 2017; 111: 42-48.

BACKGROUND: Neonates who undergo major surgery are at risk of neurodevelopmental disability. The General Movements Assessment (GMA) is a valid and reliable method to predict neurodevelopment, however, there are minimal data on the applicability among infants post-surgery. AIM: To describe GMs trajectories following neonatal surgery. STUDY DESIGN: Prospective cohort study. SUBJECTS: 217 infants following major cardiac and non-cardiac neonatal surgery. OUTCOME MEASURES: Infants were assessed following surgery at term age (mean 40weeks, SD 2.3), and at 3months of age (mean 12weeks, SD 1.6) using the GMA and the Bayley Scales of Infant and Toddler Development III. GMA videos were independently scored by three advanced trained assessors, two blinded to infant details. RESULTS: The most common result in the writhing period was 'poor repertoire' (n=117, 54%), however, 99 (84%) of these infants had normal fidgety movements. For infants with normal writhing (n=75, 34%), only four had absent fidgety movements. Cramped synchronised movements were seen in 10 infants, and three of these were rated as absent fidgety. There was no significant difference between the surgical groups. In total, 24 infants (11%) had absent fidgety movements and lower scores on average in all subtests of the BSID-III than those with normal fidgety movements. CONCLUSIONS: This is the first report describing GMs trajectories in infants who have undergone neonatal surgery. Similar to other high risk infant populations, this group showed a high proportion of poor repertoire writhing movements, however, most infants demonstrated normal fidgety movements and development at 3months of age.

199. Campbell M, Rabbidge B, Ziviani J, Sakzewski L.
Clinical feasibility of pre-operative neurodevelopmental assessment of infants undergoing open heart surgery.
J Paediatr Child Health 2017; 53: 794-799.

AIM: Assessing the neurodevelopmental status of infants with congenital heart disease before surgery provides a means of identifying those at heightened risk of developmental delay. This study aimed to investigate factors impacting clinical feasibility of pre-operative neurodevelopmental assessment of infants undergoing early open heart surgery. METHODS: Infants who underwent open heart surgery prior to 4 months of age participated in this cross-sectional study. The Test of Infant Motor Performance and Prechtl's Assessment of General Movements were undertaken on infants pre-operatively. When assessments could not be undertaken, reasons were ascribed to either infant or environmental circumstances. Demographic data and Aristotle scores were compared between groups of infants who did or did not undergo assessment. Binary logistic regression was used to explore associations. RESULTS: A total of 60 infants participated in the study. Median gestational age was 38.78 weeks (interquartile range: 36.93-39.72). Of these infants, 37 (62%) were unable to undergo pre-operative assessment. Twenty-four (40%) could not complete assessment due to infant-related factors and 13 (22%) due to environmental-related factors. For every point increase in the Aristotle Patient-Adjusted Complexity score, the infants likelihood of being unable to undergo assessment increased by 35% (odds ratio: 0.35; 95% confidence interval: 1.03-1.77, P = 0.03). CONCLUSION: Over half of the infants undergoing open heart surgery were unable to complete pre-operative neurodevelopmental assessment. The primary reason for this was infant-related medical instability. Findings suggest further research is warranted to investigate whether the Aristotle Patient-Adjusted Complexity score might serve as an indicator to inform developmental surveillance with this medically fragile cohort.

198. Pansy J, Baik N, Schwaberger B, Scheuchenegger A, Pichler-Stachl E, Avian A, Schmölzer GM, Urlesberger B, Pichler G.
Cerebral hypoxia during immediate transition after birth and short term neurological outcome.
Early Hum Dev 2017; 110: 13-15.

In preterm neonates we investigated cerebral hypoxia assessed with near-infrared-spectroscopy during immediate transition after birth and general movement optimality score assessed before discharge. General movement optimality score decreased with increasing cerebral hypoxia. Burden of cerebral hypoxia during immediate transition might be associated with impaired short-term neurological outcome in preterm neonates.

197. Allinson LG, Doyle LW, Denehy L, Spittle AJ.
Survey of neurodevelopmental allied health teams in Australian and New Zealand neonatal nurseries: Staff profile and standardised neurobehavioural/neurological assessment.
J Paediatr Child Health 2017; 53: 578-584.

AIMS: The primary aim of this study was to establish how many neonatal nurseries in Australia and New Zealand had a neurodevelopmental allied health team, to ascertain the disciplines involved, their qualifications and experience. The secondary aim was to evaluate which standardised neurobehavioural/neurological assessments were currently being implemented, and the existing practice in relation to their use. METHODS: A descriptive cross-sectional survey, sampling 179 eligible public and private hospital neonatal intensive care units (NICUs) and special care nurseries (SCNs) throughout Australia and New Zealand, was purpose-developed and administered electronically from the 5th April to 23rd July 2013. RESULTS: A total of 117 units (65%) overall, and 26 of 26 (100%) NICUs responded to the survey. NICUs had more neurodevelopmental allied health staff than SCNs, with physiotherapists and speech pathologists the most common disciplines. Physiotherapists were more likely to administer standardised neurobehavioural/neurological assessments in NICUs, while medical staff were more likely to do so in SCNs. A wide variety of standardised neurobehavioural/neurological assessment tools were used, with Prechtl's General Movements Assessment the most common in the NICUs (50%) and the Hammersmith Neonatal Neurological Examination the most common in the special care units (25%). Standardised neurobehavioural assessments were not administered in 22% of SCNs. CONCLUSIONS: Although neurodevelopmental allied health teams and standardised neurobehavioural/neurological assessments are valued by many, there was little consistency across Australian and New Zealand neonatal nurseries.

196. Cunha M, Correa F, Cadete A, Oliveira A, Figueiredo H, Valerio P, Barroso R, Carreiro H.
[Predictive value of cerebellar growth and general movements assessments for neurodevelopment of very preterm infants at 18-24 months' corrected age].
Rev Neurol 2017; 64: 63-69.

INTRODUCTION: Fidgety movements assessments is very sensitive predicting long-term outcome or cerebral palsy of preterm, disrupted cerebellar growth has been reported in these patients. AIM: To compare the predictive value of cerebellar ultrasound growth and fidgety movements assessments, for neurodevelopment outcome of very preterm at 18-24 month's corrected age (CA). SUBJECTS AND METHODS: Prospective study of 88 infants cohort (<= 32 weeks' gestation), transverse cerebellar diameter was obtained by ultrasound via mastoid fontanel, in a weekly basis, until 40 weeks CA. Fidgety movements were assessed at 3 months CA. Neurodevelopment outcome at 18-24 month's CA was evaluated in 68 using Schedule of Growing Skills II Scale (SGS-II) and Amiel-Tison Neurologic Assessment (ATNA). RESULTS: At term age, cerebellar growth was under 3rd percentile in 11 (10.3%). Fidgety movements were normal in 42 (61.8%) and abnormal or absent in 7 (10.3%). At 18-24 months CA, 54 (79.4%) were normal by the SGS-II and in 6 (8.8%) ATNA classified as cerebral palsy. Cerebellar diameter under 3rd percentile at term was associated with abnormal motor outcome and normal fidgety movements correlated with normal neurodevelopment. CONCLUSION: Ultrasound cerebellar measurements and functional examinations (fidgety movements) have important complementary roles in predicting neurodevelopment of very preterm.

195. Sousa KG, Pereira SA.
Commentary on "Validity of the General Movement Optimality List in Infants Born Preterm".
Pediatr Phys Ther 2017; 29: 321.

194. Ustad T, Evensen KAI, Bertoncelli N, Frassoldati R, Ferrari F.
Validity of the General Movement Optimality List in Infants Born Preterm.
Pediatr Phys Ther 2017; 29: 315-320.

PURPOSE: To examine concurrent and predictive validity of the optimality list "Detailed Assessment of General Movements (GMs) During Preterm and Term Age." METHODS: Video clips of general movements were analyzed for 20 infants born preterm without severe brain lesions. Concurrent validity of the optimality list compared with the General Movement Assessment (GMA) was examined. The General Movement Optimality Scores (GMOSs) between infants with normal and poor repertoire GMA were examined. Estimates of diagnostic accuracy were calculated. RESULTS: The GMOS correlated with the GMA and differed between infants with normal and poor repertoire GMA. The area under the curve was below 0.53 with respect to normal or abnormal general movements at 3 months' corrected age. CONCLUSIONS: Concurrent validity of the optimality list was moderate to high compared with the GMA, but its predictive validity for general movements at 3 months' corrected age was low.

193. Fjørtoft T, Ustad T, Follestad T, Kaaresen PI, Øberg GK.
Does a parent-administrated early motor intervention influence general movements and movement character at 3months of age in infants born preterm?
Early Hum Dev 2017; 112: 20-24.

BACKGROUND: Studies of preterm and term-born infants have shown absent fidgety movements and an abnormal movement character to be related to brain lesions and unfavourable neurological outcomes. AIMS: The present study examines what effect a parent-administered early intervention program applied to preterm infants in a randomised control trial (RCT) between 34 and 36weeks gestational age has on their fidgety movements and overall movement character at three months of age. STUDY DESIGN: The study was part of the RCT in an early intervention programme including preterm infants born between 2010 and 2014 at three Norwegian university hospitals. SUBJECTS: 130 preterm infants participated in the study, with 59 of them in the control group and 71 in the intervention group. OUTCOME MEASURES: Fidgety movements and overall movement character at three months corrected age. RESULTS: No difference was found between the intervention group and the control group in terms of fidgety movements or movement character. Approximately half of the infants in both groups showed an abnormal movement character. CONCLUSION: No evidence was found in this RCT to suggest that an intervention at 34 to 37weeks gestational age has a significant effect on the fidgety movements or overall movement character of preterm infants. This is in line with the assumption that absent fidgety movements and an abnormal movement character are due to permanent brain injury and are therefore good predictors for later neurological impairments.

192. Herrero D, Einspieler C, Panvequio Aizawa CY, Mutlu A, Yang H, Nogolová A, Pansy J, Nielsen-Saines K, Marschik PB, GenGM Study Group.
The motor repertoire in 3- to 5-month old infants with Down syndrome.
Res Dev Disabil 2017; 67: 1-8.

BACKGROUND: Even though Down syndrome is the most common chromosomal cause of intellectual disability, studies on early development are scarce. To describe movements and postures in 3- to 5-month-old infants with Down syndrome and assess the relation between pre- and perinatal risk factors and the eventual motor performance. Exploratory study; 47 infants with Down syndrome (26 males, 27 infants born preterm, 22 infants with congenital heart disease) were videoed at 10-19 weeks post-term (median=14 weeks). We assessed their Motor Optimality Score (MOS) based on postures and movements (including fidgety movements) and compared it to that of 47 infants later diagnosed with cerebral palsy and 47 infants with a normal neurological outcome, matched for gestational and recording ages. The MOS (median=13, range 10-28) was significantly lower than in infants with a normal neurological outcome (median=26), but higher than in infants later diagnosed with cerebral palsy (median=6). Fourteen infants with Down syndrome showed normal fidgety movements, 13 no fidgety movements, and 20 exaggerated, too fast or too slow fidgety movements. A lack of movements to the midline and several atypical postures were observed. Neither preterm birth nor congenital heart disease was related to aberrant fidgety movements or reduced MOS. The heterogeneity in fidgety movements and MOS add to an understanding of the large variability of the early phenotype of Down syndrome. Studies on the predictive values of the early spontaneous motor repertoire, especially for the cognitive outcome, are warranted. The significance of this exploratory study lies in its minute description of the motor repertoire of infants with Down syndrome aged 3-5 months. Thirty percent of infants with Down syndrome showed age-specific normal fidgety movements. The rate of abnormal fidgety movements (large amplitude, high/slow speed) or a lack of fidgety movements was exceedingly high. The motor optimality score of infants with Down syndrome was lower than in infants with normal neurological outcome but higher than in infants who were later diagnosed with cerebral palsy. Neither preterm birth nor congenital heart disease were related to the motor performance at 3-5 months.

191. Kepenek-Varol B, Çaliskan M, Înce Z, Tatli B, Eraslan E, Çoban A.
The comparison of general movements assessment and neurological examination during early infancy.
Turk J Pediatr 2016;58(1):54-62.

This prospective single-blinded study was performed to evaluate general movements (GMs) in group of high-risk, low-birth-weight and preterm infants and to compare results with neurologic examination. All infants' neurologic examinations, Gross Motor Function Measurement (GMFM) and Bayley-III Scale were performed at the corrected age of 12 months. A total of 22 infants were included. Eight infants (group-1) (mean: 31.6±3.29 weeks, range: 25-36 weeks) had normal GMs in all recordings and were ultimately evaluated as "normal"; 12 (group-2) (mean: 31.6±3.29 weeks, range:2 5-35 weeks) had abnormal GMs during writhing movements period but had normal GMs in subsequent recordings and were evaluated as "normal"; and 2 infants (group-3) (mean:29.5±7.78 weeks, range:24-35 weeks) with consistent abnormal GMs who were evaluated as "abnormal." Complete agreement (kappa=1) was found between GMs and neurologic examination and significant agreement between GMs and cranial ultrasonography (kappa=0.76). When results of GMFM and Bayley-III were compared; statistically significant differences were found between group-1 and group-2 in "standing" parameter of GMFM (p < 0.05) and "cognitive" parameter of Bayley-III (p < 0.05). GMs assessment can help determine neurologic disorders in high-risk infant populations as an adjunct to other diagnostic techniques.

190. Peyton C, Yang E, Msall ME, Adde L, Støen R, Fjørtoft T, Bos AF, Einspieler C, Zhou Y, Schreiber MD, Marks JD, Drobyshevsky A.
White matter injury and general movements in high-risk preterm infants.
Am J Neuroradiol 2017, 38: 162-169. 

BACKGROUND AND PURPOSE: Very preterm infants (birth weight, <1500 g) are at increased risk of cognitive and motor impairment, including cerebral palsy. These adverse neurodevelopmental outcomes are associated with white matter abnormalities on MR imaging at term-equivalent age. Cerebral palsy has been predicted by analysis of spontaneous movements in the infant termed “General Movement Assessment.” The goal of this study was to determine the utility of General Movement Assessment in predicting adverse cognitive, language, and motor outcomes in very preterm infants and to identify brain imaging markers associated with both adverse outcomes and aberrant general movements. MATERIALS AND METHODS: In this prospective study of 47 preterm infants of 24–30 weeks' gestation, brain MR imaging was performed at term-equivalent age. Infants underwent T1- and T2-weighted imaging for volumetric analysis and DTI. General movements were assessed at 10–15 weeks' postterm age, and neurodevelopmental outcomes were evaluated at 2 years by using the Bayley Scales of Infant and Toddler Development III. RESULTS: Nine infants had aberrant general movements and were more likely to have adverse neurodevelopmental outcomes, compared with infants with normal movements. In infants with aberrant movements, Tract-Based Spatial Statistics analysis identified significantly lower fractional anisotropy in widespread white matter tracts, including the corpus callosum, inferior longitudinal and fronto-occipital fasciculi, internal capsule, and optic radiation. The subset of infants having both aberrant movements and abnormal neurodevelopmental outcomes in cognitive, language, and motor skills had significantly lower fractional anisotropy in specific brain regions. CONCLUSIONS: Aberrant general movements at 10–15 weeks' postterm are associated with adverse neurodevelopmental outcomes and specific white matter microstructure abnormalities for cognitive, language, and motor delays.

189. Crowle C, Galea C, Morgan C, Novak I, Walker K, Badawi N.
Inter-observer agreement of the General Movements Assessment with infants following surgery.
Early Hum Dev 2017; 104: 17-21.

BACKGROUND: The General Movements Assessment (GMA) is a validated and reliable method of identifying infants at risk of adverse neurodevelopmental outcomes, however there is minimal data available on the use of the GMA with infants following surgery. AIMS: The aim of this study was to investigate the inter-observer agreement for the GMA with this infant population. STUDY DESIGN: Reliability and agreement study. SUBJECTS: This was a prospective cohort study of 190 infants (male n=112) born at term (mean 38weeks, SD 2weeks). OUTCOME MEASURES: A GMA was conducted in the Neonatal Intensive Care Unit (NICU) following either cardiac surgery (n=92), non-cardiac surgery (n=93) or both types of surgery (n=5), and then again at three months of age. All videos were independently assessed by three advanced trained clinicians. Agreement and reliability statistics were calculated between each pair. RESULTS: We found moderate to substantial levels of agreement in the writhing period (66-77%, AC1=0.53-0.69). For fidgety general movements, agreement was classified as almost perfect, ranging from 86 to 89% (AC1=0.84-0.88). CONCLUSIONS: The GMA has high levels of inter-observer agreement when used with infants who have undergone surgery in the neonatal period, making it a valid, complementary assessment tool. Research is now underway to determine the ability of the GMA to predict neurodevelopmental outcomes in this population.

188. Setoh P, Marschik PB, Einspieler C, Esposito G. 
Autism spectrum disorder and early motor abnormalities: Connected or coincidental companions?
Res Dev Disabil 2017; 60: 13-15. 

Research in the past decade has produced a growing body of evidence showing that motor abnormalities in individuals with autism spectrum disorder (ASD) are the rule rather than the exception. The paper by Chinello and colleagues furthers our understanding of the importance of studying motor functions in ASD by testing a non-clinical population of parents-infant triads. Chinello and colleagues' findings seem to suggest that subclinical motor impairments may exist in the typical population with inherited non-clinical ASD traits. Chinello and colleagues' discovery also urges us to ask why motor abnormalities exist in typically developing infants when their parents present some subclinical ASD traits. We believe that there are at least two possibilities. In the first possible scenario, motor impairments and ASD traits form a single cluster of symptoms unique to a subgroup of individuals with autism. A second possible scenario is that motor atypicalities are the first warning signs of vulnerability often associated with atypical development. In conclusion, Chinello et al.'s findings inform us that subclinical atypical phenotypes such as sociocommunicative anomalies may be related to subclinical motor performances in the next generation. This adds to our knowledge by shedding some light on the relation of vulnerability in one domain with vulnerability in another domain.

187. Datta AN, Furrer MA, Bernhardt I, Hüppi PS, Borradori-Tolsa C, Bucher HU, Latal B, Grunt S, Natalucci G, GM Group. 
Fidgety movements in infants born very preterm: predictive value for cerebral palsy in a clinical multicentre setting.
Dev Med Child Neurol 2017 Jan 19, doi: 10.1111/dmcn.13386.

AIM: This study assessed predictive values of fidgety movement assessment (FMA) in a large sample of infants born very preterm for developmental abnormalities, in particular for cerebral palsy (CP) at 2 years in an everyday clinical setting. METHOD: This is a multicentre study of infants born preterm with gestational age lower than 32.0 weeks. FMA was performed at 3 months corrected age; neurodevelopment (Bayley Scales of Infant Development, 2nd edition) and neurological abnormalities were assessed at 2 years. Predictive values of FMA for the development of CP were calculated and combined with abnormalities at cerebral ultrasound. RESULTS: Five hundred and thirty-five infants (gestational age 28.2wks [standard deviation 1.3wks]) were included. Eighty-one percent showed normal fidgety movements and 19% atypical (82 absent, 21 abnormal) fidgety movements. Absent fidgety movements predicted CP at 2 years with an odds ratio (OR) of 8.9 (95% confidence interval [CI] 4.1-17.0), a combination of atypical fidgety movements and major brain lesion on cerebral ultrasound predicted it with an OR of 17.8 (95% CI 5.2-61.6). Mean mental developmental index of infants with absent fidgety movements was significantly lower (p=0.012) than with normal fidgety movements. INTERPRETATION: Detection of infants at risk for later CP through FMA was good, but less robust when performed in a routine clinical setting; prediction improved when combined with neonatal cerebral ultrasound.

186. Chen CY, Georgieff M, Elison J, Chen M, Stinear J, Mueller B, Rao R, Rudser K, Gillick B. 
Understanding brain reorganization in infants with perinatal stroke through neuroexcitability and neuroimaging.
Pediatr Phys Ther 2017, 29: 173-178.

PURPOSE: The primary aim of this proposed study is to evaluate brain reorganization patterns in infants with perinatal stroke between 3 and 5 months of age using transcranial magnetic stimulation and magnetic resonance imaging, with the addition of the General Movements Assessment. A secondary aim is to demonstrate feasibility and safety of infant-appropriate brain assessment protocols. METHODS: Ten infants with perinatal stroke will be enrolled. In this exploratory study, infants will first receive magnetic resonance imaging scanning during natural sleep to examine their corticospinal tract integrity. Infants will then receive transcranial magnetic stimulation to assess their corticomotor excitability. A General Movements Assessment video of at least 5 minutes will also be recorded. DISCUSSION: Study results will enhance our understanding of brain reorganization in infants with perinatal stroke. We expect these results will also guide the development of early interventions designed to mitigate maladaptive neuroplastic changes and improve long-term motor outcomes.

185. Allinson LG, Doyle LW, Denehy L, Spittle AJ.
Survey of neurodevelopmental allied health teams in Australian and New Zealand neonatal nurseries: Staff profile and standardised neurobehavioural/neurological assessment.
Journal Paediatr Child Health 2017, Mar 23, doi: 10.1111/jpc.13484. 

AIMS: The primary aim of this study was to establish how many neonatal nurseries in Australia and New Zealand had a neurodevelopmental allied health team, to ascertain the disciplines involved, their qualifications and experience. The secondary aim was to evaluate which standardised neurobehavioural/neurological assessments were currently being implemented, and the existing practice in relation to their use. METHODS: A descriptive cross-sectional survey, sampling 179 eligible public and private hospital neonatal intensive care units (NICUs) and special care nurseries (SCNs) throughout Australia and New Zealand, was purpose-developed and administered electronically from the 5th April to 23rd July 2013. RESULTS: A total of 117 units (65%) overall, and 26 of 26 (100%) NICUs responded to the survey. NICUs had more neurodevelopmental allied health staff than SCNs, with physiotherapists and speech pathologists the most common disciplines. Physiotherapists were more likely to administer standardised neurobehavioural/neurological assessments in NICUs, while medical staff were more likely to do so in SCNs. A wide variety of standardised neurobehavioural/neurological assessment tools were used, with Prechtl's General Movements Assessment the most common in the NICUs (50%) and the Hammersmith Neonatal Neurological Examination the most common in the special care units (25%). Standardised neurobehavioural assessments were not administered in 22% of SCNs. CONCLUSIONS: Although neurodevelopmental allied health teams and standardised neurobehavioural/neurological assessments are valued by many, there was little consistency across Australian and New Zealand neonatal nurseries.

184. Brown AK, Greisen G, Haugsted U, Jonsbo F. 
Formal training in general movement assessment is required to effectively evaluate infants with perinatal asphyxia in outpatient settings.
Acta Paediatr 2016, 105: 1056-1560

AIM: General movement assessment (GMA) can help to identify children with a high risk of developing neurological dysfunction, such as cerebral palsy, and certified training is provided in this specialism. The aim of this study was to investigate the feasibility and reliability of using video recordings to assess GMA, in a busy Danish outpatient clinic. METHODS: The study comprised 30-term infants born with perinatal asphyxia, who were video recorded at three months. They were assessed by two certified GMA observers and re-assessed two weeks later. Interobserver and intra-observer agreements were analysed using proportional agreement, and nominal kappa statistics were used to calculate 95% confidence intervals (95% CI). RESULTS: We found substantial and almost perfect interobserver and intra-observer reliability. Intra-observer agreement was 0.85 (95% CI: 0.65-1.00; p < 0.0001) and 0.85 (95% CI: 0.62-1.00; p < 0.0001), and interobserver agreement was 0.71 (95% CI: 0.45-0.96; p < 0.0001) at time point one and 0.85 (95% CI: 0.63-1.00; p < 0.0001) two weeks later. All video recordings were completed within our multidisciplinary outpatient clinic without delay. CONCLUSION: This study demonstrated the reliability of the GMA method in a busy multidisciplinary Danish paediatric outpatient setting, when assessors had been formally trained in the method and used it regularly.

183. Tanis, JC, Schmitz DM, Boelen MR, Casarella L, van den Berg PP, Bilardo CM, Bos, AF. 
Relationship between general movements in neonates who were growth restricted in utero and prenatal Doppler flow patterns.
Ultrasound Obstet Gynecol 2016, 48: 772-778.

OBJECTIVE: To investigate whether Doppler pulsatility indices (PIs) of the fetal circulation in cases of fetal growth restriction (FGR) are associated with the general movements (GMs) of the neonate after birth. METHODS: This was a prospective observational cohort study including pregnancies with FGR diagnosed between June 2012 and September 2014. A diagnosis of FGR was based on an abdominal circumference or estimated fetal weight < 10th percentile (in conjuction with abnormal Doppler) or declining fetal growth of at least 30 percentiles with respect to previous size measurements. Doppler parameters of the umbilical artery (UA), fetal middle cerebral artery (MCA) and ductus venosus (DV) were measured maximally 1 week prior to delivery. Cerebroplacental ratio (CPR) was calculated as MCA-PI divided by UA-PI. We assessed the quality of neonatal GMs 7 days after birth, around the due date if cases were born preterm, and at 3 months post-term. We performed a detailed analysis of the motor repertoire by calculating a motor optimality score (MOS). RESULTS: Forty-eight FGR cases were included with a median gestational age at delivery of 35 (range, 26–40) weeks. UA-PI, MCA-PI and CPR correlated strongly (ρ, −0.374 to 0.472; P < 0.01) with the MOS on day 7 after birth, but DV-PI did not. Doppler PI measurements did not correlate with MOS at 3 months post-term. CONCLUSION: Fetal arterial Doppler measurements are associated with the quality of neonatal GMs 1 week after birth, but this association is no longer evident at 3 months post-term. Brain sparing in particular is associated strongly with GMs of an abnormal quality.

182. Spittle AJ, Olsen J, Kwong A, Doyle LW, Marschik PB, Einspieler C, Cheong J.
The Baby Moves prospective cohort study protocol: using a smartphone application with the General Movements Assessment to predict neurodevelopmental outcomes at age 2 years for extremely preterm or extremely low birthweight infants. 
BMJ Open 2016; 6: e013446

INTRODUCTION: Infants born extremely preterm (EP; <28 weeks' gestation) and/or with extremely low birth weight (ELBW; <1000g birth weight) are at increased risk for adverse neurodevelopmental outcomes. However, it is challenging to predict those EP/ELBW infants destined to have long-term neurodevelopmental impairments in order to target early intervention to those in most need. The General Movements Assessment (GMA) in early infancy has high predictive validity for neurodevelopmental outcomes in preterm infants. However, access to a GMA may be limited by geographical constraints and a lack of GMA-trained health professionals. Baby Moves is a smartphone application (app) developed for caregivers to video and upload their infant's general movements to be scored remotely by a certified GMA assessor. The aim of this study is to determine the predictive ability of using the GMA via the Baby Moves app for neurodevelopmental impairment in infants born EP/ELBW. METHODS AND ANALYSIS: This prospective cohort study will recruit infants born EP/ELBW across the state of Victoria, Australia in 2016 and 2017. A control group of normal birth weight (>2500 g birth weight), term-born (≥37 weeks' gestation) infants will also be recruited as a local reference group. Parents will video their infant's general movements at two time points between 3 and 4 months' corrected age using the Baby Moves app. Videos will be scored by certified GMA assessors and classified as normal or abnormal. Parental satisfaction using the Baby Moves app will be assessed via survey. Neurodevelopmental outcome at 2 years' corrected age includes developmental delay according to the Bayley Scales of Infant and Toddler Development-III and cerebral palsy diagnosis. ETHICS AND DISSEMINATION: This study was approved by the Human Research and Ethics Committees at the Royal Children's Hospital, The Royal Women's Hospital, Monash Health and Mercy Health in Melbourne, Australia. Study findings will be disseminated via peer-reviewed publications and conference presentations.

181. Adde L, Thomas N, John HB, Oommen S, Vågen RT, Fjørtoft T, Jensenius AR, Støen R
Early motor repertoire in very low birth weight infants in India is associated with motor development at one year.
Eur J Paediatr Neurol 2016; 20: 918-924.

BACKGROUND: Most studies on Prechtl's method of assessing General Movements (GMA) in young infants originate in Europe. AIM: To determine if motor behavior at an age of 3 months post term is associated with motor development at 12 months post age in VLBW infants in India. METHODS: 243 VLBW infants (135 boys, 108 girls; median gestational age 31wks, range 26-39wks) were video-recorded at a median age of 11wks post term (range 9-16wks). Certified and experienced observers assessed the videos by the "Assessment of Motor Repertoire - 2-5 Months". Fidgety movements (FMs) were classified as abnormal if absent, sporadic or exaggerated, and as normal if intermittently or continually present. The motor behaviour was evaluated by repertoire of co-existent other movements (age-adequacy) and concurrent motor repertoire. In addition, videos of 215 infants were analyzed by computer and the variability of the spatial center of motion (CSD) was calculated. The Peabody Developmental Motor Scales was used to assess motor development at 12 months. RESULTS: Abnormal FMs, reduced age adequacy, and an abnormal concurrent motor repertoire were significantly associated with lower Gross Motor and Total Motor Quotient (GMQ, TMQ) scores (p<0.05). The CSD was higher in children with TMQ scores <90 (-1SD) than in children with higher TMQ scores (p=0.002). CONCLUSION: Normal FMs (assessed by Gestalt perception) and a low variability of the spatial center of motion (assessed by computer-based video analysis) predicted higher Peabody scores in 12-month-old infants born in India with a very low birth weight. 

180. van Iersel PA, Bakker SC, Jonker AJ, Hadders-Algra M.
Does general movements quality in term infants predict cerebral palsy and milder forms of limited mobility at 6 years?
Dev Med Child Neurol 2016; Aug 13. doi: 10.1111/dmcn.13228. [Epub ahead of print]

AIM: To evaluate in term infants associations between quality of general movements and developmental outcome in term infants at 6 years with either cerebral palsy (CP) or limited mobility without CP. METHOD: Participants of this prospective study were 145 term infants (86 male, 59 female). Their general movements quality was assessed at 'writhing' and 'fidgety' general movements age (3wks and 13wks post term). The assessment at 6 years consisted of a neurological examination, including assessment of minor neurological dysfunction (MND), evaluation of mobility with the Movement Assessment Battery for Children, and of behaviour and learning problems with questionnaires. RESULTS: Definitely abnormal general movements at writhing age were not associated with CP, whereas definitely abnormal general movements at fidgety age were (sensitivity 60%; specificity 91%; positive predictive value 19%, negative predictive value 98%). In children without CP, general movements quality was not associated with limited mobility, but it was associated to a minor extent with MND. INTERPRETATION: In term infants, definitely abnormal general movements at fidgety age do predict CP, but with lower accuracy than in preterm infants. General movements quality does not predict limited mobility in children without CP. The study supports suggestions that predictive value of general movements assessment in term infants is lower than that in preterm infants.

179. Einspieler C, Freilinger M, Marschik PB.
Behavioural biomarkers of typical Rett syndrome: moving towards early identification.
Wien Med Wochenschr 2016; 166: 333-337. 

The dynamic course of Rett syndrome (RTT) is still said to begin with a period of apparently normal development although there is mounting evidence that individuals with RTT show behavioural peculiarities and abnormalities during their infancy. Their spontaneous general movements are abnormal from birth onwards. Normal cooing vocalisation and canonical babbling (if at all required) are interspersed with abnormalities such as proto-vowel and proto-consonant alternations produced on ingressive airstream, breathy voice characteristics, and pressed or high-pitched vocalisations. The gestural repertoire is limited. Certain developmental motor and speech-language milestones are not at all acquired or show a significant delay. Besides abnormal blinking, repetitive and/or long lasting tongue protrusion, and bizarre smiling, there are already the first body and/or hand stereotypies during the first year of life. We are currently on a promising way to define a specific set of behavioural biomarkers pinpointing RTT. 

178. Miyagishima S, Asaka T, Kamatsuka K, Kozuka N, Kobayashi M, Igarashi R, Hori T, Yoto Y, Tsutsumi H.
Characteristics of antigravity spontaneous movements in preterm infants up to 3 months of corrected age.
Infant Behav Dev 2016; 44: 227-239. 

AIMS: We investigated whether spontaneous antigravity limbs movements in very low birth weight preterm infants were insufficient compared to those in term infants. The relationship between the quality of general movements (GMs) and antigravity limbs movements was also examined. METHODS: Preterm infants with very low birth weight without central nervous system disorders nor severe respiration disorders, and healthy term infants were recruited. The infants were set in a supine position. The distance between both hands and between both feet, and the height of both hands and feet from the floor were recorded at 1-3 corrected months for preterm infants, and at 1-3 months for term infants by a 3D motion capture system. The measurements were adjusted for body proportions. GMs in preterm and term infants were assessed similarly. RESULTS: Thirteen preterm and 15 term infants completed the study. In preterm infants, the distance between both hands and between both feet were longer, and the height of both hands and feet were lower than those in term infants in all measurements. In term infants, the height of both hands and feet increased as they developed, but no change was observed in preterm infants. In preterm infants with abnormal GMs, the distance between both hands was longer, and the height of both hands and feet was lower than that in those with normal GMs. There were no such differences between preterm infants with normal GMs and term infants with normal GMs. CONCLUSION: Antigravity limbs movements in preterm infants within the first 3 month of corrected age were insufficient compared with those in term infants. Furthermore, no improvement with development was observed in preterm infants. In addition, preterm infants with abnormal GMs showed worse antigravity limbs movements than preterm and term infants with normal GMs. The preterm infants with normal GMs could behave similar to the full term infants.

177. Olsen JE, Brown NC, Eeles AL, Einspieler C, Lee KJ, Thompson DK, Anderson PJ, Cheong JL, Doyle LW, Spittle AJ.
Early general movements and brain magnetic resonance imaging at term-equivalent age in infants born <30weeks' gestation. 
Early Hum Dev 2016; 101: 63-68. 

BACKGROUND: Neurodevelopmental assessments and brain magnetic resonance imaging (MRI) at term-equivalent age (TEA) predict developmental outcomes in preterm infants. However, the relationship between neurodevelopment prior to term and cerebral structure is currently unknown. AIMS: To examine the relationships between General Movements (GMs) assessed from birth to TEA and brain MRI at TEA in infants born <30weeks' gestation. STUDY DESIGN: Prospective cohort study. GMs (categorised as 'normal' or 'abnormal') were recorded weekly from birth to 32weeks, and at 34 and 36weeks' postmenstrual age. At TEA, GMs were assessed concurrently with brain MRI (using a validated scoring system). SUBJECTS: 149 infants born <30weeks' gestation were recruited from a tertiary hospital. RESULTS: 103 infants had MRI at TEA and GMs recorded. Abnormal GMs prior to term were associated with cortical grey matter abnormality (p<0.03), deep grey matter abnormality (p=0.02) and increased interhemispheric distance (p<0.02). Abnormal GMs at TEA (n=55/90) were associated with more global brain abnormality (p<0.01) and cortical grey matter abnormality (p=0.01), and decreased transcerebellar diameter (p=0.04) on concurrent brain MRI. CONCLUSIONS: Abnormal GMs both prior to term and at TEA were associated with more marked brain abnormality, and smaller brains at TEA. Abnormal GMs are an early marker of brain abnormalities in very preterm infants.

176. So S, Patterson C, Gold A, Rogers A, Kosar C, de Silva N, Burghardt KM, Avitzur Y, Wales PW.
Early neurodevelopmental outcomes of infants with intestinal failure.
Early Hum Dev 2016; 101: 11-16. 

BACKGROUND: The survival rate of infants and children with intestinal failure is increasing, necessitating a greater focus on their developmental trajectory. AIMS: To evaluate neurodevelopmental outcomes in children with intestinal failure at 0-15months corrected age. STUDY DESIGN: Analysis of clinical, demographic and developmental assessment results of 33 children followed in an intestinal rehabilitation program between 2011 and 2014. Outcome measures included: Prechtl's Assessment of General Movements, Movement Assessment of Infants, Alberta Infant Motor Scale and Mullen Scales of Early Learning. Clinical factors were correlated with poorer developmental outcomes at 12-15months corrected age. RESULTS: Thirty-three infants (17 males), median gestational age 34weeks (interquartile range 29.5-36.0) with birth weight 1.98kg (interquartile range 1.17-2.50). Twenty-nine (88%) infants had abnormal General Movements. More than half had suspect or abnormal scores on the Alberta Infant Motor Scale and medium to high-risk scores for future neuromotor delay on the Movement Assessment of Infants. Delays were seen across all Mullen subscales, most notably in gross motor skills. Factors significantly associated with poorer outcomes at 12-15months included: prematurity, low birth weight, central nervous system co-morbidity, longer neonatal intensive care admission, necrotizing enterocolitis diagnosis, number of operations and conjugated hyperbilirubinemia. CONCLUSION: Multiple risk factors contribute to early developmental delay in children with intestinal failure, highlighting the importance of close developmental follow-up.

175. Zang FF, Yang H, Han Q, Cao JY, Tomantschger I, Krieber M, Shi W, Luo DD, Zhu M, Einspieler C.
Very low birth weight infants in China: the predictive value of the motor repertoire at 3 to 5months for the motor performance at 12months.
Early Hum Dev 2016; 100: 27-32. 

BACKGROUND: Studies on motor performance and its early markers are rare in China, especially in very low birth weight (VLBW) infants. OBJECTIVE: Apart from the assessment of the inter-scorer agreement, we aimed to analyze to what extent the motor repertoire at 10 to 18weeks postterm was related to neonatal complications, and gross and fine motor performance at 12months after term. STUDY DESIGN: Exploratory prospective study. SUBJECTS: Seventy-four VLBW infants (58 males; mean gestational age=29weeks; mean birth weight=1252g). METHOD: Five-minute video recordings were performed at 10 to 18weeks after term; fidgety movements and the concurrent motor patterns (resulting in a motor optimality score) were assessed according to the Prechtl general movements assessment (GMA). The gross and fine motor performance was assessed by means of the Peabody Developmental Motor Scales, second edition, at 12months. RESULTS: Reliability was excellent. Pneumonia was associated with absent fidgety movements; the motor optimality score was lower in infants with pneumonia and/or bronchopulmonary dysplasia. Both absent fidgety movements and a lower motor optimality score were associated with a poor or very poor gross and fine motor performance at the 12-month-assessment. CONCLUSION: Both the assessment of fidgety movements and the evaluation of the concurrent motor repertoire contribute significantly to an identification of VLBW children with a poor gross and fine motor outcome at 12months. The results of this study document the need for an early identification of infants at high risk for a poor motor performance.

174. Caesar R, Boyd RN, Colditz P, Cioni G, Ware RS, Salthouse K, Doherty J, Jackson M, Matthews L, Hurley T, Morosini A, Thomas C, Camadoo L, Baer E; PREMTiME Study Group.
Early prediction of typical outcome and mild developmental delay for prioritisation of service delivery for very preterm and very low birthweight infants: a study protocol.
BMJ Open 2016; 6:e010726. 

INTRODUCTION: Over 80% of very preterm (<32 weeks) and very low birthweight (<1500 g) infants will have either typical development (TD) or mild developmental delay (MDD) in multiple domains. As differentiation between TD and MDD can be difficult, infants with MDD often miss opportunities for intervention. For many clinicians, the ongoing challenge is early detection of MDD without over servicing the population. This study aims to: (1) identify early clinical biomarkers for use in this population to predict and differentiate between TD and MDD at 24 months corrected age. (2) Determine the extent to which family and caregiver factors will contribute to neurodevelopmental and behavioural outcomes. METHODS AND ANALYSIS: Participants will be a prospective cohort of 90 infants (<32 weeks and/or <1500 g). Between 34 weeks gestational age and 16 weeks post-term, infants will have a series of 5 neurological, neuromotor, neurobehavioural and perceptual assessments including General Movement Assessment at preterm, writhing and fidgety age. Primary caregivers will complete questionnaires to identify social risk, maternal depression and family strain. Extensive perinatal data will be collected from the medical record. At 24 months, corrected age (c.a) infants will be assessed using standardised tools including the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley III). Longitudinal trajectories of early assessment findings will be examined to determine any predictive relationship with motor and cognitive outcomes at 24 months c.a. Published data of a cohort of Australian children assessed with the Bayley III at 24 months c.a will provide a reference group of term-born controls. ETHICS: Ethical approval has been obtained from the Queensland Children's Health Services Human Research Ethics Committee (HREC/13/QRCH/66), the University of Queensland (2013001019) and the Sunshine Coast Hospital and Health Service, SC-Research Governance (SSA/13/QNB/66). Publication of all study outcomes will be in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12614000480684; Pre-results.

173. Dimitrijević L, Bjelaković B, Čolović H, Mikov A, Živković V, Kocić M, Lukić S.
Assessment of general movements and heart rate variability in prediction of neurodevelopmental outcome in preterm infants.
Early Hum Dev 2016; 99: 7-12. 

BACKGROUND: Adverse neurologic outcome in preterm infants could be associated with abnormal heart rate (HR) characteristics as well as with abnormal general movements (GMs) in the 1st month of life. AIMS: To demonstrate to what extent GMs assessment can predict neurological outcome in preterm infants in our clinical setting; and to assess the clinical usefulness of time-domain indices of heart rate variability (HRV) in improving predictive value of poor repertoire (PR) GMs in writhing period. STUDY DESIGN: Qualitative assessment of GMs at 1 and 3 months corrected age; 24h electrocardiography (ECG) recordings and analyzing HRV at 1 month corrected age. SUBJECTS: Seventy nine premature infants at risk of neurodevelopmental impairments were included prospectively. OUTCOME MEASURES: Neurodevelopmental outcome was assessed at the age of 2 years corrected. Children were classified as having normal neurodevelopmental status, minor neurologic dysfunction (MND), or cerebral palsy (CP). RESULTS: We found that GMs in writhing period (1 month corrected age) predicted CP at 2 years with sensitivity of 100%, and specificity of 72.1%. Our results demonstrated the excellent predictive value of cramped synchronized (CS) GMs, but not of PR pattern. Analyzing separately a group of infants with PR GMs we found significantly lower values of HRV parameters in infants who later developed CP or MND vs. infants with PR GMs who had normal outcome. CONCLUSIONS: The quality of GMs was predictive for neurodevelopmental outcome at 2 years. Prediction of PR GMs was significantly enhanced with analyzing HRV parameters.

172. Craciunoiu O, Holsti L.
A Systematic Review of the Predictive Validity of Neurobehavioral Assessments During the Preterm Period.
Phys Occup Ther Pediatr 2016; 17:1-16. 

AIMS: For high-risk newborns, early assessment of neurobehavior that accurately predicts neurodevelopmental outcome is the first step towards determining early intervention needs. This study reviews systematically the validity of neurobehavioral assessments administered to premature newborns before term-equivalent age to predict long-term neurodevelopmental outcome. METHODS: A systematic literature search of CINAHL, EMBASE, MEDLINE, PubMed, Web of Science, PsychInfo, Cochrane Library databases was conducted. PRISMA and COSMIN guidelines were followed. RESULTS: Five assessments and 11 studies were identified: (a) Neonatal Behavioral Assessment Scale (NBAS); (b) Test of Infant Motor Performance (TIMP); (c) General Movements (GMs); (d) Neurobehavioral Assessment of the Preterm Infant (NAPI); (e) Neonatal Oral Motor Assessment Scale (NOMAS). Predictive validity estimates were variable. The GMs and TIMP showed the strongest associations with neurodevelopmental outcome. Threats to validity included small sample size, sample bias, limited reliability testing. CONCLUSIONS: Five neurobehavioral measures have established predictive validity for the assessment of premature newborns while they reside in the NICU. Although the GMs and TIMP have the strongest evidence, further higher quality research is required. New methods of testing should be developed that provide accurate prediction and minimize the potential stress induced during developmental assessments.

171. Yeh KK, Liu WY, Wong AM, Chung CY, Lien R, Chuang YF.
Intra-observer reliability of Prechtl's method for the qualitative assessment of general movements in Taiwanese infants.
J Phys Ther Sci 2016; 28: 1588-1594. 

[Purpose] The aim of this study was to examine the intra-observer reliability for Prechtl's General Movements Assessment in Taiwanese infants. This includes the global General Movements Assessment, the Optimality List for Preterm General Movements and Writhing Movements, and the Assessment of Motor Repertoire-3 to 5 Months. [Subjects and Methods] Fifty-nine videos of 37 infants were observed and rated by one physical therapist twice. [Results] The intra-observer reliability ranged from good to very good for the global General Movements Assessment. The overall intra-observer reliabilities for the total score of the Optimality List from preterm up to postmenstrual age 46 weeks and the total score of the Assessment of Motor Repertoire for postmenstrual age 49 to 60 weeks were both good. [Conclusion] The results suggest that the intra-observer reliability of a certified physical therapist was satisfactory for Prechtl's method in Taiwanese infants. 

170. Brown AK, Greisen G, Haugsted U, Jonsbo F.
Formal training in general movement assessment is required to effectively evaluate infants with perinatal asphyxia in outpatient settings.
Acta Paediatr 2016; 105: 1056-1060. 

AIM: General movement assessment (GMA) can help to identify children with a high risk of developing neurological dysfunction, such as cerebral palsy, and certified training is provided in this specialism. The aim of this study was to investigate the feasibility and reliability of using video recordings to assess GMA, in a busy Danish outpatient clinic. METHODS: The study comprised 30-term infants born with perinatal asphyxia, who were video recorded at three months. They were assessed by two certified GMA observers and re-assessed two weeks later. Interobserver and intra-observer agreements were analysed using proportional agreement, and nominal kappa statistics were used to calculate 95% confidence intervals (95% CI). RESULTS: We found substantial and almost perfect interobserver and intra-observer reliability. Intra-observer agreement was 0.85 (95% CI: 0.65-1.00; p < 0.0001) and 0.85 (95% CI: 0.62-1.00; p < 0.0001), and interobserver agreement was 0.71 (95% CI: 0.45-0.96; p < 0.0001) at time point one and 0.85 (95% CI: 0.63-1.00; p < 0.0001) two weeks later. All video recordings were completed within our multidisciplinary outpatient clinic without delay. CONCLUSION: This study demonstrated the reliability of the GMA method in a busy multidisciplinary Danish paediatric outpatient setting, when assessors had been formally trained in the method and used it regularly.

169. Sæther R, Støen R, Vik T, Fjørtoft T, Vågen RT, Silberg IE, Loennecken M, Møinichen UI, Lydersen S, Adde L.
A change in temporal organization of fidgety movements during the fidgety movement period is common among high risk infants.
Eur J Paediatr Neurol 2016; 20: 512-517. 

AIM: General movement assessment (GMA) at 9-20 weeks post-term, can effectively predict cerebral palsy. Our aim was to evaluate intra-individual variability of the temporal organization of fidgety movements (FMs) in high risk infants. 104 High risk infants (66 males) with at least two video recordings from the FMs period participated. 45 of the infants had GA <28 weeks and/or BW ≤800 g. Mean post-term age at first and second assessments was 11.0 (8-16) and 14.0 (11-17) weeks, respectively, and median time-difference between the assessments was 2.0 (range: three days to six weeks) weeks. Video recordings were analyzed according to Prechtl's GMA. RESULTS: 33 (32%) Infants were classified differently at first and second assessments. Six infants (6%) changed from normal to abnormal, and 10 (10%) changed from abnormal to normal FMs. Seven of the ten who changed classification from abnormal to normal were born before GA 26 weeks. A change between intermittent and continual, which are both considered normal, was observed in 17 (16%) infants. CONCLUSION: A change in temporal organization of FMs is common in high risk infants. Especially in extremely preterm infants with abnormal FMs, more than one assessment should be performed before long-term prognosis is considered.

168. Einspieler C, Bos AF, Libertus ME, Marschik PB.
The General Movement Assessment Helps Us to Identify Preterm Infants at Risk for Cognitive Dysfunction.
Front Psychol 2016; 7:406. doi: 10.3389/fpsyg.2016.00406.

Apart from motor and behavioral dysfunctions, deficits in cognitive skills are among the well-documented sequelae of preterm birth. However, early identification of infants at risk for poor cognition is still a challenge, as no clear association between pathological findings based on neuroimaging scans and cognitive functions have been detected as yet. The Prechtl General Movement Assessment (GMA) has shown its merits for the evaluation of the integrity of the young nervous system. It is a reliable tool for identifying infants at risk for neuromotor deficits. Recent studies on preterm infants demonstrate that abnormal general movements (GMs) also reflect impairments of brain areas involved in cognitive development. The aim of this systematic review was to discuss studies that included (i) the Prechtl GMA applied in preterm infants, and (ii) cognitive outcome measures in six data bases. Seven studies met the inclusion criteria and yielded the following results: (a) children born preterm with consistently abnormal GMs up to 8 weeks after term had lower intelligence quotients at school age than children with an early normalization of GMs; (b) from 3 to 5 months after term, several qualitative, and quantitative aspects of the concurrent motor repertoire, including postural patterns, were predictive of intelligence at 7-10 years of age. These findings in 428 individuals born preterm suggest that normal GMs along with a normal motor repertoire during the first months after term are markers for normal cognitive development until at least age 10. 

167. Einspieler C, Peharz R, Marschik PB.
Fidgety movements - tiny in appearance, but huge in impact.
J Pediatr (Rio J) 2016; 92(3 Suppl 1): S64-70. 

OBJECTIVES: To describe fidgety movements (FMs), i.e., the spontaneous movement pattern that typically occurs at 3-5 months after term age, and discuss its clinical relevance. SOURCES: A comprehensive literature search was performed using the following databases: MEDLINE/PubMed, CINAHL, The Cochrane Library, Science Direct, PsycINFO, and EMBASE. The search strategy included the MeSH terms and search strings ('fidgety movement*') OR [('general movement*') AND ('three month*') OR ('3 month*')], as well as studies published on the General Movements Trust website (www.general-movements-trust.info). SUMMARY OF THE DATA: Virtually all infants develop normally if FMs are present and normal, even if their brain ultrasound findings and/or clinical histories indicate a disposition to later neurological deficits. Conversely, almost all infants who never develop FMs have a high risk for neurological deficits such as cerebral palsy, and for genetic disorders with a late onset. If FMs are normal but concurrent postural patterns are not age-adequate or the overall movement character is monotonous, cognitive and/or language skills at school age will be suboptimal. Abnormal FMs are unspecific and have a low predictive power, but occur exceedingly in infants later diagnosed with autism. CONCLUSIONS: Abnormal, absent, or sporadic FMs indicate an increased risk for later neurological dysfunction, whereas normal FMs are highly predictive of normal development, especially if they co-occur with other smooth and fluent movements. Early recognition of neurological signs facilitates early intervention. It is important to re-assure parents of infants with clinical risk factors that the neurological outcome will be adequate if FMs develop normally.

166. Spittle AJ, Walsh J, Olsen JE, McInnes E, Eeles AL, Brown NC, Anderson PJ, Doyle LW, Cheong JL.
Neurobehaviour and neurological development in the first month after birth for infants born between 32-42 weeks' gestation.
Early Hum Dev 2016; 96: 7-14. 

AIMS: The objective of this study was to generate reference values for infants born moderate preterm (MPT), late preterm (LPT) and full term (FT) for three newborn neurobehavioural/neurological examinations in the first weeks after birth. STUDY DESIGN: Prospective cohort study to examine the expected range of values for MPT (born 32(+0) to 33(+6)), LPT (34(+0) to 36(+6)) and FT (born 37 to 42weeks' gestation) infants' performance on the Hammersmith Neonatal Neurological Examination (HNNE), the Neonatal Intensive Care Unit Network Neurobehavioural Scale (NNNS) and Prechtl's General Movements Assessment (GMA) in the first weeks after birth. Further, to determine the effects of sex, gestational age at birth, and postmenstrual age at assessment on the 3 different assessments within the gestational age groups. SUBJECTS: 80 MPT, 129 LPT and 201 FT infants were recruited shortly after birth from a tertiary hospital. RESULTS: The means, standard deviations and 5th, 10th, 25th, 50th, 75th, 90th and 95th centiles are presented for the HNNE and NNNS for each of the three gestational age groups. Overall, FT infants performed better than MPT and LPT infants. The rate of normal GMA within the first few weeks after birth was 25% for MPT, 32% for LPT, and 90% for FT infants. The effects of sex, gestational age at birth, and postmenstrual age at assessment varied between test and gestational age groups. CONCLUSIONS: This study provides normative data for the HNNE, NNNS, and GMA administered within the first weeks after birth in a sample of MPT, LPT and healthy FT infants.

165. Hamer EG, Bos AF, Hadders-Algra M.
Specific characteristics of abnormal general movements are associated with functional outcome at school age. 
Early Hum Dev 2016; 95: 9-13. 

BACKGROUND: Assessing the quality of general movements (GMs) is a non-invasive tool to identify at early age infants at risk for developmental disorders. AIM: To investigate whether specific characteristics of definitely abnormal GMs are associated with developmental outcome at school age. STUDY DESIGN: Observational cohort study (long-term follow-up). SUBJECTS: Parents of 40 children (median age 8.3 years, 20 girls) participated in this follow-up study. In infancy (median corrected age 10 weeks), the children (median gestational age 30.3 weeks; birth weight 1243 g) had shown definitely abnormal GMs according to Hadders-Algra (2004). Information on specific GM characteristics such as the presence of fidgety movements, degree of complexity and variation, and stiff movements, was available (see Hamer et al. 2011). OUTCOME MEASURES: A standardised parental interview (presence of CP, attendance of school for special education, Vineland Adaptive Behavior Scale to determine functional performance) and questionnaires (Developmental Coordination Disorder Questionnaire [DCD-Q] to evaluate mobility and Child Behavior Checklist to assess behaviour) were used as outcome measures. RESULTS: Six children had cerebral palsy (CP), ten children attended a school for special education, and eight children had behavioural problems. Both the absence of fidgety movements and the presence of stiff movements were associated with CP (p=0.001; p=0.003, respectively). Stiff movements were also related to the need of special education (p=0.009). A lack of movement complexity and variation was associated with behavioural problems (p=0.007). None of the GM characteristics were related to DCD-Q scores. CONCLUSIONS: The evaluation of fidgety movements and movement stiffness may increase the predictive power of definitely abnormal GMs for motor outcome--in particular CP. This study endorses the notion that the quality of GMs reflects the integrity of the infant's brain, assisting prediction of long-term outcome.

164. Bennema AN, Schendelaar P, Seggers J, Haadsma ML, Heineman MJ, Hadders-Algra M.
Predictive value of general movements' quality in low-risk infants for minor neurological dysfunction and behavioural problems at preschool age.
Early Hum Dev 2016; 94: 19-24. 

BACKGROUND: General movement (GM) assessment is a well-established tool to predict cerebral palsy in high-risk infants. Little is known on the predictive value of GM assessment in low-risk populations. AIMS: To assess the predictive value of GM quality in early infancy for the development of the clinically relevant form of minor neurological dysfunction (complex MND) and behavioral problems at preschool age. STUDY DESIGN: Prospective cohort study. SUBJECTS: A total of 216 members of the prospective Groningen Assisted Reproductive Techniques (ART) cohort study were included in this study. ART did not affect neurodevelopmental outcome of these relatively low-risk infants born to subfertile parents. OUTCOME MEASURES: GM quality was determined at 2 weeks and 3 months. At 18 months and 4 years, the Hempel neurological examination was used to assess MND. At 4 years, parents completed the Child Behavior Checklist; this resulted in the total problem score (TPS), internalizing problem score (IPS), and externalizing problem score (EPS). Predictive values of definitely (DA) and mildly (MA) abnormal GMs were calculated. RESULTS: DA GMs at 2 weeks were associated with complex MND at 18 months and atypical TPS and IPS at 4 years (all p<0.05). Sensitivity and positive predictive value of DA GMs at 2 weeks were rather low (13%-60%); specificity and negative predictive value were excellent (92%-99%). DA GMs at 3 months occurred too infrequently to calculate prediction. MA GMs were not associated with outcome. CONCLUSIONS: GM quality as a single predictor for complex MND and behavioral problems at preschool age has limited clinical value in children at low risk for developmental disorders.

163. Fjørtoft T, Evensen KA, Øberg GK, Songstad NT, Labori C, Silberg IE, Loennecken M, Møinichen UI, Vågen R, Støen R, Adde L.
High prevalence of abnormal motor repertoire at 3 months corrected age in extremely preterm infants.
Eur J Paediatr Neurol 2016; 20: 236-242. 

AIMS: To compare early motor repertoire between extremely preterm and term-born infants. An association between the motor repertoire and gestational age and birth weight was explored in extremely preterm infants without severe ultrasound abnormalities. METHODS: In a multicentre study, the early motor repertoire of 82 infants born extremely preterm (ELGAN:<28 weeks) and/or with extremely low birth weight (ELBW:<1000 g) and 87 term-born infants were assessed by the "Assessment of Motor Repertoire - 2 to 5 Months" (AMR) which is part of Prechtl's "General Movement Assessment", at 12 weeks post-term age. Fidgety movements were classified as normal if present and abnormal if absent, sporadic or exaggerated. Concurrent motor repertoire was classified as normal if smooth and fluent and abnormal if monotonous, stiff, jerky and/or predominantly fast or slow. RESULTS: Eight-teen ELBW/ELGAN infants had abnormal fidgety movements (8 absent, 7 sporadic and 3 exaggerated fidgety movements) compared with 2 control infants (OR:12.0; 95%CI:2.7-53.4) and 46 ELBW/ELGAN infants had abnormal concurrent motor repertoire compared with 17 control infants (OR:5.3; 95%CI:2.6-10.5). Almost all detailed aspects of the AMR differed between the groups. Results were the same when three infants with severe ultrasound abnormalities were excluded. In the remaining ELBW/ELGAN infants, there was no association between motor repertoire and gestational age or birth weight. CONCLUSION: ELBW/ELGAN infants had poorer quality of early motor repertoire than term-born infants. The findings were not explained by severe abnormalities on neonatal ultrasound scans and were not correlated to the degree of prematurity. The consequences of these abnormal movement patterns remain to be seen in future follow-up studies.

162. Olsen JE, Brown NC, Eeles AL, Lee KJ, Anderson PJ, Cheong JL, Doyle LW, Spittle AJ.
Trajectories of general movements from birth to term-equivalent age in infants born <30 weeks' gestation.
Early Hum Dev 2015; 91: 683-688.

BACKGROUND: General movements (GMs) is an assessment with good predictive validity for neurodevelopmental outcomes in preterm infants. However, there is limited information describing the early GMs of very preterm infants, particularly prior to term. AIMS: To describe the early GMs trajectory of very preterm infants (born <30weeks' gestation) from birth to term-equivalent age, and to assess the influence of known perinatal risk factors on GMs. STUDY DESIGN: Prospective cohort study. SUBJECTS: 149 very preterm infants born <30weeks' gestation. OUTCOME MEASURES: GMs were recorded weekly from birth until 32weeks' postmenstrual age, and then fortnightly until 38weeks' postmenstrual age. GMs were also assessed at term-equivalent age. Detailed perinatal data were collected. RESULTS: Of 669 GMs assessed, 551 were preterm and 118 were at term-equivalent age. Prior to term, 15% (n=82) of GMs were normal and 85% (n=469) were abnormal, with the proportion of abnormal GMs decreasing with increasing postmenstrual age (p for trend <0.001). By term-equivalent 30% (n=35) of GMs were normal. On univariable analysis, lower gestational age (p<0.001), postnatal infection (p<0.001) and bronchopulmonary dysplasia (p=0.001) were associated with abnormal GMs. Postnatal infection was the only independent perinatal association with abnormal GMs on multivariable analysis. All four infants with grade III/IV intraventricular haemorrhage (IVH) had persistently abnormal GMs. CONCLUSIONS: GMs were predominantly abnormal in very preterm infants, with a higher proportion of normal GMs at term-equivalent age than prior to term. Abnormal GMs were associated with postnatal infection and IVH.

161. Zahed M, Berbis J, Brevaut-Malaty V, Busuttil M, Tosello B, Gire C.
Posture and movement in very preterm infants at term age in and outside the nest.
Childs Nerv Syst 2015; 31: 2333-2340. 

OBJECTIVE: The objective of this study is to evaluate the use of nests on general movements (GM) and posture in very preterm infants at term age. METHOD: Seventeen high-risk preterm infants-less than 30 weeks of gestation (GA)-underwent a video recording, lying in supine position, with or without nest. Posture, GM quality, and movements made around the child's midline, as well as abrupt movements and frozen postures-in extension or flexion of the four limbs-were analyzed. RESULTS: Nest did not modify quality of GM. Children significantly adopted a curled-up position. The nest system was associated with an increase in movements toward or across the midline, as well as reduction of the hyperextension posture and head rotation movements. Frozen postures in flexion or extension, as well as abrupt movements of the four limbs, were reduced but not significantly. CONCLUSIONS: Nest helps very preterm infants to adopt semi-flexed posture and facilitates movements across the midline and reduces movements of spine hyperextension, without GM global quality modifications.

160. Chen N, Wen XH, Huang JH, Wang SY, Zhu YE.
[Predictive value of qualitative assessment of general movements for adverse outcomes at 24 months of age in infants with asphyxia].
Zhongguo Dang Dai Er Ke Za Zhi 2015; 17: 1322-1326.

OJBECTIVE: To investigate the predictive value of the qualitative assessment of general movements (GMs) for adverse outcomes at 24 months of age in full-term infants with asphyxia. METHODS: A total of 114 full-term asphyxiated infants, who were admitted to the neonatal intensive care unit between 2009 and 2012 and took part in follow-ups after discharge were included in the study. All of them received the qualitative assessment of GMs within 3 months after birth. The development quotient was determined with the Bayley Scales of Infant Development at 24 months of age. RESULTS: The results of the qualitative assessment of GMs within 3 months after birth showed that among 114 infants, 20 (17.5%) had poor repertoire movements and 7 (6.1%) had cramped-synchronized movements during the writhing movements’ period; 8 infants (7.0%) had the absence of fidgety movements during the fidgety movements period. The results of development quotient at 24 months of age showed that 7 infants (6.1%) had adverse developmental outcomes: 6 cases of cerebral palsy and mental retardation and 1 case of mental retardation. There was a poor consistency between poor repertoire movements during the writhing movements period and the developmental outcomes at 24 months of age (Kappa=-0.019; P>0.05). There was a high consistency between cramped-synchronized movements during the writhing movements period and the developmental outcomes at 24 months of age (Kappa=0.848; P<0.05), and the results of predictive values of cramped-synchronized movements were shown as follows: predictive validity 98.2%, sensitivity 85.7%, specificity 99.1%, positive predictive value 85.7%, and negative predictive value 99.1%. There was a high consistency between the absence of fidgety movements during the fidgety movements period and the developmental outcomes at 24 months of age (Kappa=0.786; P<0.05), and its predictive values were expressed as follows: predictive validity 97.4%, sensitivity 85.7%, specificity 98.1%, positive predictive value 75.0%, and negative predictive value 99.1%. CONCLUSIONS: Cramped-synchronized movements and absence of fidgety movements can predict adverse developmental outcomes at 24 months of age in full-term infants with asphyxia.

159. Peyton C, Yang E, Kocherginsky M, Adde L, Fjørtoft T, Støen R, Bos AF, Einspieler C, Schreiber MD, Msall ME.
Relationship between white matter pathology and performance on the General Movement Assessment and the Test of Infant Motor Performance in very preterm infants.
Early Hum Dev 2016; 95: 23-27.  

BACKGROUND: Cerebral Magnetic Resonance Imaging, the General Movement Assessment, and the Test of Infant Motor Performance are all tools that can predict neurodevelopmental outcome in preterm infants. However, how these tests relate to each other is unclear. AIMS: To examine the relationship between cerebral Magnetic Resonance Imaging measured at term age, and the General Movement Assessment and Test of Infant Motor Performance measured at 10-15weeks post-term age. STUDY DESIGN: Prospectively collected data in a sample of very preterm infants SUBJECTS: Fifty-three infants (23 female, 30 male) with a median gestational age of 28weeks (range: 23-30weeks) and a median birth weight of 1000g (range: 515-1465g). OUTCOME MEASURES: Test of Infant Motor Performance, General Movement Assessment. RESULTS: Infants with abnormal white matter were significantly more likely to have both abnormal general movements (p=0.01) and abnormal Test of Infant Motor Performance scores (p=0.001). Infants with abnormal general movements were significantly more likely to have lower Test of Infant Motor Performance Scores (p=0.01). CONCLUSIONS: Abnormal white matter is related to motor deviations as measured by the General Movement Assessment and the Test of Infant Motor Performance as early as 3months post-term age in a cohort of preterm infants.

158. Raith W, Marschik PB, Sommer C, Maurer-Fellbaum U, Amhofer C, Avian A, Löwenstein E, Soral S, Müller W, Einspieler C, Urlesberger B.
General Movements in preterm infants undergoing craniosacral therapy: a randomised controlled pilot-trial.
BMC Complement Altern Med 2016; 16: 12ff. doi: 10.1186/s12906-016-0984-5.

BACKGROUND: The objective of this study was to investigate neurological short-term effects of craniosacral therapy as an ideal form of osteopathic manipulative treatment (OMT) due to the soft kinaesthetic stimulation. METHODS: Included were 30 preterm infants, with a gestational age between 25 and 33 weeks, who were admitted to the neonatal intensive care unit of the University Hospital of Graz, Austria. The infants were randomized either into the intervention group (IG) which received standardised craniosacral therapy, or the control group (CG) which received standard care. To guarantee that only preterm infants with subsequent normal neurodevelopment were included, follow up was done regularly at the corrected age (= actual age in weeks minus weeks premature) of 12 and 24 months. After 2 years 5 infants had to be excluded (IG; n = 12; CG: n = 13). General Movements (GMs) are part of the spontaneous movement repertoire and are present from early fetal life onwards until the end of the first half year of life. To evaluate the immediate result of such an intervention, we selected the General Movement Assessment (GMA) as an appropriate tool. Besides the global GMA (primary outcome) we used as detailed GMA, the General Movement Optimality Score (GMOS- secondary outcome), based on Prechtl's optimality concept. To analyse GMOS (secondary outcome) a linear mixed model with fixed effects for session, time point (time point refers to the comparisons of the measurements before vs. after each session) and intervention (IG vs. CG), random effect for individual children and a first order autoregressive covariance structure was used for calculation of significant differences between groups and interactions. Following interaction terms were included in the model: session*time point, session*intervention, time point*intervention and session*time point*intervention. Exploratory post hoc analyses (interaction: session*time point*intervention) were performed to determine group differences for all twelve measurement (before and after all 6 sessions) separately. RESULTS: Between groups no difference in the global GMA (primary outcome) could be observed. The GMOS (secondary outcome) did not change from session to session (main effect session: p = 0.262) in the IG or the CG. Furthermore no differences between IG and CG (main effect group: p = 0.361) and no interaction of time*session could be observed (p = 0.658). Post hoc analysis showed a trend toward higher values before (p = 0.085) and after (p = 0.075) the first session in CG compared to IG. At all other time points GMOS were not significantly different between groups. CONCLUSION: We were able to indicate that a group of "healthy" preterm infants undergoing an intervention with craniosacral therapy (IG) showed no significant changes in GMs compared to preterm infants without intervention (CG). In view of the fact that the global GMA (primary outcome) showed no difference between groups and the GMOS (detailed GMA-secondary outcome) did not deteriorate in the IG, craniosacral therapy seems to be safe in preterm infants.

157. Morgan C, Crowle C, Goyen TA, Hardman C, Jackman M, Novak I, Badawi N.
Sensitivity and specificity of General Movements Assessment for diagnostic accuracy of detecting cerebral palsy early in an Australian context.
J Paediatr Child Health 2016; 52: 54-59. 

AIM: The aim of this study was to calculate the sensitivity and specificity of the General Movements Assessment (GMA) for estimating diagnostic accuracy in detecting cerebral palsy (CP) in an Australian context by a newly established NSW rater network. METHODS: A prospective longitudinal cross-sectional study was conducted. The GMA was blind-rated from conventional video by two independent certified raters, blinded to medical history. A third rater resolved disagreements. High-risk population screening for CP using the GMA during the fidgety period (12-20 weeks) was carried out in four neonatal intensive care units and one CP service over a 30-month period (2012-2013). Participants were 259 high-risk infants. Sensitivity and specificity values were calculated with true positives defined as a confirmed diagnosis of CP from a medical doctor. RESULTS: Of the 259 infants assessed, 1-year follow-up data were available for 187. Of these, n = 48 had absent fidgety (high risk for CP), n = 138 had normal fidgety (low risk for CP), and n = 1 had abnormal fidgety (high risk for a neurological disorder). Of the 48 with absent fidgety movements, 39 had received a diagnosis of CP by 18 months and another 6 had an abnormal outcome. Of the n = 138 normal fidgety cases, n = 99 cases had a normal outcome, n = 38 had an abnormal outcome but not CP, and n = 1 had CP. For detecting CP, we had a sensitivity of 98% and specificity of 94%. CONCLUSION: GMA was feasible in an Australian context and accurately identified CP with a sensitivity and specificity comparable with European standards and published neuroimaging data.

156. Lev-Enacab O, Sher-Censor E, Einspieler C, Daube-Fishman G, Beni-Shrem, S.
The Quality of Spontaneous Movements of Preterm Infants: Associations with the Quality of Mother-Infant Interaction 
INFANCY 2015; 20: 634-660.

The assessment of the quality of infants’ spontaneous movements is a diagnostic tool for the young nervous system. We examined whether it relates to the quality of the interactions between infants born preterm and their mothers. Thirty-nine healthy infants born preterm (Mage in weeks=14.59, SD=2.21; 38.46% female) and their mothers participated in the study. Infants’ quality of spontaneous movements was assessed using the General Movement Assessment according to Prechtl (Prechtl, Early Human Development 1990, 23, 151). A new measurement was employed to evaluate the following aspects of the mother–infant interaction: maternal sensitivity in the motor modality (i.e., when touching, picking up, holding, and putting down the infant), maternal sensitivity in the modalities of vocalization and eye contact, and infants’ positive engagement. Several aspects of infants’ quality of movements were associated with maternal sensitivity in the motor modality and infants’ positive engagement, but not with maternal sensitivity in the modalities of vocalization and eye contact. These findings suggest that the quality of infants’ spontaneous movements may explain some of the variability in the interactions between infants born preterm and their mothers. The results also highlight the importance of differentiating between the modalities of mothers’ behavior when assessing their sensitivity. Implications for research and practice with families of preterm infants are discussed.

155. Einspieler C, Marschik PB, Pansy J, Scheuchenegger A, Krieber M, Yang H, Kornacka MK, Rowinska E, Soloveichick M, Bos AF, et al. 
The general movement optimality score: a detailed assessment of general movements during preterm and term age.
Dev Med Child Neurol 2015; Sep 14. doi: 10.1111/dmcn.12923. 

AIM: To explore the appropriateness of applying a detailed assessment of general movements and characterize the relationship between global and detailed assessment. METHOD: The analysis was based on 783 video recordings of 233 infants (154 males, 79 females) who had been videoed from 27 to 45 weeks postmenstrual age. Apart from assessing the global general movement categories (normal, poor repertoire, cramped-synchronized, or chaotic general movements), we scored the amplitude, speed, spatial range, proximal and distal rotations, onset and offset, tremulous and cramped components of the upper and lower extremities. Applying the optimality concept, the maximum general movement optimality score of 42 indicates the optimal performance. RESULTS: General movement optimality scores (GMOS) differentiated between normal general movements (median 39 [25-75th centile 37-41]), poor repertoire general movements (median 25 [22-29]), and cramped-synchronized general movements (median 12 [10-14]; p<0.01). The optimality score for chaotic general movements (mainly occurring at late preterm age) was similar to those for cramped-synchronized general movements (median 14 [12-17]). Short-lasting tremulous movements occurred from very preterm age (<32wks) to post-term age across all general movement categories, including normal general movements. The detailed score at post-term age was slightly lower compared to the scores at preterm and term age for both normal (p=0.02) and poor repertoire general movements (p<0.01). INTERPRETATION: Further research might demonstrate that the GMOS provides a solid base for the prediction of improvement versus deterioration within an individual general movement trajectory. 

154. Zappella M, Einspieler C, Bartl-Pokorny KD, Krieber M, Coleman M, Bölte S, Marschik PB.
What do home videos tell us about early motor and socio-communicative behaviours in children with autistic features during the second year of life - An exploratory study.
Early Hum Dev 2015; 91: 569-575.

BACKGROUND: Little is known about the first half year of life of individuals later diagnosed with autism spectrum disorders (ASD). There is even a complete lack of observations on the first 6 months of life of individuals with transient autistic behaviours who improved in their socio-communicative functions in the pre-school age. AIM: To compare early development of individuals with transient autistic behaviours and those later diagnosed with ASD. STUDY DESIGN: Exploratory study; retrospective home video analysis. SUBJECTS: 18 males, videoed between birth and the age of 6 months (ten individuals later diagnosed with ASD; eight individuals who lost their autistic behaviours after the age of 3 and achieved age-adequate communicative abilities, albeit often accompanied by tics and attention deficit). METHOD: The detailed video analysis focused on general movements (GMs), the concurrent motor repertoire, eye contact, responsive smiling, and pre-speech vocalisations. RESULTS: Abnormal GMs were observed more frequently in infants later diagnosed with ASD, whereas all but one infant with transient autistic behaviours had normal GMs (p<0.05). Eye contact and responsive smiling were inconspicuous for all individuals. Cooing was not observable in six individuals across both groups. CONCLUSIONS: GMs might be one of the markers which could assist the earlier identification of ASD. We recommend implementing the GM assessment in prospective studies on ASD.

153. Valle SC, Støen R, Sæther R, Jensenius AR, Adde L.
Test-retest reliability of computer-based video analysis of general movements in healthy term-born infants.
Early Hum Dev 2015; 91: 555-558. 

BACKGROUND: A computer-based video analysis has recently been presented for quantitative assessment of general movements (GMs). This method's test-retest reliability, however, has not yet been evaluated. AIMS: The aim of the current study was to evaluate the test-retest reliability of computer-based video analysis of GMs, and to explore the association between computer-based video analysis and the temporal organization of fidgety movements (FMs). STUDY DESIGN: Test-retest reliability study. SUBJECTS: 75 healthy, term-born infants were recorded twice the same day during the FMs period using a standardized video set-up. OUTCOME MEASURES: The computer-based movement variables "quantity of motion mean" (Qmean), "quantity of motion standard deviation" (QSD) and "centroid of motion standard deviation" (CSD) were analyzed, reflecting the amount of motion and the variability of the spatial center of motion of the infant, respectively. In addition, the association between the variable CSD and the temporal organization of FMs was explored. Intraclass correlation coefficients (ICC 1.1 and ICC 3.1) were calculated to assess test-retest reliability. RESULTS: The ICC values for the variables CSD, Qmean and QSD were 0.80, 0.80 and 0.86 for ICC (1.1), respectively; and 0.80, 0.86 and 0.90 for ICC (3.1), respectively. There were significantly lower CSD values in the recordings with continual FMs compared to the recordings with intermittent FMs (p<0.05). CONCLUSION: This study showed high test-retest reliability of computer-based video analysis of GMs, and a significant association between our computer-based video analysis and the temporal organization of FMs.

152. Øberg GK, Jacobsen BK, Jørgensen L.
Predictive Value of General Movement Assessment for Cerebral Palsy in Routine Clinical Practice.
Phys Ther 2015; 95: 1489-1495. 

BACKGROUND: Early identification of children at high risk of future neurodevelopmental disability is important for the initiation of appropriate therapy. In research settings, the assessment of fidgety movements (FMs) at 3 months supports a general movement assessment (GMA) as a strong predictor for subsequent motor development, but there are few studies from routine clinical settings. OBJECTIVE: The study objective was to examine the relationship between FMs and neurodevelopmental outcome by the age of 2 years in high-risk infants in a routine hospital clinical setting. DESIGN: This was a prospective study. METHODS: A GMA was performed in 87 high-risk infants at 3 months after term age. The infants were clinically assessed for cerebral palsy (CP) at 2 years. Sensitivity, specificity, likelihood ratios, and positive and negative predictive values were computed. The relative risk of motor problems by the age of 2 years, according to the GMA, was estimated. RESULTS: Of the infants with normal FMs, 93% (50/54) had normal development and none was diagnosed with CP, whereas 75% (12/16) with abnormal or sporadic FMs had normal development. In contrast, 53% (9/17) of those without FMs had CP. When the GMA was considered to be a test for CP and absent FMs were considered to be a positive test result, the sensitivity was 90% and the specificity was 90%. The likelihood ratios for positive and negative test results were 8.7 and 0.1, respectively. The negative predictive value was 99%, and the positive predictive value was 53%. The risk of motor problems by the age of 2 years increased linearly with the extent of pathological results on the GMA and was 10 times higher when FMs were absent at 3 months than when FMs were normal. LIMITATIONS: The relatively small study sample was a study limitation.

151. Soleimani F, Badv RS, Momayezi A, Biglarian A, Marzban A. 
General movements as a predictive tool of the neurological outcome in term born infants with hypoxic ischemic encephalopathy. 
Early Hum Dev 2015; 91: 479-82.

BACKGROUND: At a time of increasing high risk neonates, an assessment method is needed that can reliably predict neurological deficits at an early age. AIMS: The objective of this study was to determine whether the assessment of fidgety movements (FMs) will predict the neurological outcome of infants with hypoxic ischemic encephalopathy (HIE). STUDY DESIGN: This study employed a prospective and descriptive plan. SUBJECTS: The study sample consisted of 15 infants (8 male and 7 female) born at term. Video recording of FMs were analyzed at 3 to 5months' infants, who identified with perinatal asphyxia and neonatal HIE. FMs were classified as present or absent. OUTCOME MEASURES: At 12-18months age, the infants' developmental outcome was classified as normal or abnormal according to the Infant Neurological International Battery test. "Abnormal outcome" was denoted as poor motor or neurological outcome such as cerebral palsy, whereas "Normal outcome" denotes normal motor and neurological outcomes. RESULTS: The predictive values of FMs were: a sensitivity 0.80 (95% CI: 0.44-0.96), a specificity 1.00 (95% CI: 0.47-1.00), and the accuracy 0.87 (0.57 to 1.00). CONCLUSIONS: FMs assessment improves our ability to predict later neurodevelopmental outcomes in term born children with neonatal HIE.

150. Einspieler C, Yang H, Bartl-Pokorny KD, Chi X, Zang FF, Marschik PB, Guzzetta A, Ferrari F, Bos AF, Cioni G.
Are sporadic fidgety movements as clinically relevant as is their absence?
Early Hum Dev 2015; 91: 247-252. 

BACKGROUND: Infants with normal fidgety movements at 3 to 5 months after term are very likely to show neurologically normal development, while the absence of fidgety movements is an early marker for an adverse neurological outcome, mainly cerebral palsy (CP). The clinical significance of so-called sporadic fidgety movements (i.e., fidgety movements occur isolated in a few body parts and are of 1- to 3-second-duration) is not yet known. AIMS: Our objective was to determine whether infants who had developed CP and had sporadic fidgety movements have a better outcome than infants who did not have fidgety movements. STUDY DESIGN: Longitudinal study. Retrospective analysis of prospectively collected data. SUBJECTS: 61 infants who developed CP (46 male, 15 female; 29 infants born preterm; videoed for the assessment of movements and postures at 9 to 16 weeks post-term age). OUTCOME MEASURES: The Gross Motor Function Classification System (GMFCS) was applied at 3 to 5 years of age. RESULTS: There was no difference between children diagnosed with CP who had sporadic fidgety movements at 9 to 16 weeks post-term age (n = 9) and those who never developed fidgety movements (n = 50) with regard to their functional mobility and activity limitation at 3 to 5 years of age. One infant had normal FMs and developed unilateral CP, GMFCS Level I; the remaining infant had abnormal FMs and developed bilateral CP, GMFCS Level II. CONCLUSIONS: There is no evidence that the occurrence of occasional isolated fidgety bursts indicates a milder type of CP.

149. Marcroft C, Khan A, Embleton ND, Trenell M, Plötz T.
Movement recognition technology as a method of assessing spontaneous general movements in high risk infants.
Front Neurol 2015; Jan 9;5: 284. doi: 10.3389/fneur.2014.00284

Preterm birth is associated with increased risks of neurological and motor impairments such as cerebral palsy. The risks are highest in those born at the lowest gestations. Early identification of those most at risk is challenging meaning that a critical window of opportunity to improve outcomes through therapy-based interventions may be missed. Clinically, the assessment of spontaneous general movements is an important tool, which can be used for the prediction of movement impairments in high risk infants. Movement recognition aims to capture and analyze relevant limb movements through computerized approaches focusing on continuous, objective, and quantitative assessment. Different methods of recording and analyzing infant movements have recently been explored in high risk infants. These range from camera-based solutions to body-worn miniaturized movement sensors used to record continuous time-series data that represent the dynamics of limb movements. Various machine learning methods have been developed and applied to the analysis of the recorded movement data. This analysis has focused on the detection and classification of atypical spontaneous general movements. This article aims to identify recent translational studies using movement recognition technology as a method of assessing movement in high risk infants. The application of this technology within pediatric practice represents a growing area of inter-disciplinary collaboration, which may lead to a greater understanding of the development of the nervous system in infants at high risk of motor impairment. 

148. Herskind A, Greisen G, Nielsen JB.
Early identification and intervention in cerebral palsy.
Dev Med Child Neurol 2015; 57: 29-36. 

Infants with possible cerebral palsy (CP) are commonly assumed to benefit from early diagnosis and early intervention, but substantial evidence for this is lacking. There is no consensus in the literature on a definition of 'early', but this review focuses on interventions initiated within the first 6 months after term age. We cover basic neuroscience, arguing for a beneficial effect of early intervention, and discuss why clinical research to support this convincingly is lacking. We argue that infants offered early intervention in future clinical studies must be identified carefully, and that the intervention should be focused on infants showing early signs of CP to determine an effect of treatment. Such signs may be efficiently detected by a combination of neuroimaging and the General Movements Assessment. We propose a research agenda directed at large-scale identification of infants showing early signs of CP and testing of high-intensity, early interventions.

147. Ma L, Yang B, Meng L, Wang B, Zheng C, Cao A.
Effect of early intervention on premature infants' general movements.
Brain Dev 2015; 37: 387-393. 

This study is to investigate the characteristics of premature infants' general movements (GMs) and the effect of early intervention on their GMs. METHODS: The survey was carried among 285 premature infants. (1) Before intervention, the correlation between the gestational age/ birth weight and the GMs was evaluated. (2) The cases were divided into early intervention group (n=145) and control group (n=140), each group was divided into <32 weeks, 32-34 weeks and >34 weeks group according to gestational age. The early intervention was begun at the 3rd day after birth to 54th week gestational age. The rate of GMs among each group was compared after intervention. RESULTS: (1) Before intervention, gestational age/birth weight was negatively correlated with the rate of cramped-synchronized (CS) (r=-0.988, r=-0.95, p<0.01), while no correlation with the rate of poor repertoire (PR) (r=0.122, r=0.168, p>0.05). (2) After intervention, for the writhing movement, there was no significant difference (χ2=0.509, 1.401, 0.519, p>0.05) between the early intervention group and the control group. Nevertheless, for the fidgety movement, there was significant difference (χ2=7.921, χ2=5.763, p<0.05) between the two groups, especially in <32 weeks group (χ2=5.578, 4.067 p<0.05) and in >34 weeks group (χ2=5.757, p<0.05). CONCLUSIONS: (1) It shows that the lower birth weight or the younger delivery gestational age, the more abnormal GMs in premature infants. (2) Early intervention could improve the fidgety movements of premature infant.

146. Hitzert MM, van Geert PL, Hunnius S, Van Braeckel KN, Bos AF, Geuze RH.
Associations between developmental trajectories of movement variety and visual attention in fullterm and preterm infants during the first six months postterm.
Early Hum Dev 2015; 91: 89-96. 

BACKGROUND: During early infancy major developmental changes, both in the variety of body movements and in visual attention, help the infant to explore its surroundings. Both behaviours depend on a gradual shift from subcortical to cortical functioning. AIMS: First, to determine whether preterms reach mature levels of movement variety (the number of different movement patterns) and visual attention earlier than fullterms. Second, to determine whether individual developmental trajectories of movement variety and visual attention were associated. Finally, we compared the associations of developmental trajectories between fullterm and preterm infants. STUDY DESIGN: In this longitudinal study, 20 fullterm and 9 low-risk preterm infants performed a visual disengagement task every four weeks from six weeks until six months postterm. For each infant we drew up developmental trajectories for movement variety, and for frequencies and latencies of looks. We analyzed the developmental trajectories by means of general linear model (GLM) repeated measures and Monte Carlo analyses. RESULTS: In comparison to fullterms, preterm infants showed a similar increase in movement variety over time (F(4,108)=0.27; partial eta(2)=0.01; P=.90). Visual attention reached mature levels four weeks earlier than movement variety. This effect was stronger in fullterm infants. Neither in fullterm nor in preterm infants did we find an association between the developmental trajectories of movement variety and visual attention. P values ranged from .37 to .99. CONCLUSIONS: During the first 6 months postterm, movement variety and visual attention developed independently. Temporarily, preterm exposure to the extrauterine environment led to shorter latencies of looks but it did not affect developmental trajectories of frequencies of looks and movement variety.

145. Crowle C, Badawi N, Walker K, Novak I.
General Movements Assessment of infants in the neonatal intensive care unit following surgery.
J Paediatr Child Health 2015; Mar 31. doi: 10.1111/jpc.12886. 

AIM: There is an identified gap in the literature regarding the use of the General Movements (GMs) Assessment to identify risk in infants post-surgery. This paper aims to examine the GMs for infants who have undergone surgery to identify common risk profiles in the writhing age. METHODS: This was a prospective cohort study of 170 infants (99 male, 58%) admitted to a neonatal surgical unit from 2012 until June 2014. Infants were born at a mean age of 38 weeks (standard deviation (SD) 2.3), and writhing GMs were conducted at term (40 weeks, SD 2.6) following either cardiac (n = 84, 49%) or non-cardiac surgery (n = 86, 51%). GMs were categorised by three trained assessors. RESULTS: Normal writhing was recorded in 64 infants (38%). The most common profile was poor repertoire (n = 80, 47%), with 14 (8%) cramped synchronised. There was no difference in scores between infants who had undergone cardiac versus non-cardiac surgery (P = 0.45).
CONCLUSION: This is the first report on the GMs assessment in an infant surgical population. Infants who have undergone surgery most commonly display poor repertoire writhing movements. Research is needed to determine the ability of the GMs to predict neurodevelopmental outcomes in this population.

144. Mehler K, Mainusch A, Hucklenbruch-Rother E, Hahn M, Hünseler C, Kribs A.
Increased rate of parental postpartum depression and traumatization in moderate and late preterm infants is independent of the infant's motor repertoire.
Early Hum Dev 2014; 90: 797-801. 

BACKGROUND: Moderately and late preterm infants represent a considerable and increasing proportion of infants cared for in neonatal departments worldwide. Parents of preterm infants are at risk of postpartal depression (PPD) and posttraumatic stress disorder (PTSD), and preterm infants are at risk of developmental impairment. AIM: This study aimed to assess (1) the incidence of parental PPD and PTSD in moderate to late preterm infants in comparison to full-term infants and (2) the influence of infants' motor repertoire assessed by Prechtl's general movements and illness severity on parental PPD and PTSD. SUBJECTS: We studied 60 mothers and 56 fathers of 69 preterm infants (born at 32 to 37 weeks of gestation) and 32 mothers and 29 fathers of 34 full-term infants. OUTCOME MEASURES: We assessed the incidence of parental PPD, PTSD and perceived social support as well as infants' illness severity and motor repertoire at birth, term and 3 months corrected age. RESULTS: Preterm mothers and fathers had significant higher depression scores after birth compared to full-term parents (p=0.033 and 0.021). Preterm fathers also had higher traumatization scores compared to full-term fathers (p=0.007). Probable or possible PPD/PTSD was not associated with infant's illness severity or quality of motor repertoire. No differences in motor development were found between preterm and full-term infants. CONCLUSION: Moderate to late preterm infants' parents are at increased risk for PPD irrespective of infants' motor repertoire or illness severity.

143. Grunewaldt KH, Fjørtoft T, Bjuland KJ, Brubakk AM, Eikenes L, Håberg AK, Løhaugen GC, Skranes J.
Follow-up at age 10 years in ELBW children - functional outcome, brain morphology and results from motor assessments in infancy.
Early Hum Dev 2014; 90: 571-578. 

BACKGROUND: Extremely-low-birth-weight (ELBW) children without severe brain injury or CP are at high risk of developing deficits within cognition, attention, behavior and motor function. Assessing the quality of an infant's spontaneous motor-repertoire included in Prechtl's General-Movement-Assessment (GMA) has been shown to relate to later motor and cognitive functioning in preterm children without CP. AIMS: To investigate functional outcome and cerebral MRI morphometry at 10 years in ELBW children without CP compared to healthy controls and to examine any relationship with the quality of infant-motor-repertoire included in the GMA. STUDY DESIGN: A cohort-study-design. SUBJECTS: 31 ELBW children (mean birth-weight: 773 g, SD 146, mean gestational age 26.1 weeks, SD 1.8) and 33 term-born, age-matched controls. OUTCOME MEASURES: GMA was performed in ELBW children at 3 months corrected age. At 10 years the children underwent comprehensive motor, cognitive, behavioral assessments and cerebral MRI. RESULTS: The non-CP ELBW children had similar full-IQ but poorer working memory, poorer motor skills, and more attentional and behavioral problems compared to controls. On cerebral MRI reduced volumes of globus pallidus, cerebellar white matter and posterior corpus callosum were found. Cortical surface-area was reduced in temporal, parietal and anterior-medial-frontal areas. Poorer test-results and reduced brain volumes were mainly found in ELBW children with fidgety movements combined with abnormal motor-repertoire in infancy. CONCLUSION: Non-CP ELBW children have poorer functional outcomes, reduced brain volumes and cortical surface-area compared with term-born controls at 10 years. ELBW children with abnormal infant motor-repertoire seem to be at increased risk of later functional deficits and brain pathology.

142. Hadders-Algra M.
Early diagnosis and early intervention in cerebral palsy.
Front Neurol 2014; Sep 24;5:185. doi: 10.3389/fneur.2014.00185. 

This paper reviews the opportunities and challenges for early diagnosis and early intervention in cerebral palsy (CP). CP describes a group of disorders of the development of movement and posture, causing activity limitation that is attributed to disturbances that occurred in the fetal or infant brain. Therefore, the paper starts with a summary of relevant information from developmental neuroscience. Most lesions underlying CP occur in the second half of gestation, when developmental activity in the brain reaches its summit. Variations in timing of the damage not only result in different lesions but also in different neuroplastic reactions and different associated neuropathologies. This turns CP into a heterogeneous entity. This may mean that the best early diagnostics and the best intervention methods may differ for various subgroups of children with CP. Next, the paper addresses possibilities for early diagnosis. It discusses the predictive value of neuromotor and neurological exams, neuroimaging techniques, and neurophysiological assessments. Prediction is best when complementary techniques are used in longitudinal series. Possibilities for early prediction of CP differ for infants admitted to neonatal intensive care and other infants. In the former group, best prediction is achieved with the combination of neuroimaging and the assessment of general movements, in the latter group, best prediction is based on carefully documented milestones and neurological assessment. The last part reviews early intervention in infants developing CP. Most knowledge on early intervention is based on studies in high-risk infants without CP. In these infants, early intervention programs promote cognitive development until preschool age; motor development profits less. The few studies on early intervention in infants developing CP suggest that programs that stimulate all aspects of infant development by means of family coaching are most promising. More research is urgently needed. 

141. Morgan C, Novak I, Dale RC, Guzzetta A, Badawi N.
GAME (Goals - Activity - Motor Enrichment): protocol of a single blind randomised controlled trial of motor training, parent education and environmental enrichment for infants at high risk of cerebral palsy.
BMC Neurol 2014, Oct 7;14:203. doi: 10.1186/s12883-014-0203-2.

BACKGROUND: Cerebral palsy is the most common physical disability of childhood and early detection is possible using evidence based assessments. Systematic reviews indicate early intervention trials rarely demonstrate efficacy for improving motor outcomes but environmental enrichment interventions appear promising. This study is built on a previous pilot study and has been designed to assess the effectiveness of a goal - oriented motor training and enrichment intervention programme, "GAME", on the motor outcomes of infants at very high risk of cerebral palsy (CP) compared with standard community based care. METHODS/DESIGN: A two group, single blind randomised controlled trial (n = 30) will be conducted. Eligible infants are those diagnosed with CP or designated "at high risk of CP" on the basis of the General Movements Assessment and/or abnormal neuroimaging. A physiotherapist and occupational therapist will deliver home-based GAME intervention at least fortnightly until the infant's first birthday. The intervention aims to optimize motor function and engage parents in developmental activities aimed at enriching the home learning environment. Primary endpoint measures will be taken 16 weeks after intervention commences with the secondary endpoint at 12 months and 24 months corrected age. The primary outcome measure will be the Peabody Developmental Motor Scale second edition. Secondary outcomes measures include the Gross Motor Function Measure, Bayley Scales of Infant and Toddler Development, Affordances in the Home Environment for Motor Development - Infant Scale, and the Canadian Occupational Performance Measure. Parent well-being will be monitored using the Depression Anxiety and Stress Scale. DISCUSSION: This paper presents the background, design and intervention protocol of a randomised trial of a goal driven, motor learning approach with customised environmental interventions and parental education for young infants at high risk of cerebral palsy. TRIAL REGISTRATION: This trial is registered on the Australian New Zealand Clinical Trial register: ACTRN12611000572965.

140. Ma L, Meng LD, Zheng CH, Zhao FQ, Cao AH.
[High-risk factors for quality of general movements in infants]. [Article in Chinese]
Zhongguo Dang Dai Er Ke Za Zhi 2014; 16: 887-891.

OBJECTIVE: To investigate the high-risk factors for the quality of general movements (GMs), which has a predictive value for brain dysfunction in infants. METHODS: A total of 618 infants in the stage of writhing movements and 539 infants in the stage of fidgety movements were selected separately for the evaluation of GMs. The high-risk factors for the quality of GMs in infants were analyzed by ANOVA, chi-square test, and multivariate logistic regression. RESULTS: Multivariate logistic regression analysis showed that the factors significantly associated with the quality of GMs in the stage of writhing movements were gestational age (OR=0.762, P<0.001), birth weight (OR=0.264, P<0.001), severe asphyxia (OR=2.445, P=0.012), and intrauterine distress (OR=4.865, P<0.001); the factors significantly associated with the quality of GMs in the stage of fidget movements were gestational age (OR=0.786, P=0.003), birth weight (OR=0.217, P<0.001), severe asphyxia (OR=3.765, P=0.001), and hyperbilirubinemia (OR=2.640, P=0.028). CONCLUSIONS: Low gestational age, low birth weight, severe asphyxia, hyperbilirubinemia and intrauterine distress are high-risk factors for abnormal GMs in infants, and early screening and intervention should be performed to reduce the incidence of abnormal nervous system sequelae. 

139. Hitzert MM, Roescher AM, Bos AF.
The quality of general movements after treatment with low-dose dexamethasone in preterm infants at risk of bronchopulmonary dysplasia.
Neonatology 2014; 106: 222-228. 

BACKGROUND: High-dose dexamethasone (DXM) treatment of preterms at risk of bronchopulmonary dysplasia leads to a deterioration in quality of their general movements (GMs). It is unknown whether low-dose DXM affects GM quality similarly. OBJECTIVES: To assess the effect of low-dose DXM treatment on the quality of GMs and fidgety GMs (FMs). METHODS: A prospective study of preterms admitted to our NICU between 2010 and 2012, and treated with DXM (starting dose 0.25 mg/kg/day). We assessed GM/FM quality and calculated their motor optimality score (MOS) before, during, and after treatment up to 3 months postterm. Neurological follow-up was performed between 12 and 36 months. We related risk factors with infants' GM trajectories and MOSs. At 3 months we compared the MOSs of low-dose DXM infants and a historical cohort of infants treated with high-dose DXM or hydrocortisone. RESULTS: 17 infants were included. GM/FM quality improved in 9 out of 13 initially abnormal infants (p = 0.004). Shorter periods of mechanical ventilation and higher birth weights were associated with better GM trajectories (p = 0.032 and p = 0.042, respectively). Infants starting treatment later had higher MOSs on day 7 (p = 0.047). Low-dose DXM infants had higher MOSs than high-dose DXM infants (β = -0.535; 95% CI -0.594 to -0.132; p = 0.003). Out of 17 infants, 2 died, 14 developed normally, and 1 developed with mild neurodevelopmental impairments. Infants whose GMs/FMs remained normal or improved had better outcomes than infants whose GMs/FMs remained abnormal (p = 0.019). CONCLUSIONS: Out of the 17 infants treated with low-dose DXM, 2 died. Of the surviving infants, neurological functioning improved with the majority having normal neurodevelopment at the age of 12-36 months.

138. Ploegstra WM, Bos AF, de Vries NK.
General movements in healthy full term infants during the first week after birth.
Early Hum Dev 2014; 90: 55-60. 

BACKGROUND: The quality of general movements (GMs) is a widely used criterion to assess neurological dysfunction in young infants. It is unknown, however, whether the birth process influences the motor repertoire of healthy full term infants during the first week after birth. AIMS: To assess the quality of GMs and to determine the motor optimality score (OS) in healthy full term infants during the first week after birth and to evaluate the influence of the mode of delivery on GM quality. STUDY DESIGN: Thirty-three healthy full term infants born either vaginally or after caesarean section (CS) under spinal anaesthesia were video recorded in the first week after birth in order to assess GM quality and to determine OS with Prechtl's method. RESULTS: Abnormal GMs were observed mainly on the early recordings: 86% on the day of birth (day 0), 94% on day 1, and 68% on day 2. On days 5 to 7 (day 5-7) all GMs were normal (P<.001). The OSs increased significantly from median 12 on day 0 to 18 on day 5-7 (P<.001). Monotonously slow movements were frequently seen during the first days but not on day 5-7 (P<.001). GM quality and OS did not differ between infants born by vaginal delivery or after CS under spinal anaesthesia. CONCLUSIONS: Healthy full term infants often showed abnormal GM quality and lower OSs during the first week after birth, irrespective of the mode of delivery. GM quality normalised during subsequent days and was normal on day 5-7.

137. Picciolini O, Porro M, Meazza A, Giannì ML, Rivoli C, Lucco G, Barretta F, Bonzini M, Mosca F.
Early exposure to maternal voice: effects on preterm infants development.
Early Hum Dev 2014; 90: 287-292. 

BACKGROUND: Preterm infants complete their development in Neonatal Intensive Care Unit being exposed to environmental stimuli that lead to the early maturation of the sensory systems. It is known that the fetus perceives sounds and reacts to them with movements since the 26th-28th week of gestational age. Maternal voice represents a source of sensory stimulation for the fetus. AIMS: To investigate the effect of the exposure to maternal voice, administered by bone conduction, on preterm infants autonomic and neurobehavioral development. STUDY DESIGN: Longitudinal, explorative, case control study. SUBJECTS: 71 preterm infants with birth weight <1500g, born adequate for gestational age. OUTCOME MEASURES: vital and neurobehavioral parameters at term, neurofunctional assessment at 3 and 6months of corrected age. RESULTS: Infants in the treatment group had lower heart rate values and a higher proportion of stable skin color at each study point as compared to the control group. The scores in the visual attention performance and in the quality of the general movements at term were better in the treatment group than in the control one. Neurofunctional assessment score at 3months of corrected age was higher in the treatment group whereas no difference between the two groups was detected at 6months of corrected age. CONCLUSIONS: Early exposure to maternal voice exerts a beneficial effect on preterm infants autonomic and neurobehavioral development. 

136. Pierrat V.
Computer-based analysis of general movements reveals stereotypies predicting cerebral palsy.
Dev Med Child Neurol 2014; 56: 922-993. 

135. Adde L, Helbostad J, Jensenius AR, Langaas M, Støen R.
Identification of fidgety movements and prediction of CP by the use of computer-based video analysis is more accurate when based on two video recordings.
Physiother Theory Pract 2013; 29: 469-475. 

This study evaluates the role of postterm age at assessment and the use of one or two video recordings for the detection of fidgety movements (FMs) and prediction of cerebral palsy (CP) using computer vision software. Recordings between 9 and 17 weeks postterm age from 52 preterm and term infants (24 boys, 28 girls; 26 born preterm) were used. Recordings were analyzed using computer vision software. Movement variables, derived from differences between subsequent video frames, were used for quantitative analysis. Sensitivities, specificities, and area under curve were estimated for the first and second recording, or a mean of both. FMs were classified based on the Prechtl approach of general movement assessment. CP status was reported at 2 years. Nine children developed CP of whom all recordings had absent FMs. The mean variability of the centroid of motion (CSD) from two recordings was more accurate than using only one recording, and identified all children who were diagnosed with CP at 2 years. Age at assessment did not influence the detection of FMs or prediction of CP. The accuracy of computer vision techniques in identifying FMs and predicting CP based on two recordings should be confirmed in future studies. 

134. Einspieler C, Sigafoos J, Bartl-Pokorny KD, Landa R, Marschik PB, Bolte S.
Highlighting the first 5 months of life: General movements in infants later diagnosed with autism spectrum disorder or Rett syndrome. 
Res Autism Spectr Disord 2014; 8: 286-291.

We review literature identifying an association between motor abnormality in the first 5 months of infancy and later diagnosis of autism spectrum disorder (ASD) or Rett syndrome (RU). The assessment of the quality of early spontaneous movements (also known as the assessment of general movements; GMs) is a diagnostic tool that has repeatedly proven to be valuable in detecting early markers for neurodevelopmental disorders. Even though the rate of occurrence of abnormal GMs is exceedingly high in infants later diagnosed with ASD, we endorse further studies using this method either based on family videos or its prospective implementation in high-risk sibling studies to evaluate the power of GM assessment as one potential marker for early maldevelopment in this cohort. 

133. Philippi H, Karch D, Kang KS, Wochner K, Pietz J, Dickhaus H, Hadders-Algra M. 
Computer-based analysis of general movements reveals stereotypies predicting cerebral palsy.
Dev Med Child Neurol. 2014; 56: 960-967.

AIM: To evaluate a kinematic paradigm of automatic general movements analysis in comparison to clinical assessment in 3-month-old infants and its prediction for neurodevelopmental outcome. METHOD: Preterm infants at high risk (n=49; 26 males, 23 females) and term infants at low risk (n=18; eight males, 10 females) of developmental impairment were recruited from hospitals around Heidelberg, Germany. Kinematic analysis of general movements by magnet tracking and clinical video-based assessment of general movements were performed at 3 months of age. Neurodevelopmental outcome was evaluated at 2 years. By comparing the general movements of small samples of children with and without cerebral palsy (CP), we developed a kinematic paradigm typical for infants at risk of developing CP. We tested the validity of this paradigm as a tool to predict CP and neurodevelopmental impairment. RESULTS: Clinical assessment correctly identified almost all infants with neurodevelopmental impairment including CP, but did not predict if the infant would be affected by CP or not. The kinematic analysis, in particular the stereotypy score of arm movements, was an excellent predictor of CP, whereas stereotyped repetitive movements of the legs predicted any neurodevelopmental impairment. INTERPRETATION: The automatic assessment of the stereotypy score by magnet tracking in 3-month-old spontaneously moving infants at high risk of developmental abnormalities allowed a valid detection of infants affected and unaffected by CP.

132. Roescher AM, Timmer A, Hitzert MM, de Vries NK, Verhagen EA, Erwich JJ, Bos AF.
Placental pathology and neurological morbidity in preterm infants during the first two weeks after birth.
Early Hum Dev 2014; 90: 21-25. 

BACKGROUND: The placenta plays a crucial role during pregnancy and dysfunction causes long-term neurological problems. Identifying placenta-related risks for neurological problems shortly after birth may provide clues for early interventions aiming to improve neurological outcome. OBJECTIVE: To determine the association between placental pathology and neurological morbidity in preterm infants during the first two weeks after birth. STUDY DESIGN: Placentas of 52 singleton, preterm infants (GA: 25-31weeks, BW: 560-2250 grammes) were examined for histopathology. The infants' neurological condition shortly after birth was determined by assessing the quality of their general movements (GMs): normal, abnormal, or hypokinetic, on days 5, 8, and 15. A motor optimality score (MOS) was also assigned. RESULTS: Examination of the placentas revealed maternal vascular underperfusion (n=29), ascending intrauterine infection (AIUI) (n=19), villitis of unknown aetiology (n=6), chronic deciduitis (n=11), foetal thrombotic vasculopathy (FTV) (n=9), and elevated nucleated red blood cells (NRBCs) as a marker for foetal hypoxia (n=7). None of the placental lesions were significantly associated with the quality of GMs or MOS. CONCLUSIONS: This study indicated that placental lesions were not associated with infants' neurological condition as measured by the quality of their general movements during the first two weeks after birth.

131. Luxwolda MF, Kuipers RS, Boersma ER, van Goor SA, Dijck-Brouwer DA, Bos AF, Muskiet FA.
DHA status is positively related to motor development in breadfed African and Dutch infants.
Nutr Neurosci 2014; 17: 97-103.

OBJECTIVES: Docosahexaenoic (DHA) and arachidonic (AA) acids are important for neurodevelopment. We investigated the relation between erythrocyte (RBC) DHA and AA contents and neurological development, by assessment of General Movements (GMs), in populations with substantial differences in fish intakes. METHODS: We included 3-month-old breastfed infants of three Tanzanian tribes: Maasai (low fish, n=5), Pare (intermediate fish, n=32), and Sengerema (high fish, n = 60); and a Dutch population (low-intermediate, fish, n=15). GMs were assessed by motor optimality score (MOS) and the number of observed movement patterns (OMP; an MOS sub-score). RBC-DHA and AA contents were determined by capillary gas chromatography. RESULTS: We found no between-population differences in MOS. OMP of Sengerema infants (high fish) was higher than OMP of Dutch infants (low-intermediate fish). MOS related to age. OMP related positively to infant age (P<0.001) and RBC-DHA (P=0.015), and was unrelated to ethnicity and RBC-AA. DISCUSSION: The positive relation between RBC-DHA and the number of observed movement patterns of 3-month old infants might reflect the connection of DHA with motor development.

130. Berghuis SA, Soechitram SD, Hitzert MM, Sauer PJ, Bos AF.
Prenatal exposure to polychlorinated biphenyls and their hydroxylated metabolites is associated with motor development of three-month-old infants.
Neurotoxicology 2013; 38: 124-130

BACKGROUND: Polychlorinated biphenyls (PCBs) are ubiquitous environmental pollutants that are potentially toxic to the developing brain. Hydroxylated metabolites of PCBs (OH-PCBs) are suggested to be even more toxic. Little is known about their short-term effects on human health. OBJECTIVES: To determine whether prenatal background exposure to PCBs and OH-PCBs was associated with the motor development of three-month-old infants. METHODS: Ninety-seven mother-infant pairs participated in this Dutch, observational cohort study. We determined the concentrations of PCBs and OH-PCBs in cord blood samples. When the infants were three months old we evaluated their motor development by assessing the presence and performance of spontaneous movement patterns from video recordings. We calculated a Motor Optimality Score (MOS). The score could range from low (5) to high (28) optimality. We explored the correlations between PCB and OH-PCB levels and MOS. Subsequently, we tested whether the levels differed between infants with a low (<26) or high (≥26) MOS and whether the levels associated with detailed aspects of their motor repertoires. RESULTS: We found several associations between PCB and OH-PCB levels and MOS, including detailed aspects of the early motor development. High 4-OH-PCB-107 levels were associated with a low MOS (P=.013). High PCB-187 levels were associated with reduced midline arm and leg movements (P=.047 and P=.043, respectively). High 4'-OH-PCB-172 levels were associated with more manipulation (P=.033). CONCLUSIONS: Prenatal exposure to high background levels of most PCBs and 4-OH-PCB-107 seems to impair early motor development, whereas only 4'-OH-PCB-172 showed the opposite.

129. de Vries NK, van der Veere CN, Reijneveld SA, Bos AF.
Early neurological outcome of young infants exposed to selective serotonin reuptake inhibitors during pregnancy: results from the observational SMOK study.
PLoS One 2013; May 28;8(5):e64654.

BACKGROUND: Use of selective serotonin reuptake inhibitors (SSRI) during pregnancy is common while the effect on the infant's neurological outcome is unknown. Our objective was to determine the effects of prenatal SSRI-exposure on the infants' neurological functioning, adjusted for maternal mental health. METHODS: A prospective observational study from May 2007 to April 2010. The study groups comprised 63 SSRI-exposed infants (SSRI group) and 44 non-exposed infants (non-SSRI group). Maternal depression and anxiety were measured using questionnaires. The main outcome measures during the first week after birth and at three to four months were the quality of the infants' general movements (GMs) according to Prechtl and a detailed motor optimality score. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for abnormal GM quality in the SSRI and non-SSRI groups, and adjusted for maternal depression, anxiety, and other confounders. The study was registered under 53506435 in the ISRCTN. FINDINGS: All infants were born around term. During the first week, abnormal GMs occurred more frequently in the SSRI group than in the non-SSRI group (59% versus 33%) and the median MOS was lower (13 versus 18). The OR for abnormal GMs in the SSRI versus the non-SSRI group was 3.0 (95% CI, 1.3 to 6.9) and increased after adjustment for confounders. At three to four months, more SSRI-exposed infants had monotonous movements (48% versus 20%) with lower median MOSs (26 versus 28). The OR for monotonous movements was 3.5 (95% CI, 1.5 to 8.6) and increased after adjusting for confounders. INTERPRETATION: Prenatal exposure to SSRI had an adverse effect on early neurological functioning as reflected by GM quality, irrespective of maternal depression and anxiety, and other confounders. Physicians should take this into account in consultation with parents.

128. Waldmeier S, Grunt S, Delgado-Eckert E, Latzin P, Steinlin M, Fuhrer K, Frey U.
Correlation properties of spontaneous motor activity in healthy infants: a new computer-assisted method to evaluate neurological maturation.
Exp Brain Res 2013; 227: 433-446. 

Qualitative assessment of spontaneous motor activity in early infancy is widely used in clinical practice. It enables the description of maturational changes of motor behavior in both healthy infants and infants who are at risk for later neurological impairment. These assessments are, however, time-consuming and are dependent upon professional experience. Therefore, a simple physiological method that describes the complex behavior of spontaneous movements (SMs) in infants would be helpful. In this methodological study, we aimed to determine whether time series of motor acceleration measurements at 40-44 weeks and 50-55 weeks gestational age in healthy infants exhibit fractal-like properties and if this self-affinity of the acceleration signal is sensitive to maturation. Healthy motor state was ensured by General Movement assessment. We assessed statistical persistence in the acceleration time series by calculating the scaling exponent α via detrended fluctuation analysis of the time series. In hand trajectories of SMs in infants we found a mean α value of 1.198 (95 % CI 1.167-1.230) at 40-44 weeks. Alpha changed significantly (p = 0.001) at 50-55 weeks to a mean of 1.102 (1.055-1.149). Complementary multilevel regression analysis confirmed a decreasing trend of α with increasing age. Statistical persistence of fluctuation in hand trajectories of SMs is sensitive to neurological maturation and can be characterized by a simple parameter α in an automated and observer-independent fashion. Future studies including children at risk for neurological impairment should evaluate whether this method could be used as an early clinical screening tool for later neurological compromise.

127. Brogna C, Romeo DM, Cervesi C, Scrofani L, Romeo MG, Mercuri E, Guzzetta A.
Prognostic value of the qualitative assessments of general movements in late-preterm infants.
Early Hum Dev 2013; 89: 1063-1066.

BACKGROUND: The quality of general movements (GMs) and its predictive value have never been evaluated in late-preterm (LP) infants. AIMS: To determine the characteristics of GMs and their predictive value for neurodevelopmental outcome in a cohort of infants born between 34 and 36weeks' gestation. STUDY DESIGN AND SUBJECTS: 574 LP infants were examined using the standard methodological principles of Prechtl's method for assessing GMs both during writhing and fidgety periods. OUTCOME MEASURES: Infants were assessed at 2years of age with neuromotor and developmental scales. RESULTS: A significant correlation was found between GMs and outcome both at writhing (rs 0.68; p<0.001) and at fidgety age (rs 0.78; p<0.001). The assessment at 1month showed 100% sensitivity and 86% specificity of predicting the development of cerebral palsy (CP), that at 3months was 100% sensitivity and 97% specificity. CONCLUSIONS: During the fidgety age GMs predict CP with very high sensitivity and specificity. The qualitative assessment of GMs should be employed to help identify LP infants who require early intervention for neurological abnormalities.

126. Spittle AJ, Spencer-Smith MM, Cheong JL, Eeles AL, Lee KJ, Anderson PJ, Doyle LW.
General movements in very preterm children and neurodevelopment at 2 and 4 years.
Pediatrics 2013; 132(2): e452-458.

OBJECTIVE: Although ∼50% of very preterm (VP) children have neurodevelopmental impairments, early prediction of infants who will experience problems later in life remains a challenge. This study evaluated the predictive value of general movements (GM; spontaneous and endogenous movements) at 1 and 3 months' corrected age for neurodevelopment at 2 and 4 years of age in VP children. METHODS: At 1 and 3 months' corrected age, infants born <30 weeks' gestation had GM assessed as normal or abnormal. Motor, cognitive, and language development at 2 years was assessed by using the Bayley Scales of Infant and Toddler Development, Third Edition. At 4 years, cognitive and language outcomes were assessed by using the Differential Ability Scale-Second Edition and motor outcomes with the Movement Assessment Battery for Children-Second Edition; a diagnosis of cerebral palsy was documented. RESULTS: Ninety-nine VP infants were recruited, with 97% and 88% of survivors followed up at age 2 and 4 years, respectively. Abnormal GM at 1 month were associated with worse motor outcomes at 2 and 4 years but not language or cognitive outcomes. Abnormal GM at 3 months were associated with worse motor, cognitive, and language outcomes at both 2 and 4 years. Overall, GM at 1 month demonstrated better sensitivity to impairments at 2 and 4 years, whereas GM at 3 months had better specificity and were more accurate overall at distinguishing between children with and without impairment. CONCLUSIONS: Abnormal GM in VP infants, particularly at 3 months postterm, are predictive of worse neurodevelopment at ages 2 and 4 years.

125. Fjørtoft T, Grunewaldt KH, Løhaugen GC, Mørkved S, Skranes J, Evensen KA.  
Assessment of motor behaviour in high-risk-infants at 3months predicts motor and cognitive outcomes in 10years old children. 
Early Hum Dev 2013; 89: 787-793. 

BACKGROUND: The general movement assessment has mainly been used to identify children with cerebral palsy (CP). A detailed assessment of quality of infant motor repertoire using parts of the "Assessment of Motor Repertoire - 3 to 5 Months" which is based on Prechtl's general movement assessment can possibly identify later motor and cognitive problems in children without CP. AIMS: This study aims to determine whether analysis of quality of infant motor repertoire has predictive value for motor and cognitive outcomes at age 10 in children at risk for later neurological impairment. STUDY DESIGN: A longitudinal study design was used. SUBJECTS: Video-recordings of 40 "neurologically high-risk" infants at 14weeks post-term age were analysed with respect to motor repertoire. OUTCOME MEASURES: Fidgety movements were classified as present or absent. Quality of concurrent motor repertoire was classified as normal if smooth and fluent and abnormal if jerky, monotonous or stiff. Poor motor outcome was defined as a score ≤5th centile on the Movement-Assessment-Battery-2, while poor cognitive outcome as total IQ <85 on Wechsler Intelligence Scale-III. RESULTS: Among the high-risk children with presence of fidgety movements, poor motor and/or cognitive outcome at 10years was identified by abnormal concurrent motor repertoire at 14weeks post-term age in 86% (95% CI: 0.60-0.96) of the children. On the other hand, 71% (95% CI: 0.47-0.87) of those with normal motor and cognitive outcomes were identified by presence of fidgety movements and normal motor repertoire. CONCLUSIONS: Assessment of quality of infant motor repertoire may be a valuable early clinical marker for later impaired motor and cognitive outcomes in high-risk children who do not develop CP.

124. Einspieler C, Marschik PB.
Complementary thinking: future perspectives on the assessment of general movements.
Dev Med Child Neurol 2013; 55: 682-683.

123. Kanemaru N, Watanabe H, Kihara H, Nakano H, Takaya R, Nakamura T, Nakano J, Taga G, Konishi Y.
Specific characteristics of spontaneous movements in preterm infants at term age are associated with developmental delays at age 3 years.
Dev Med Child Neurol 2013; 55: 713-721.

AIM: The aim of this study was to investigate the relationship between the characteristics of spontaneous movements in preterm infants at term age and developmental delay at 3 years of age. METHOD: We analysed video recordings of the spontaneous movements in the supine position of 124 preterm infants (44 males, 80 females) at 36 to 44 weeks postmenstrual age (PMA). The infants were born preterm (22-36wks PMA; birthweight 489-1696g) and had not received a diagnosis of a neurological or developmental disorder by the age of 3 years. The recorded spontaneous movements were quantified using six movement indices, which were calculated from two-dimensional trajectories of all limbs. The infants were divided into three developmental groups, normal, borderline, or delayed, based on their developmental quotient as calculated using the Kyoto Scale of Psychological Development 2001 (Kyoto Scale) at 3 years of age. Group differences in the movement indices were analysed. RESULTS: In the delayed group, average velocity of arms and legs were significantly lower (p<0.05 and p<0.01 respectively), the numbers of movement units of arms and legs were significantly lower (p<0.05 and p<0.01 respectively), kurtosis of acceleration of arms and legs was significantly higher (p<0.05 in each case), and correlation between limb velocities was higher (p<0.05) than in the normal group. INTERPRETATION: In children who exhibited developmental delay at 3 years of age, the spontaneous movements at term age can be described as less active with intermittent occurrences of abrupt and synchronized movements of the limbs. Recognition of these characteristics of spontaneous movements at term age may be used as a predictor for subsequent cognitive and behavioural development in preterm infants.

122. Marschik PB, Soloveichick M, Windpassinger C, Einspieler C.
General movements in genetic disorders: A first look into Cornelia de Lange syndrome.
Dev Neurorehabil 2013; Dec 4. [Epub ahead of print]

The assessment of General Movements (GMs), i.e. age-specific motor patterns during the first months of life, has repeatedly proven to be a valuable tool to predict neurodevelopmental outcomes. Abnormal spontaneous GMs were found to be among the most reliable markers for cerebral palsy. To add to the knowledge of the abnormal early motor repertoire we analysed prospectively collected video recordings of a boy clinically diagnosed with Cornelia de Lange syndrome. The observed atypical GMs are a further step to disentangle early motor peculiarities in the light of the genetic impact on the developing brain.

108. Noble Y, Boyd R.
Neonatal assessments for the preterm infant up to 4 months corrected age: a systematic review.
Dev Med Child Neurol 2012; 54: 129-139.
 
Aim: The aim of this study was to systematically review the clinimetric properties of longitudinal neonatal neurobehavioural and neuromotor assessments for preterm infants. Method: Twenty-seven assessment measures were identified. The following eight measures met the study inclusion criteria: Assessment of Preterm Infants' Behaviour (APIB), Neonatal Intensive Care Unit Network Neurobehavioural Scale (NNNS), Test of Infant Motor Performance (TIMP), Prechtl's Assessment of General Movements (GMs), Neurobehavioural Assessment of the Preterm Infant (NAPI), Dubowitz Neurological Assessment of the Preterm and Full-term Infant (Dubowitz), Neuromotor Behavioural Assessment (NMBA), and the Brazelton Neonatal Behavioural Assessment Scale (NBAS). The primary purposes included prediction (TIMP, GMs, Dubowitz), discrimination (all assessments), and evaluation of change (TIMP, NAPI). Measures of assessment were included in the study if they were (1) primarily neurobehavioural or neuromotor assessments that were suitable for use with preterm infants (<37 weeks gestation) up to 4 months corrected age and were discriminative, predictive, or evaluative; (2) standardized procedures designed for serial/longitudinal use; or (3) criterion or norm referenced. However, all assessment tools that were not published in English in a peer-reviewed journal or were primarily neurological assessments, one-time evaluations, screening tools, or not commercially available were not used. Results: All of the measures included in the review demonstrated adequate content and construct validity. Concurrent validity was reported for APIB, NNNS, Dubowitz, and GMs. Predictive validity was high for GMs with studies reporting up to 100% senstivity for predicting cerebral palsy at the age of 12 to 24 months. Interrater reliability was strong for the TIMP (intraclass correlation=0.95), GMs (K=0.8), and moderate for the NAPI (r=0.67-0.97). Clinical utility was variable for ease of scoring, interpretability, cost, and access. Interpretation: In the absence of a criterion standard for neonatal neuromotor assessments, the NNNS and APIB have strong psychometric qualities with better utility for research. Similarly, the GMs, TIMP, and NAPI have strong psychometric qualities but better utility for clinical settings. The GMs has best prediction of future outcome and the TIMP has best evaluative validity.

BACKGROUND: It continues to be a challenge for clinicians to identify preterm infants likely to experience subsequent neurodevelopmental deficits. The Test of Infant Motor Performance (TIMP) and the assessment of spontaneous general movements (GMs) are the only reliable diagnostic and predictive tools for the functionality of the developing nervous system, if applied before term. AIM: To determine to what extent singular preterm assessments of motor performance can predict the neurodevelopmental outcome in 14-month olds. METHODS: Thirty-seven preterm infants born <34weeks gestational age were recruited for the study at the NICU of the São Lucas University Hospital, Porto Alegre, RS, Brazil. At 34weeks, their GMs were assessed; and the Test of Infant Motor Performance (TIMP) was applied. A prospective design was used to examine (A) the association between the GM assessment and the TIMP; and (B) the relation between GMs or the TIMP and the developmental status at 14months, assessed by means of Alberta Infant Motor Scales (AIMS) and the Pediatric Evaluation of Disability Inventory (PEDI). RESULTS: Nineteen infants (41%) had abnormal GMs; only one scored within the TIMP average range. Hence, GMs and TIMP were not related. Children with cramped-synchronized GMs at 34weeks preterm had a lower AIMS centile rank than those with poor repertoire or normal GMs. There was a marginal association between cramped-synchronized GMs and a lower PEDI mobility score. CONCLUSIONS: A single preterm GM assessment is only fairly to moderately associated with the 14-month motor development. The TIMP is not suitable as a complementary assessment tool at such a young age.

BACKGROUND: Observation of the quality of endogenously generated "General Movements" has been proved to be a reliable and sensitive tool in the assessment of fragile neonates. The absence of fidgety movements at 2-4months post-term is highly predictive of Cerebral Palsy. On the contrary, the presence of a poor repertoire pattern during the writhing period is not reliable in predicting motor or neurobehavioral disorders at any stage of development. AIM: To examine if the presence of a PR pattern at 1month post-term was associated with lower neurodevelopmental quotients at 2years. STUDY DESIGN: General Movements evaluation at 1 and 3months and the Griffiths Scales of Mental Development at 2years were administered to a sample of very preterm infants. Infants were divided into two groups: poor repertoire pattern group and normal pattern group. Student's t Test and Chi squared test and ANOVA were used to compare neonatal variables and results between the two groups. SUBJECTS: 79 very preterm infants (birthweight≤1500g or gestational age≤32weeks), born January 2003 to December 2006 who had a follow-up at 2years. OUTCOME MEASURE: Griffiths developmental quotient at 2years. RESULTS: The Poor Repertoire group had lower Gestational Age, lower Birth Weight, lower Apgar scores at birth and lower Developmental Quotient at 2years. Eye and Hand Coordination (subscale D) was the domain mostly responsible for such a difference. Quality of fidgety movements (normal or abnormal fidgety) at 3months did not show any correlation with outcome measures at 2years. CONCLUSION: The presence of a PR pattern at 1month post-term seems to predict lower neurodevelopmental scores at 2years especially in the domain of eye and hand coordination. Longer follow-up is necessary in order to ascertain if such difference will continue to persist at older ages.

105. Zuk L.
Fetal and infant spontaneous general movements as predictors of developmental disabilities.
Dev Disabil Res Rev 2011, 17: 93-101. 

The challenge of identifying infants who are at risk for developmental delay and possible adverse neurodevelopmental outcome demands methods of evaluation that will lead to early intervention to minimize developmental disability and to maximize the infant's potential. A qualitative assessment of spontaneous general movements (GMs) in the preterm, term, and young infant at risk is a valid and reliable tool for evaluation (Prechtl [1990] Early Hum. Dev. 23:151-158). The aim of this review is to describe the theoretical and clinical bases for the assessment of GMs and its relationship to developmental delay and brain dysfunction. Thirty-seven studies related to the predictive validity of GMs were included in this review. Results suggested that consistent cramped synchronized GMs are highly predictive of later development of cerebral palsy. The fidgety movement quality that appears at the age of 2 to 3 months was found to be a most sensitive predictor of neurodevelopmental outcome in different populations of infants.

AIM: The aim of this study was to assess the motor repertoire of extremely low-birthweight infants at term-equivalent age (TEA), in relation to their neurological outcome. METHOD: Using Prechtl's method, we assessed both the quality of general movements and a detailed motor optimality score in 13 extremely low-birthweight infants (four males; nine females; mean gestational age 27.9wks, SD 2.9wks; mean birthweight 798g, SD 129g) at TEA, and related them to general movements at the age of 3 months after term and neurological outcome at the age of 2 years 6 months. RESULTS: At TEA, 10 of the 13 infants had abnormal general movements. All infants showed abnormal leg lifting with extended legs; nine showed stiff movements, three showed cramped movements, and two showed cramped synchronized general movements. At 3 months, three infants still had abnormal general movements. Concurrent movements were abnormal in nine infants owing to monotony and jerkiness. Abnormal posture was seen in seven infants. None developed cerebral palsy; one infant showed cognitive and motor delay. Neurological outcome was not related to general movement quality and optimality score at TEA. INTERPRETATION: Abnormal general movements at TEA are common in extremely low-birthweight infants. General movements often appear stiff and cramped with extended legs. At the age of 3 months after term, general movements are mostly normal, but concurrent movements are not. Nevertheless, these abnormalities do not imply an impaired neurological outcome such as cerebral palsy.

AIM: Abnormal general movements at around 3 months corrected age indicate a high risk of cerebral palsy (CP). We aimed to determine whether specific movement characteristics can improve the predictive power of definitely abnormal general movements. METHOD: Video recordings of 46 infants with definitely abnormal general movements at 9 to 13 weeks corrected age (20 males; 26 females; median gestational age 30wks; median birthweight 1200g) were analysed for the following characteristics: presence of fidgety, cramped synchronized, stiff, or jerky movements and asymmetrical tonic neck reflex pattern. Neurological condition (presence or absence of CP), gross motor development (Alberta Infant Motor Scales), quality of motor behaviour (Infant Motor Profile), functional mobility (Pediatric Evaluation of Disability Inventory), and Mental Developmental Index (Bayley Scales) were assessed at 18 months corrected age. Infants were excluded from participating in the study if they had severe congenital anomalies or if their caregivers had an insufficient knowledge of the Dutch language. RESULTS: Of the 46 assessed infants, 10 developed spastic CP (Gross Motor Function Classification System levels I to V; eight bilateral spastic CP, two unilateral spastic CP). The absence of fidgety movements and the presence of predominantly stiff movements were associated with CP (Fisher's exact test, p=0.018 and p=0.007 respectively) and lower Infant Motor Profile scores (Mann-Whitney U test, p=0.015 and p=0.022 respectively); stiff and predominantly stiff movements were associated with lower Alberta Infant Motor Scales scores (Mann-Whitney U test, p=0.01 and p=0.004 respectively). Cramped synchronized movements and the asymmetrical tonic neck reflex pattern were not related to outcome. None of the movement characteristics were associated with Pediatric Evaluation of Disability Inventory scores or the Mental Developmental Index. INTERPRETATION: The assessment of fidgety movements and movement stiffness may improve the predictive power of definitely abnormal general movements for developmental outcome. However, the presence of fidgety movements does not preclude the development of CP.

AIM: The aim of this systematic review was to examine the evidence for the predictive validity of Prechtl's Method on the Qualitative Assessment of General Movements (GMsA) with respect to neurodevelopmental outcomes. METHOD: Six electronic databases (PsychINFO, Embase, Health and Psychosocial Instruments, PubMed, and AMED) were searched using the following keywords to identify all studies that examined the predictive validity of the GMsA: 'general movements', 'assessment', 'movement', 'child development', 'infant', and 'predictive value of test'. Only English- and French-language studies were included, whereas studies that focused on spontaneous mobility in preterm infants, but not necessarily the GMsA, or which did not report on the predictive value of the GMsA were excluded. A total of 39 studies were included in the final analysis. RESULTS: Studies were separated according to the age at follow-up: 12 to 23 months, 2 to 3, 4 to 11, and 12 to 18 years. All used a longitudinal cohort study design; however, the outcome measures differed greatly amongst the studies. Values for sensitivity, specificity, positive predictive value, and negative predictive value varied amongst studies. The overall trend indicated that the presence of abnormalities in the quality of fidgety movements at 12 weeks adjusted age is more predictive of adverse outcomes than abnormal writhing movements. INTERPRETATION: The GMsA demonstrates potential as a cost-effective, non-intrusive means of infant examination. However, current studies include important sources of bias. Future methodologically rigorous studies with functional outcomes are suggested.

BACKGROUND: At a time of increasing demands on South African limited healthcare resources, there is a need for an assessment method that can reliably predict neurological deficits in high-risk infants at an early age. OBJECTIVE: The objective of the study is to determine whether the qualitative assessment of fidgety movements will predict the neurological outcome of very low birth weight and extremely low birth weight infants admitted to Tygerberg Children's Hospital (TCH), Cape Town, South Africa. METHODOLOGY: A prospective descriptive study was conducted using Prechtl's method of qualitative assessment of fidgety movements at three months corrected age (CA). The study sample consisted of 115 infants, with a birth weight of ≤1250 g each. At 12 months CA, the infants' final motor outcome was classified as normal, abnormal or suspect according to assessments undertaken in line with those of Amiel-Tison and Gosselin, the Peabody Developmental Motor Scale and the Alberta Infant Motor Scale (AIMS). RESULTS: A significant relationship was found (ρ<0.01) between fidgety movement outcome and the infants' final motor outcome at 12 months corrected age, with a sensitivity of ≥71%, a specificity of ≥89%, a positive predictive value of ≥80%, and a negative predictive value of ≥96%. CONCLUSIONS: The results of the study indicated that Prechtl's qualitative method of fidgety movement assessment, as used in a clinical setting, is a highly sensitive and specific predictor of neurological outcome in preterm infants, which might effectively be used at TCH.

BACKGROUND: The quality of spontaneous general movements (GMs), assessed in the individual infant, has emerged as one of the most reliable and valid predictors especially of severe neurological impairments. AIMS: To implement a more detailed assessment of GMs and co-existing movements and postural patterns in a rehabilitation clinic, and to examine to what extend is the optimality of movements and postures of infants aged 3 to 5 months related to perinatal events and the neurological outcome. STUDY DESIGN: Prospective study of 41 infants (15 boys and 26 girls; 11 infants born preterm) admitted to the Department of Paediatric Neurology and Rehabilitation of the St. Joseph's Hospital in Kyoto (Japan). OUTCOME MEASURES: Clinical, neurological and psychological status at age 5. RESULTS: Motor optimality at age 3 to 5 months correlated positively with neonatal optimality (r=0.48, p<0.01), especially regarding factors associated with hypoxic events. A non-optimal motor performance (lowest possible scores) predicted cerebral palsy with 100% accuracy. Other adverse outcomes such as developmental delays, developmental coordination disorders, pervasive developmental disorder or attention deficit hyperactivity disorder turned out not to be associated with early motor performance. In 13% of cases absence of fidgety movements proved to be false positives, but their normal appearance along with a smooth concurrent motor performance was solely found in infants with a normal neurological development. CONCLUSION: Assessing the quality of motor performance at age 3 to 5 months considerably improves our ability to identify infants at risk for maldevelopment.

Lack of complexity in general movements in early infancy is an important marker of potential motor disorders of neurological origin, such as cerebral palsy. Quantitative approaches to characterising this complexity are hampered by experimental difficulties in recording from infants in their first few months of life. The aim of this study was to design and validate bespoke surface-marker clusters to facilitate data acquisition and enable full quantification of joint rotations. The clusters were validated by recording the controlled movements of a soft-body dummy doll simultaneously with an optical (Qualisys) and inertial (XSens) motion capture system. The angles estimated from the optical system were compared with those measured by the inertial system. We demonstrate that the surface-marker based approach compares well with the use of an inertial system to obtain "direct" readings of the rotations whilst alleviating the issues associated with the use of an optical motion capture system. We briefly report use of this technique in 1-5 month old infants. By enabling full quantification of joint rotation, use of the custom made markers could pave the way for early diagnosis of movement disorders.  

STUDY AIM: To describe general movement in extremely premature infants and examine correlations with risk factors for antenatal, perinatal, and postnatal morbidity. STUDY TYPE: Prospective, single-center study. Nineteen patients were followed up. METHODOLOGY: The infants' general movement was analyzed using video recordings. Qualitative and quantitative assessments were performed during the writhing movement (WM) period and fidgety movement (FM) period. The quality of the general movements (GMs) and the scores achieved were then correlated with antenatal, perinatal, and postnatal factors. RESULTS: Infants' motor activity fluctuated during the WM period, especially in extremely premature infants where poor repertoire is often observed. No correlations were found between WMs and obstetric factors. Gestational age correlated with WMs' quality (p=0.023). WMs correlated with factors of postnatal morbidity such as chronic lung disease (CLD) (p=0.034) and nosocomial infections (p=0.05). At 3 months corrected age, the spontaneous movement quality are correlated with neurological explorations such as US brain (p=0.032), MRI (p=0.039), EEG (p=0.036), and neurological follow-up assessments (p=0.015). CONCLUSION: Prudence must be used when performing the analysis of general movement in extremely preterm infants. WMs may be influenced by perinatal morbidity, and possibly by the severe brain immaturity of these infants. WMs correlate with CLD and nosocomial infections. Analysis of general movement in infants of 3 months corrected age is a valuable means to detect neurological disorders.

BACKGROUND: Prechtl's method on the qualitative assessment of general movements (GMs) has been shown to be a good predictor of neurological outcome. There is substantial evidence that this method has good inter- and intra-observer agreement. AIMS: We wanted to find out whether this high agreement is reproducible in the clinical setting. STUDY DESIGN: Reliability study (inter- and intra-observer agreement). SUBJECTS: Twenty video-sequences of children at the age of preterm and writhing movements (31-41 weeks postmenstrual age) and 10 video-sequences of children at the fidgety movements age (49-54 weeks postmenstrual age) were rated by five physiotherapists. OUTCOME MEASURES: Intra- and inter-observer agreements were analyzed with percentage agreement and with nominal kappa statistic with bootstrapped bias corrected 95% confidence intervals. RESULTS: We found fair to substantial inter-observer reliability for the six response categories (time-point 1(t1): median kappa 0.44, range 0.27 to 0.59, time-point 2 (t2): median kappa 0.55, range 0.41 to 0.77) and fair to almost perfect for the normal/abnormal ratings (t1: median kappa 0.53, range 0.29 to 0.61, t2: median kappa 0.63, range 0.29 to 0.85). There was statistically significant improvement from t1 to t2 for the six response categories. The intra-observer reliability for the 9-week interval was moderate to almost perfect (median kappa 0.68, range 0.41 to 0.86). CONCLUSIONS: We were not able to exactly reproduce the generally very good results. In our clinical setting now videos are evaluated by at least two trained therapists and the results are discussed, if necessary, to reach a consensus.

OBJECTIVE: To correlate the site and severity of brain lesions seen on magnetic resonance imaging (MRI) with the quality of general movements in term infants with hypoxic-ischemic encephalopathy (HIE) and compare the prognostic value of general movements and MRI for motor outcome. STUDY DESIGN: Early brain MRI scans in 34 term infants with HIE not treated with hypothermia were reviewed and scored for site of injury and lesion pattern by an experienced neuroradiologist. General movement quality and trajectories at 1 and 3 postnatal months were evaluated. Motor outcome was assessed at 24 months. RESULTS: MRI scores for the basal ganglia and thalami, posterior limb of the internal capsule, white matter, and cortex and lesion patterns were correlated with 1-month and 3-month general movements and general movement trajectories; central gray matter scores were correlated most strongly with cramped-synchronized general movements and abnormal motor outcome. MRI scores were 100% sensitive and 72.2% specific for motor outcome, and cramped-synchronized general movements were 100% specific and 68.7% sensitive for motor outcome. CONCLUSIONS: In term infants with HIE, the site and severity of brain lesions seen on early MRI are highly correlated with general movements. Central gray matter damage leads to cramped-synchronized general movements and poor motor outcome. Early MRI scans and general movements are complementary tools for predicting motor outcome.

BACKGROUND: While the predictive value of general movements for later cerebral palsy is well known, its value to predict minor neurological and developmental impairments is less clear. AIM: To analyze the results of the assessment of general movements in relation to the developmental outcome measured by the Bayley scales of infant development in a group of preterm infants. METHODS: Twenty-six preterm infants (gestational age from 23 weeks to 36 weeks) were included. The results of the assessment of general movements at term age and at 3 months corrected age were compared to the results of the mental and psychomotor developmental index of the Bayley scales assessed between two and three years of chronological age. RESULTS: Infants with normal writhing general movements achieved the highest scores on the mental and psychomotor developmental index, and those with cramped-synchronized general movements had the lowest scores. Infants with normal general movements during the fidgety period achieved the highest scores on both scales; those with an absence of fidgety movements achieved the lowest scores. We found the sensitivity of general movements to predict cognitive impairments to be 1.00 during the writhing period and 0.83 during the fidgety period; and 0.85 and 0.54, respectively, to predict motor impairments. The differences in the mental developmental index score between the groups with different qualities of general movements were significant in the writhing period and approached significance in the fidgety period, while for the psychomotor developmental index the differences between the groups with different qualities of general movements were not significant. CONCLUSION: The quality of general movements may be predictive of later development.

This study was performed to assess the neurological status of high-risk infants by "general movements" (GMs) method and to compare it with the findings of standard clinical neurological examination and neuroimaging findings during the early rehabilitation period. Neurodevelopmental examination was performed by a neonatologist at the corrected ages of 40 weeks, and 3, 6 and 12 months. Assessment of the physiotherapist included video recording of "Prechtl Analysis of GMs" from the first week of life to the corrected age of 5 months. All infants underwent an early physiotherapy program, and follow-up examinations continued until 12 months. A percentage of agreement of 0.86 was found between cranial ultrasound imaging results and GMs and of 0.78 between neurological examination and GMs. Prechtl analysis was found to be important for detecting neurological dysfunction and differentiating normal neurological development in high-risk infants during the early intervention period. This analysis can be used complementary to other diagnostic and imaging techniques in the follow-up of preterm infants.

OBJECTIVE: The goal was to determine whether the quality of general movements (GMs) for preterm children had predictive value for cognitive development at school age. METHODS: In this prospective cohort study, 60 preterm infants (gestational age, median: 30.0 weeks [range: 25-33 weeks]; birth weight, median: 1130 g [range: 595-1800 g]) without cerebral palsy were studied. The quality of GMs was assessed prospectively as normal or abnormal, from video recordings that were made at regular intervals until 17 weeks after term. At 7 to 11 years, intelligence was tested by using the Wechsler Intelligence Scale for Children III, Dutch version. Total IQ (TIQ), verbal IQ (VIQ), and performance IQ (PIQ) scores were calculated. RESULTS: The median TIQ was 93 (range: 67-113), VIQ 96 (range: 68-117), and PIQ 92 (range: 65-119). Fifteen children (25%) had low TIQ scores (<85). When the quality of GMs normalized before 8 weeks after term, TIQ, VIQ, and PIQ scores were in the normal range. Consistently abnormal GMs to 8 weeks after term were associated with lower TIQ, VIQ, and PIQ scores. With correction for male gender and the educational levels of the parents, the likelihood ratio of consistently abnormal GMs for a low TIQ was 4.9 (95% confidence interval: 1.3-17.6). The model explained 22.4% of the variance. CONCLUSIONS: The quality of GMs during the early postterm period is a marker for intelligence at school age. Abnormal GMs during the early postterm period may reflect injury or developmental disruptions of brain areas involved in cognitive development.

AIM: The aim of this study was to investigate the predictive value of a computer-based video analysis of the development of cerebral palsy (CP) in young infants. METHOD: A prospective study of general movements used recordings from 30 high-risk infants (13 males, 17 females; mean gestational age 31wks, SD 6wks; range 23-42wks) between 10 and 15 weeks post term when fidgety movements should be present. Recordings were analysed using computer vision software. Movement variables, derived from differences between subsequent video frames, were used for quantitative analyses. CP status was reported at 5 years. RESULTS: Thirteen infants developed CP (eight hemiparetic, four quadriparetic, one dyskinetic; seven ambulatory, three non-ambulatory, and three unknown function), of whom one had fidgety movements. Variability of the centroid of motion had a sensitivity of 85% and a specificity of 71% in identifying CP. By combining this with variables reflecting the amount of motion, specificity increased to 88%. Nine out of 10 children with CP, and for whom information about functional level was available, were correctly predicted with regard to ambulatory and non-ambulatory function. INTERPRETATION: Prediction of CP can be provided by computer-based video analysis in young infants. The method may serve as an objective and feasible tool for early prediction of CP in high-risk infants.

BACKGROUND: Abnormal General Movements (GMs) early in life are predictive of later neuromotor deficits and are related to white matter abnormalities on magnetic resonance imaging (MRI). However, other structural correlates of abnormal GMs have not been defined. AIMS: The objective of this study was to explore brain-metrics (linear brain measurements on MRI representative of 3-D brain volumes) at term as a predictor of abnormal GMs at 1 and 3months' corrected age in preterm infants. It was hypothesized that abnormal GMs would be related to reduced brain-metrics in primary motor areas, namely the cerebellum and parietal lobes. STUDY DESIGN: Eighty three preterm infants (<30weeks' gestational age) were scanned at term-equivalent age. MRI was assessed for white matter abnormality and brain-metrics in six predefined brain regions (i.e. bifrontal, biparietal, lateral ventricles and transverse cerebellar diameters, and inter-hemispheric distance). OUTCOME MEASURES: At 1 and 3months' corrected age infants' GMs were assessed from video-taped footage and rated as normal or abnormal using standardized methodology. RESULTS: At 1month, 63% (n=52) of infants had abnormal GMs with no association between any of the brain-metrics and abnormal GMs. At 3months, 23% (n=18) of infants had abnormal GMs (absent fidgety movements n=18; abnormal fidgety movements n=0). Reduced bifrontal, biparietal, and cerebellar transverse diameters, along with an increase in lateral ventricle sizes were associated with an increased risk of abnormal GMs at 3months' corrected age. After controlling for white matter abnormality and grade III/IV intraventricular haemorrhage, only the cerebellar transverse diameter was predictive of abnormal GMs at 3months. CONCLUSIONS: Reduced cerebellar diameter at term equivalent age is related to abnormal GMs at 3months' corrected age, independent of white matter abnormality and intraventricular haemorrhage.

BACKGROUND: Qualitative aspects of the motor repertoire, at 11-16 weeks post-term are predictive for minor neurological dysfunction (MND) at 7 to 11 years of age. Predictive value of quantitative aspects is unknown so far. AIM: To investigate whether quantitative aspects of the motor repertoire between 6 and 24 weeks post-term also have predictive value for neurological outcome at 7 to 11 years of age. STUDY DESIGN: Prospective cohort study. SUBJECTS: Preterm infants from whom several quantitative aspects of the motor repertoire were assessed between 6 and 24 weeks post-term. OUTCOME MEASURES: Neurological outcome at 7-11 years of age was assessed according to Touwens' neurological examination. Children were classified as neurologically normal, or as having complex MND or cerebral palsy (CP). RESULTS: Eighty-two children were included. At 7 to 11 years of age 15 children (18%) had developed CP, 49 (60%) were neurologically normal, and 18 (22%) had MND. Multiple logistic regression analysis showed that, when the qualitative aspects of the motor repertoire known to predict neurological outcome were taken into account, only the asymmetric tonic neck (ATN) posture provided additional predictive value. In case of normal fidgety movements (FMs) accompanied by an abnormal concurrent motor repertoire, the presence of an obligatory ATN increased the risk for developing complex MND to 75%; absence of an obligatory ATN reduced the risk to 15% (p<0.05). CONCLUSIONS: Quantitative aspects of the motor repertoire at 11-16 weeks post-term, in particular the presence of an obligatory ATN posture, contribute to the prediction of neurological outcome at 7 to 11 years of age.

85. Butcher PR, van Braeckel K, Bouma A, Einspieler C, Stremmelaar EF, Bos AF.
The quality of preterm infants' spontaneous movements: an early indicator of intelligence and behaviour at school age.
J Child Psychol Psychiatry 2009; 50: 920-930.

BACKGROUND: The quality of very preterm infants' spontaneous movements at 11 to 16 weeks post-term age is a powerful predictor of their later neurological status. This study investigated whether early spontaneous movements also have predictive value for the intellectual and behavioural problems that children born very preterm often experience. METHODS: Spontaneous movement quality was assessed, using Prechtl's method, at 11 to 16 weeks post-term in 65 infants born at <or= 33 weeks of gestation in a single centre. Intelligence and behaviour were assessed with standardised tests at 7 to 11 years of age. Neurological status was assessed with Touwen's test. Multiple regression was used to determine the predictive value of movement quality for intelligence and behavioural problems. The Sobel test was used to determine if neurological status mediated associations found between early movement quality and outcome. RESULTS: Spontaneous movement quality at 11 to 16 weeks post-term was significantly, positively associated with later intelligence. The number of normal postural patterns displayed contributed most strongly to the association, which was not mediated by neurological status. Fidgety movements, strong predictors of later neurological dysfunction, were not associated with intelligence. Spontaneous movement quality was not associated with internalising or externalising problems but showed a trend to an association with attention problems. CONCLUSION: These findings suggest that, in children born preterm, early spontaneous movement quality has clear prognostic value for neurological and intellectual outcome, and to a lesser extent, for attentional outcome. However, cognitive outcome was associated with the presence of specific, age-appropriate postural patterns, while neurological outcome has been associated with the presence of global movement abnormalities. The presence of specific, age-appropriate postural patterns may reflect the integrity of areas of the brain involved in cognitive processing and the regulation of attention later in childhood. Alternately, it may facilitate cognitive and attentional development.

OBJECTIVE: The objective of this study was to compare the predictive value of qualitative MRI of brain structure at term and general movements assessments at 1 and 3 months' corrected age for motor outcome at 1 year's corrected age in very preterm infants. PATIENTS AND METHODS: Eighty-six very preterm infants (<30 weeks' gestation) underwent MRI at term-equivalent age, were evaluated for white matter abnormality, and had general movements assessed at 1 and 3 months' corrected age. Motor outcome at 1 year's corrected age was evaluated with the Alberta Infant Motor Scale, the Neuro-Sensory Motor Development Assessment, and the diagnosis of cerebral palsy by the child's pediatrician. RESULTS: At 1 year of age, the Alberta Infant Motor Scale categorized 30 (35%) infants as suspicious/abnormal; the Neuro-Sensory Motor Development Assessment categorized 16 (18%) infants with mild-to-severe motor dysfunction, and 5 (6%) infants were classified with cerebral palsy. White matter abnormality at term and general movements at 1 and 3 months significantly correlated with Alberta Infant Motor Scale and Neuro-Sensory Motor Development Assessment scores at 1 year. White matter abnormality and general movements at 3 months were the only assessments that correlated with cerebral palsy. All assessments had 100% sensitivity in predicting cerebral palsy. White matter abnormality demonstrated the greatest accuracy in predicting combined motor outcomes, with excellent levels of specificity (>90%); however, the sensitivity was low. On the other hand, general movements assessments at 1 month had the highest sensitivity (>80%); however, the overall accuracy was relatively low. CONCLUSION: Neuroimaging (MRI) and functional (general movements) examinations have important complementary roles in predicting motor development of very preterm infants.  

79. Sustersic B, Paro-Panjan D.
Assessment of general movements in relation to neurologic signs at age two years.
Pediatr Neurol 2008; 39: 108-112.

Abnormal movement patterns during the fidgety period, as identified by Prechtl's method for qualitative assessment of general movements, and the presence of minor neurologic and cranial signs at age 2 years, as defined by Amiel-Tison, are related to minor developmental disorders. Our study analyzed the relationship between the two assessment methods in 45 preterm infants. Cerebral palsy was identified in 4, minimal cerebral palsy in 2, and the Amiel-Tison triad in 4 children; in all, continuously abnormal patterns of general movements were present. In the intermediate group with 2 signs of the triad, one child exhibited normal movements in the writhing period, and all were abnormal in the fidgety period. The intermediate group, with one sign of the triad, comprised 9 children: abnormal findings in the writhing period were present in 8, and in the fidgety period in 7. Among 16 children without neurologic signs, normal general movements were present in 7 children during the writhing period, and in 5 during the fidgety period. We confirmed good correlation between general movements and neurologic outcome at age 2 years (Pearson's R at term age, 0.51; at fidgety period, 0.62). 

78. Santos RS, Araújo AP, Porto MA.
Early diagnosis of abnormal development of preterm newborns: assessment instruments.
J Pediatr (Rio J) 2008; 84: 289-299. 

OBJECTIVE: To review the literature regarding screening psychomotor tests for the early identification of developmental problems. SOURCES: A search on SciELO, PubMed and Google Scholar was performed using the terms "prematurity," "developmental delay," "cerebral palsy," "early diagnosis" and "evaluation tests." SUMMARY OF THE FINDINGS: A total of 455 references were listed, and 174 studies were selected for this review based on title, relevance, and abstract. Only original and electronically available material, from 1985 forward, with information on design, applicability, and psychometric properties of those tests was included. CONCLUSIONS: Screening tests are important to speed the beginning of treatment measures in order to allow for better developmental outcome. Among the many tests that can be employed for this purpose, the DENVER II and the Alberta Infant Motor Scale are the most often used in Brazilian studies. The Movement Assessment of Infants is starting to be used in our country. Two other tests are recommended in the literature due to their high sensibility and specificity: the Test of Infant Motor Performance and the General Movements. 

 OBJECTIVE: To assess the quality of general movements (GMs) in the first fourteen days of life in relation to obstetric and postnatal risk factors and neurodevelopmental outcome in extremely low birth weight (ELBW) infants. STUDY DESIGN: The GMs of nineteen infants were assessed on days 2, 4, 6, 10 and 14 with Prechtl's method. Additionally, detailed GM assessment produced optimality scores (OSs). GMs and the OSs were related to obstetric and postnatal data and to neurodevelopmental outcome at 18 months. RESULTS: GMs and OSs fluctuated substantially during the first fourteen days of life. Most infants had abnormal GMs, especially poor repertoire (PR) GMs. No relation was found between GMs and obstetric factors. Regarding postnatal factors, septicaemia correlated to hypokinesia (H) and artificial ventilation correlated to a lower OS. CONCLUSIONS: Due to physiological disturbances the quality of GM in ELBW infants fluctuates substantially during the first fourteen days of life. Abnormal GMs, especially PR GMs, are mostly seen for the same reason. Septicaemia and artificial ventilation are associated with deterioration of the GMs (lower OSs), and in case of septicaemia also with hypokinesia.  

BACKGROUND: Assessment of general movements (GMs) at three months is considered useful for prediction of adverse neurological outcome in high risk infants.AIMS: To study the prevalence of abnormal GMs in infants born from women with early-onset hypertensive disorders of pregnancy and the association of GMs with neurodevelopmental outcome at one year. STUDY DESIGN: Prospective study, part of a randomised controlled trial of pre-birth management strategies. SUBJECTS: Infants born from women with early-onset hypertensive disorders of pregnancy. OUTCOME MEASURES: GMs observation and neurological examination at term and three months corrected age; at one year neurological examination and Bayley Scales of Infant Development. RESULTS: From 216 women included, 175 of 178 surviving infants (mean gestational age 31.6 weeks [SD 2.3], mean birth weight 1346 grams [SD 458]), were examined at three months. At term age normal, mildly abnormal and definitely abnormal GMs were observed in 54%, 36% and 10% respectively; and at three months in 47%, 40% and 13%. Mildly or definitely abnormal GMs at three months were not associated with abnormal neurological examination at one year, however, they were associated with delayed psychomotor development at one year (p = 0.01). CONCLUSIONS: In this prospective study, including small for gestational age, preterm infants about half of them did not have normal GMs at term and three months. There was no association of GMs at term nor three months with neurological outcome at one year, but there was a significant association of GMs at three months with one year psychomotor development.

75. Spittle AJ, Doyle LW, Boyd RN.
A systematic review of the clinimetric properties of neuromotor assessments for preterm infants during the first year of life.
Dev Med Child Neurol 2008; 50: 254-66. 75. 

This systematic review evaluates assessments used to discriminate, predict, or evaluate the motor development of preterm infants during the first year of life. Eighteen assessments were identified; nine met the inclusion criteria. The Alberta Infant Motor Scale (AIMS), Bayley Scale of Infant and Toddler Development -- Version III, Peabody Developmental Motor Scales -- Version 2, Test of Infant Motor Performance (TIMP), and Toddler and Infant Motor Examination have good discriminative validity when examined in large populations. The AIMS, Prechtl's Assessment of General Movements (GMs), Neuro Sensory Motor Development Assessment (NSMDA), and TIMP were designed for preterm infants and are able to detect more subtle changes in movement quality. The best predictive assessment tools are age dependent: GMs, the Movement Assessment of Infants, and TIMP are strongest in early infancy (age 4 mo or less) and the AIMS and NSMDA are better at older ages (8-12 mo). The TIMP is the only tool that has demonstrated a difference between groups in response to intervention in two randomized controlled trials. The AIMS, TIMP, and GMs demonstrated the highest levels of overall reliability (interrater and intrarater intraclass correlation coefficient or kappa>0.85). Selection of motor assessment tools during the first year of life for infants born preterm will depend on the intended purpose of their use for discrimination, prediction, and/or evaluation.

74. Einspieler C.
Early markers for unilateral spastic cerebral palsy in premature infants.
Nat Clin Pract Neurol 2008; 4: 186-187.

73. Phagava H, Muratori F, Einspieler C, Maestro S, Apicella F, Guzzetta A, Prechtl HF, Cioni G.
General movements in infants with autism spectrum disorders.
Georgian Med News 2008; 156: 100-105.

General movements (GMs) are a distinct movement pattern carried out spontaneously without external stimulation and seen in fetuses of 9 weeks gestational age till 21 weeks postterm. GMs are helpful in the early diagnosis of an impaired central nervous system and the specific prediction of later neurological deficits. Autism spectrum disorder (ASD) is a neurodevelopmental disorder involving a life-long deficit in several aspects of the social and communicative behavior. Recently there appeared studies proving that children with ASD demonstrate disorders of motor development. The aim was: to detect whether abnormalities in spontaneous motor activity can be observed already in the first months of life in infants with ASD. A retrospective study was performed by analyzing the family videos provided by parents of 20 children (male 17, female 3) later diagnosed as ASD. Home videos provided by parents of a control group of healthy children (n=20; male 10, female 10) matched for age with the ASD subjects and recorded in similar conditions were also analysed. In total 70 sequences were studied. Two independent observers, blind of the infants' outcome (ASD or normal), assessed the cases applying a global and a more detailed assessment of GMs. Hence, the age-specific GM pattern (normal or abnormal) as well as the motor optimality scores were determined for each video sequence. Cohen kappa was 0.614. During the writhing movement period 70.0% sequences of infants with ASD showed poor repertoire GMs. In the control group, poor repertoire GMs were only seen in 12.5% of the sequences. In the fidgety movement period 20.8% of sequences were assessed as absent fidgety movements, 29.2% as abnormal fidgety movements. The large majority of the videos for the control cases were scored as normal (88.9%), 11.1% had no fidgety movements. According to the Mann-Whitney U test there were significant differences between the ASD and the control groups' optimality scores. The optimality scores were lower in the ASD group. The reduced optimality scores were mainly due to a lack of variable sequences, amplitude and speed of writhing GMs and an altered quality of fidgety and other spontaneous movements in the ASD group. Infants with ASD had more often poor repertoire writhing GMs as well as abnormal or absent fidgety movements than control infants. These data encourage further studies involving a larger number of family videos.

72. Spittle AJ, Brown NC, Doyle LW, Boyd RN, Hunt RW, Bear M, Inder TE.
Quality of General Movements Is Related to White Matter Pathology in Very Preterm Infants.
Pediatrics 2008; 121: 1184-1189.

OBJECTIVE. Preterm infants are at an increased risk for abnormalities of general movements, which predict subsequent poor neurodevelopmental outcome. The cerebral lesion that predisposes the preterm infant to abnormal general movements remains unknown. The objective of this study was to determine the association between MRI-defined cerebral abnormalities and general movements at 1 and 3 months' corrected age in infants who were born very preterm. METHODS. Eighty-six preterm infants (<30 weeks' gestation) were prospectively recruited and underwent brain MRI at term-equivalent age to investigate the relationship between qualitative white and gray matter pathology and abnormality of general movements. Standardized videotaped recordings of general movements were obtained at 1 and 3 months postterm (+/-1 week) and scored without knowledge of the MRI findings. At 1 month corrected age, general movements of a writhing character were classified as normal or abnormal (poor repertoire, cramped synchronized, or chaotic). At 3 months' corrected age, fidgety general movements were classified as present or absent. RESULTS. At 1 month, 53 (62%) infants had abnormal general movements, 46 of whom had poor repertoire general movements and 7 of whom had cramped synchronized general movements. At 3 months, 23 (25%) infants had absent fidgety movements. At both 1 and 3 months of age, consistently abnormal general movement classifications were related to increasing white matter abnormality on MRI. In contrast, there were no significant relationships between general movement classifications and gray matter abnormalities, either individually or in total. CONCLUSION. The significant relationships between general movements at 1 and 3 months and cerebral white matter abnormalities on MRI in the very preterm infant support the concept that abnormal general movements reflect white matter injury.

71. Mutlu A, Einspieler C, Marschik PB, Livanelioglu A.
Intra-individual consistency in the quality of neonatal general movements.
Neonatology 2008; 93: 213-216. 

BACKGROUND: The qualitative assessment of general movements (GMs) proved to be a highly sensitive and specific diagnostic tool for the assessment of the integrity of the young nervous system. It is essential that the quality of GMs remains consistent in an individual during a given recording at a certain date. OBJECTIVES: The aim of the study was to investigate the intra-individual consistency of the quality of GMs during one recording. METHODS: 39 preterm infants were recorded at least twice; some were recorded three times. In all, 88 recordings were available but three recordings were excluded due to frequent crying, seizures or hypokinesia. Three scorers assessed 2-3 sequences of these 85 GM recordings. RESULTS: The inter-scorer agreement was high (kappa 0.85-0.94). Intra-individual consistency revealed a kappa of 0.90 with a 95% CI (0.51, 1.00) for preterm GMs, 0.96 with a 95% CI (0.57, 1.00) for writhing GMs, and 0.92 with a 95% CI (0.53, 1.00) for fidgety GMs. CONCLUSIONS: The individual quality of GMs remains consistent for a neonate or young infant at a certain date.

70. Romeo DM, Guzzetta A, Scoto M, Cioni M, Patusi P, Mazzone D, Romeo GM.
Early neurologic assessment in preterm-infants: Integration of traditional neurologic examination and observation of general movements.
Eur J Pediatr Neurol 2008; 12: 183-189.  

OBJECTIVE: To evaluate the possible additional benefit in terms of prognostic accuracy of an integrated application of a traditional scorable method of neurologic examination and the Prechtl's method of qualitative assessment of general movements (GMs) in a large population of 903 consecutive preterm infants. STUDY DESIGN: Infants were enrolled from the Intensive Care Unit of the University of Catania. Inclusion criteria were a gestational age below 37 weeks and the absence of genetic disorders. All infants underwent serial ultrasound and at 3 months performed both the GMs assessment and the Hammersmith Infant Neurologic Examination (HINE). Outcome was assessed at 2 years by the Touwen neurologic examination and the Clinical Adaptive Test/Clinical, Linguistic and Auditory Milestone Scale. RESULTS: The integration of the two methods was shown to be more effective than the single assessments in predicting neurologic outcome. The additional benefit of combining the two approaches was particularly clear for the discrimination between unilateral and bilateral cerebral palsy. CONCLUSIONS: The integrated use of a scorable neurological examination and Prechtl's assessment of GMs can improve early prediction of neurodevelopmental outcome in preterm infants and should complement other clinical and instrumental exams in follow-up programs.

69. Snider LM, Majnemer A, Mazer B, Campbell S, Bos AF.
A comparison of the general movements assessment with traditional approaches to newborn and infant assessment: Concurrent validity.
Early Hum Dev 2008; 84: 297-303 

BACKGROUND: Assessment of the quality of general movements (GMs) is an early clinical marker for prediction of cerebral palsy. AIMS: To explore how the General Movements Assessment (GMsA) relates to traditional newborn and infant measures currently in use. STUDY DESIGN: A prospective cohort design was used to examine concurrent validity of the GMsA in Neonatal Intensive Care (NICU) survivors (n=100) at three age points: preterm (34 weeks gestational age GA), term (38-40 weeks GA), and post term (12 weeks adjusted age [AA]) with traditional assessments (see below). Correlation analysis was used to determine the strength of the associations between tests at each age point. SUBJECTS: Preterm infants born at </=32 weeks gestational age and birth weight <1500 g (n=108) were recruited sequentially from the NICU of a large teaching hospital and referral centre. Infants with diagnoses of metabolic disorders, cardiac, chromosomal, or congenital abnormalities were excluded. OUTCOME MEASURES: Test of Infant Motor Performance (TIMP), Einstein Neonatal Neurobehavioral Assessment Scale (ENNAS), Alberta Infant Motor Scales (AIMS). RESULTS: A low-strength relationship (r=<0.25) was found between the GMsA and the traditional tests which increased across age points (r=0.25-0.50). Relationships between the traditional tests over time was characterized by stronger associations (r=0.50-0.75). CONCLUSIONS: Evidence of concurrent validity of the GMsA with traditional assessments was not found. These early findings support Prechtl's suggestion that GMs reflect a unique neurologic construct, different from traditional tests and reinforce the complementary perspective which the GMsA brings to neonatal assessment.

68. Seme-Ciglenecki P.
Predictive values of cranial ultrasound and assessment of general movements for neurological development of preterm infants in the Maribor region of Slovenia.
Wien Klin Wochenschr 2007; 119: 490-496.

OBJECTIVE: The aim of the study was to assess the predictive values of cranial ultrasound (US) scans and assessment of general movements of fidgety character (GMs) for the later neurological development of preterm infants in the Maribor region of Slovenia. METHODS: Results of cranial US scans done longitudinally from the day of birth until the end of three months of chronologic age and results of GMs at three months of corrected age were compared with traditional neurological examination and evaluation of psychomotor development of the same children at the corrected age of six years. RESULTS: A total of 112 preterm infants (gestational age 37 weeks and below) were included in the study. The infants were classified as low-risk or high-risk for neurological impairment on the basis of cranial US scans. The scans classified as low-risk were followed by a normal neurological outcome in 74 (89%) of 83 infants; those classified as high-risk for neurological impairment were followed by abnormal neurological outcome in 21 (72%) of 29 infants. Of 77 infants with normal fidgety movements, 73 (95%) had a normal neurological outcome and 4 (5%) had an abnormal neurological outcome; of 35 infants with abnormal or absent fidgety movements, 26 (74%) had an abnormal neurological outcome and 9 (26%) had a normal neurological outcome. Of 30 children with abnormal outcome, cerebral palsy was diagnosed in 16, mental retardation in one, nine children had both of these, and four had complex minor neurological dysfunction. The validity of the scans was 85%, sensitivity 70%, specificity 90%, positive predictive value 72% and negative predictive value 89%; the validity of the GMs was 88%, sensitivity 87%, specificity 89%, positive predictive value 74% and negative predictive value 95%. CONCLUSIONS: The sensitivity of the cranial US scans was clearly lower than that of assessment of general movements of a fidgety character. The specificities of the two methods were almost the same.

67. Stahlmann N, Härtel C, Knopp A, Gehring B, Kiecksee H, Thyen U.
Predictive value of neurodevelopmental assessment versus evaluation of general movements for motor outcome in preterm infants with birth weights <1500 g.
Neuropediatr 2007; 38: 91-99.

PURPOSE: The aim of this study was to make a comparison of predictive values of neurodevelopmental assessment and evaluation of videotaped spontaneous movements of premature infants for motor outcome. METHODS: We performed a prospective longitudinal study of 103 VLBW infants, 96 (455-1490 g, 24-35 weeks gestational age) including (a) a neurodevelopmental assessment based on criteria by Amiel-Tison/Grenier at 40 weeks postconceptional age, 3 and 20 months corrected age; (b) an evaluation of general movements with fidgety character, based on criteria by Prechtl, at 3 months; and (c) a standardized testing using the Griffiths Developmental Motor Scale at 20 months. We calculated sensitivity, specificity and predictive values for each method. RESULTS: For predicting motor outcome, the assessment of general movements (GM) had a positive predictive value of 89% and negative predictive value of 84%; neurodevelopmental assessment (NA) at 40 weeks had a positive predictive value of 33% and negative predictive value of 88%, respectively, with similar results for neurodevelopmental assessment at age 3 months. CONCLUSIONS: Normal motor outcome of VLBW infants may be accurately predicted by clinical neurodevelopmental assessment, but for adverse outcomes, evaluation of general movements (fidgety movements) is superior. GM assessment has a high predictive value, especially for CP, but it needs to be complemented by NA for non-CP outcomes. It is a simple, repeatable and non-intrusive technique, and may be a valuable method for the early detection of central nervous system impairment in VLBW infants in routine follow-up.

66. Hadders-Algra M.
Putative neural substrate of normal and abnormal general movements.
Neurosci Biobehav Rev 2007, 31: 1181-1190.

During the last decade it has become clear that the assessment of the quality of general movements (GMs) in foetus and young infant is a sensitive tool to evaluate the integrity of the young nervous system. GMs are movements in which all parts of the body participate. The hallmark of typical GMs is movement complexity and variation; in abnormal GMs movement complexity and variation is reduced or absent. Abnormal GMs may predict developmental outcome. Prediction on the basis of longitudinal series of GM assessments is best. Second best is prediction on the basis of an assessment at 'fidgety' GM age, i.e. at 2-4 months post-term. Definitely abnormal GMs at 'fidgety' age are related to cerebral palsy, mildly abnormal GMs to minor neurological dysfunction at school age. In the present paper the hypothesis is advanced that GM complexity and variation are brought about by the transiently present cortical subplate and that abnormal GMs are the result of damage or dysfunction of the subplate and its efferent motor connections in the periventricular white matter.

65. Guzzetta A, Belmonti V, Battini R, Boldrini A, Paolicelli PB, Cioni G.
Does the assessment of general movements without video observation reliably predict neurological outcome?
Eur J Paediatr Neurol 2007, 11: 362-367.

OBJECTIVE: To assess the clinical value of a modified version, not employing video recording, of Prechtl's method on the qualitative assessment of general movements (GMs) in preterm, term and young infants at neurological risk. MATERIALS AND METHODS: One-hundred and fifteen infants consecutively enrolled in our follow-up program were selected for the study (103 preterm and 12 term infants). While being video recorded, each infant’s spontaneous motor activity was directly observed and documented using a written proforma. An evaluation of the video was later performed by a different assessor blind to the infant’s clinical history. RESULTS: The correlation between the two techniques was significant both at writhing age (birth to 6 weeks post-term age) and at fidgety age (9-15 weeks post-term age). Both methods showed a very high sensitivity for the prediction of cerebral palsy, as no false negatives were observed. The direct assessment showed a lower specificity, particularly during the writhing period. CONCLUSIONS: These results support the use of the direct assessment of GMs when the full application of the standard video observation cannot be routinely applied, restraining the use of video recordings to the abnormal or doubtful cases. This may facilitate the wished integration of the assessment of spontaneous motility into more general protocols of neurological examination and into clinical follow-up programs.

64. Ferrari F, Bertoncelli N, Gallo C, Roversi MF, Guerra MP, Ranzi A, Hadders-Algra M.
Posture and movement in healthy preterm infants in supine position in and outside the nest.
Arch Dis Child Fetal Neonatal Ed. 2007, 92: F386-F390.

OBJECTIVE: To evaluate whether lying in a nest affects the posture and spontaneous movements of healthy preterm infants. METHOD: 10 healthy preterm infants underwent serial video recording in the supine position, when lying in a nest and outside it, at three ages: 30-33 weeks postmenstrual age (PMA) (early preterm), 34-36 weeks PMA (late preterm) and 37-40 weeks PMA (term). The nest was shell-shaped, made by putting two rolled blankets in a form of an oval. Posture was assessed both before and after general movements by scoring the predominant postural pattern. Movements towards and across the midline, elegant wrist movements, abrupt hand and/or limb movements, rolling to side, and frozen postures of the arms and legs were assessed during four general movements. All data relating to motor and postural items were normalised into frequencies of events per minute because the general movements varied in duration. RESULTS: When lying in the nest, the infants more often displayed a flexed posture with shoulder adduction and elbow, and hip and knee flexion, and the head was frequently in the midline. The nest was also associated with an increase in elegant wrist movements and movements towards and across the midline and a reduction in abrupt movements and frozen postures of the limbs. The nest did not affect the occurrence of asymmetrical tonic neck posture. CONCLUSIONS: A nest promotes a flexed posture of the limbs with adduction of shoulders, facilitates elegant wrist movements and movements towards and across the midline and reduces abrupt movements and frozen postures of the arms and legs.

63. Constantinou JC, Adamson-Macedo EN, Mirmiran M, Fleisher BE.
Movement, imaging and neurobehavioral assessment as predictors of cerebral palsy in preterm infants.
J Perinatol 2007; 27: 225-229.

OBJECTIVE: To study the relative efficacy of three early predictors of cerebral palsy. METHOD: One Hundred and thirty infants with birth weight <1500 g were recruited. Video recordings of spontaneous general movements were made at 36 and 52 weeks postconceptional age. Magnetic resonance imaging and the neurobehavioral assessment of the preterm infant were done at 36 weeks postconceptional age. Follow-up neurological examination and Bayley assessments were made at 18 months corrected age to make early identification of cerebral palsy. RESULTS: Magnetic resonance imaging gave the best specificity and accuracy of 91 and 84% respectively. General movements at 52 weeks showed an improved specificity and accuracy over performance at 36 weeks postconceptional age. The negative predictive value for all methods tested was between 90 and 97%. Combining the results of magnetic resonance imaging and the neurobehavioral assessment improved the sensitivity of prediction to 80%, suggesting that a holistic approach to early detection of cerebral lesions is preferable to a single test. CONCLUSIONS: The majority of infants who appeared to behave within normal limits and exhibit normal brain structure in the newborn period were classified as neurologically intact at follow-up.

62. Einspieler C, Marschik PB, Milioti S, Nakajima Y, Bos AF, Prechtl HF.
Are abnormal fidgety movements an early marker for complex minor neurological dysfunction at puberty?
Early Hum Dev 2007; 83: 521-525.

BACKGROUND: Prechtl's method on the qualitative assessment of general movements (GMs) is a powerful tool for early and specific prediction of cerebral palsy. However, it is uncertain whether the GM assessment can be used to predict mild neurological impairment. AIMS: To determine whether the quality of GMs from the age of 3 to 5 months, i.e. fidgety movements, is related to the presence of complex minor neurological dysfunctions (MND) 13 to 15 years later. STUDY DESIGN: Prospectively collected data on the quality of GMs during infancy were retrospectively analysed on the basis of MND at puberty. SUBJECTS: Twenty-eight participants (14 girls and 14 boys) with a median gestational age of 40 weeks (range: 35 to 42 weeks) and an appropriate birth weight (median 3390 g; range 1900 to 4200 g). OUTCOME MEASURES: Touwen's neurological examination. RESULTS AND CONCLUSIONS: Abnormal fidgety movements were not related to later complex MND, but to fine manipulative disabilities (p<0.05). Normal fidgety movements, which are continually present in the whole body, might be required for optimal calibration of the proprioceptive system.
PMID: 17129688 [PubMed - indexed for MEDLINE]

61. Adde L, Rygg M, Lossius K, Oberg GK, Støen R.
General movement assessment: predicting cerebral palsy in clinical practise.
Early Hum Dev 2007; 83: 13-18.
 
OBJECTIVE: The general movement assessment (GMA) method is used to predict cerebral palsy (CP) in infants with high risk of developing neurological dysfunctions. Most of the work on GMA has been performed from the same group of researchers. The aim of this study was to demonstrate to what extent GMA predicted CP in our hands. METHOD: A prospective study was performed using the Prechtl classification system for GMA in the fidgety period to predict later cerebral palsy. The study population consisted of 74 term and preterm infants at low and high risk of developing neurological dysfunction. The absence or presence of CP was reported at 23 months median-corrected age by the child's physician and the parents. RESULTS: The GMA identified all 10 infants that later were classified as having CP. GMA also identified all the infants that did not develop CP except for one infant with abnormal GMA and no CP. Three infants had uncertain CP status at follow-up. The sensitivity of GMA with regard to later CP was 100% with 95% CI (0.73, 1.00) and the specificity was 98% with 95% CI (0.91, 0.99) when the three uncertain cases were excluded. CONCLUSION: Our study indicates that the GMA used in a clinical setting strongly predicts the development of CP. The work supports the results of previous studies and contributes to the validation of GMA. The qualitative nature of this method may be a problem for inexperienced observers. Larger clinical studies are needed.

60. Bouwstra H, Dijck-Brouwer DJ, Decsi T, Boehm G, Boersma ER, Muskiet FA, Hadders-Algra M.
Relationship between umbilical cord essential fatty acid content and the quality of general movements of healthy term infants at 3 months.
Pediatr Res 2006; 59: 717-722.

Prenatal essential fatty acid (EFA) status might be an important factor in the development of the central nervous system (CNS). The aim of the present study was to evaluate the relationship between the fatty acid compositions of the umbilical blood vessels at birth, used as a proxy of prenatal EFA status, and quality of general movements (GMs) at 3 mo. Umbilical artery and vein fatty acid compositions were investigated in a mixed group of breastfed infants and infants fed with formula with or without long-chain polyunsaturated fatty acid (LCPUFA) supplementation. At the age of 3 mo, video assessment of the quality of GMs was performed to evaluate neurologic condition. The quality of GMs was scored by assessing the degree of variation, complexity, and fluency. Outcomes were classified as normal-optimal, normal suboptimal, mildly abnormal, and definitely abnormal movements. Information on potential confounders, including the type of postnatal feeding, was collected prospectively. Associations between fatty acid status at birth and quality of GMs were investigated, and multinomial logistic regression analyses were carried out. None of the infants showed definitely abnormal movements. Infants with mildly abnormal GMs had a lower EFA index, lower arachidonic acid (AA) content, higher total n-9 fatty acid, and higher total monounsaturated fatty acid (MUFA) content in the umbilical artery compared with infants with normal GMs. Multivariate analyses confirmed these findings. We conclude that mildly abnormal GMs are associated with a less favorable EFA status in the umbilical artery.

59. Ivanov IS, Shukerski KG, Chepisheva EV.
Spontaneous motor activity three months after birth in comparison with clinical and ultrasound studies.
Folia Med (Plovdiv) 2005; 47: 18-23.

The introduction of the general movement assessment into pediatric practice as a prognostic method (HFR Prechtl, et al., 1997) has prompted the necessity of further, more extended study of spontaneous motor activity. Possible correlations of this method with the well-established diagnostic and prognostic methods in the neonatal and early post-neonatal period need also more extensive study. Fidgety movements seem to be considered the most convenient to study and of the greatest prognostic value. OBJECTIVE: To study prospectively the spontaneous motor activity in the period of fidgety movements and compare it with the results of the clinical and ultrasound methods of investigation. MATERIAL AND METHODS: Thirty five infants aged 0 to 3 months (7 preterm infants) referred to the Pediatric Neurology Service at Plovdiv University Clinic of Pediatrics and Medical Genetics for consultation or hospitalisation were prospectively followed up to one year of age. Fidgety movements were examined from six to 20 weeks corrected age; neurologic examination and transfontanel ultrasonography were conducted on the day of an infant’s inclusion into the study, during the period of fidgety movements and between 12 to 18 months of age. The clinical and ultrasonographic findings from the neonatal period were analysed. RESULTS: Normal fidgety movements were observed in 31 infants; four infants were with absent fidgety movements. The rate of agreement of the results was high (more than 91%, p<0.05) when presence of normal fidgety movements was correlated with absent or mild neonatal and postneonatal neurologic and ultrasonographic abnormalities, and absent fidgety movements with severe clinical and ultrasonographic abnormalities. CONCLUSION: Abnormal fidgety movements are statistically significantly correlated with the grade of neonatal neurologic and ultrasonographic abnormalities and with the clinical and imaging findings during their investigations.

58. Sival DA, Brouwer OF, Bruggink JL, Vles JS, Staal-Schreinemachers AL, Sollie KM, Sauer PJ, Bos AF.
Movement analysis in neonates with spina bifida aperta.
Early Hum Dev 2006, 82: 227-234.

INTRODUCTION: In neonates with spina bifida aperta (SBA), leg movements by myotomes caudal to the meningomyelocele (MMC) are transiently observed. It is unclear whether these leg movements relate to functional neural conduction through the MMC. For optimal therapeutical intervention, pathophysiological insight in these transient leg movements seems relevant. If leg movements by myotomes caudal to the MMC concur with the execution of general movements (GMs), functional neural conduction through the MMC is implicated. OBJECTIVE: In neonates with SBA, we aimed to determine whether the transiently present leg movements caudal to the MMC indicate functional neural conduction through the MMC. METHODS: During the perinatal period, fetuses and neonates with SBA (n = 7 and n = 13, respectively) were longitudinally analysed for concurrency between leg movements caudal to the MMC and GMs. To address the integrity of the reflex arc in spinal segments (at, or) caudal to the MMC, tendon leg reflexes were assessed during the first postnatal week. RESULTS: At postnatal day 1, leg movements caudal to the MMC concurred with GMs in 12 of 13 infants. Isolated leg movements were observed in only 3 of these 12 infants (isolated vs. concurrent; p < 0.005). Leg movements concurring with GMs lasted longer than isolated leg movements (median duration = 11 s vs. 2 s; p < 0.05). Between days 1 and 7, tendon leg reflexes (at, or) caudal to the MMC had disappeared in all but 1 neonate. However, leg movements caudal to the MMC remained concurrently present with GMs in all five neonates available for follow-up after day 7. Comparing these leg movements between days 1 and 7 indicated a decreased duration (-44%, p < 0.05). CONCLUSIONS: In neonates with SBA, leg movements caudal to the MMC concur with GMs, indicative of functional neural conduction through the MMC. The disappearance of these leg movements is caused by lower motor neuron dysfunction at the reflex arc, whereas neural conduction through the MMC is still functional.

57. Paro-Panjan D, Sustercic B, Neubauer D
Comparison of two methods of neurologic assessment in infants.
Pediatr Neurol 2005, 33:317-324.

Information provided by the neonatal neurologic assessment is important for identifying infants with neurologic abnormalities at a very early age. The aim of this study was to compare two distinct approaches to the neurologic assessment of newborns: the Amiel-Tison neurologic assessment, and Prechtl's qualitative assessment of general movements. The results of both assessments were studied in a group of 45 preterm infants with different risk factors for brain damage that were compared at term age and at a corrected age of 3 months. The predictive power of the two methods regarding the neurologic and developmental outcome at a corrected age of 12-15 months was analyzed. The agreement of the two methods was excellent at term (kappa = 0.87) and good at 3 months (kappa = 0.54). The sensitivity of both methods for detecting children with neurologic abnormalities was high both at term and at 3 months (0.92, 1.0 for the Amiel-Tison assessment and 0.96, 1.0 for general movements). The specificity of both techniques was low at both ages (0.45, 0.75 for the Amiel-Tison assessment and 0.40, 0.35 for general movements). The agreement of the neurologic and developmental outcome was better with the Amiel-Tison assessment (kappa = 0.39, 0.77) than with the observation of general movements (kappa = 0.38, 0.37).

56. Groen SE, de Blécourt AC, Postema K, Hadders-Algra M.
General movements in early infancy predict neuromotor development at 9 to 12 years of age.
Dev Med Child Neurol 2005, 47: 731-738

Assessment of the quality of general movements (GMs) in early infancy is a powerful instrument to predict cerebral palsy (CP). The aim of the present study is to explore the value of GM assessment in predicting minor neurological dysfunction (MND) at 9 to 12 years of age. Two groups of infants were studied prospectively: 28 low-risk full-term infants (11 females, 17 males) and 24 high-risk infants, mostly born preterm (<37 weeks; 11 females, 13 males). In each group the quality of GMs (normal or abnormal) was assessed during two developmental periods: the age at which 'writhing' GMs occur (36 weeks' postmenstrual age to 7 weeks' postterm) and the age at which 'fidgety' GMs occur (8 to 17 weeks' postterm). Eight of 24 high-risk infants were diagnosed as having CP at 4 to 9 years of age. The remaining 44 children were followed-up at 9 to 12 years. In children without CP, quality of GMs at 'fidgety age' was related to neurological condition (normal, simple MND, complex MND) at follow-up (rho=0.46, p<0.01). Abnormal GMs at 'fidgety-GM age' showed a specific relationship to the development of coordination problems (chi2=6.1, p=0.01) and fine manipulative disability (Fisher, p<0.05) at 9 to 12 years. This finding supports the notion that the quality of GMs may provide information on the integrity of complex supraspinal circuitries.

55. Einspieler C, Kerr AM, Prechtl HFR.
Abnormal general movements in girls with Rett disorder: The first four months of life.
Brain Dev 2005, 27: Suppl 1 S8-S13

An apparently normal early development was one of the initial criteria for classical Rett syndrome. However, several investigators considered Rett syndrome to be a developmental disorder manifesting very soon after birth. Videos of 14 infants with Rett disorder were carefully assessed for their spontaneous movements, in particular general movements (GMs), during the first 4 months of life. A detailed analysis clearly demonstrated that none of the infants had normal GMs. However, a specific abnormal GM pattern could not be detected for Rett disorder. The abnormal GMs described here, and their individual developmental trajectories are different from the abnormal GMs described in infants with acquired brain lesion. Our study is the first to apply specific standardised measures of early spontaneous movements to infants with Rett syndrome, proving conclusively that the disorder is manifest within the first weeks of life.

54. Nakayima Y, Einspieler C, Marschik PB, Bos AF, Prechtl HFR.
Does a detailed assessment of poor repertoire general movements help to identify those infants who will develop normally?
Early Hum Dev 2006, 82: 53-59.

BACKGROUND: The assessment of the quality of general movements (GMs) in young infants is a reliable and valid diagnostic tool for detecting brain dysfunction early in life. Poor repertoire GMs are the most frequently observed abnormal GMs during the preterm, term and early postterm period. However, their predictive value for the neurological outcome is low. AIM: To find out whether a detailed scoring of poor repertoire GMs might lead to a better prediction of the neurological outcome. SUBJECTS: We studied 18 preterm infants who were repeatedly videoed from birth to 22 weeks postterm age, including several recordings assessed as poor repertoire GMs. At 8 to 10 years, six children were neurologically normal, six had mild neurological abnormalities, and the remaining six were classified as cerebral palsy. STUDY DESIGN: Each GM globally assessed as poor repertoire was scored in details according to several aspects of neck and trunk, arm and leg movements applying Prechtl's optimality concept. RESULTS: By and large, the detailed score of poor repertoire GMs was not related to the neurological outcome. CONCLUSION: For the clinical application of the GM assessment, it remains important to assess the fidgety movements of those infants with poor repertoire GM trajectories in order to predict their outcome.

53. Valentin T, Uhl K, Einspieler C.
The effectiveness of training in Prechtl’s method on the qualitative assessment of general movements .
Early Hum Dev 2005, 81: 623-627.

BACKGROUND: Prechtl's method on the qualitative assessment of general movements (GMs) is a highly sensitive and specific diagnostic tool for the assessment of the integrity of the young nervous system. AIM: To find out whether the ability to assess GMs correctly could be gained after receiving a few days' standardised training. STUDY DESIGN: We evaluated 700 scoring sheets (containing a total of 8019 assessments) from the final tests of 18 training courses held between 1997 and 2002. RESULTS: Eighty-three per cent of the assessments were correct after completing a 4- to 5-day training course. The correct discrimination between normal and abnormal GMs was 92%. It proved more difficult to assess infants correctly if they had been recorded around term age. CONCLUSION: Standardised training courses enable professionals in the field of infant and child neurology to apply Prechtl's method of GM assessment accurately.

52. Einspieler C, Prechtl HFR.
Prechtl’s assessment of general movements: a diagnostic tool for the functional assessment of the young nervous system.
MRDD Research Reviews 2005, 11: 61-67.

General movements (GMs) are part of the spontaneous movement repertoire and are present from early fetal life onwards until the end of the first half a year of life. GMs are complex, occur frequently, and last long enough to be observed properly. They involve the whole body in a variable sequence of arm, leg, neck, and trunk movements. They wax and wane in intensity, force and speed, and they have a gradual beginning and end. Rotations along the axis of the limbs and slight changes in the direction of movements make them fluent and elegant and create the impression of complexity and variability. If the nervous system is impaired, GMs loose their complex and variable character and become monotonous and poor. Two specific abnormal GM patterns reliably predict later cerebral palsy: 1) a persistent pattern of cramped-synchronized GMs. The movements appear rigid and lack the normal smooth and fluent character. Limb and trunk muscles contract and relax almost simultaneously. 2) The absence of GMs of fidgety character. So-called fidgety movements are small movements of moderate speed with variable acceleration of neck, trunk, and limbs in all directions. Normally, they are the predominant movement pattern in an awake infant at 3 to 5 months. Beside a sensitivity and specificity of 95% each, the assessment of GMs is quick, noninvasive, even nonintrusive, and cost-effective compared with other techniques, e.g., magnetic resonance imaging, brain ultrasound, and traditional neurological examination.

51. Einspieler C, Prechtl HFR, Bos AF, Ferrari F, Cioni G.
Prechtl’s Method on the Qualitative Assessment of General Movements in Preterm, Term and Young Infants (incl. CD-Rom).
London: Mac Keith Press; distributed by Cambridge University Press.
Clin Dev Med 2004, 167: pp 1-91.

50. Sival DA, Brouwer OF, Meiners LC, Sauer PJJ, Prechtl HFR, Bos AF.
The influence of cerebral malformations on the quality of general movements in spina bifida aperta.
Eur J Pediatr Surg 2003; 13: S29-S30.

49. Mazzone L, Mugno D, Mazzone D.
The General Movements in children with Down syndrome.
Early Hum Dev 2004, 79:119-130.

OBJECTIVE: Aim of our study was to describe the character of General Movements (GMs) in children with Down Syndrome (DS). MATERIAL AND METHODS: GMs of 23 children with DS and of 30 healthy full-term infants were assessed from birth to 6th month corrected age. A qualitative and a semi-quantitative evaluation of GMs were achieved for each child. Data were graphically displayed to obtain growth curves of motor optimality scores. RESULTS: GMs in children with DS are characterised by low-low/moderate speed, large-large/moderate amplitude, partially creating impression of fluency, smoothness and complexity, abrupt beginning and end, few other concurrent gross movements. During the 6 months, all children showed an improvement of qualitative and semi-quantitative evaluation, but it was possible to observe great heterogeneity among children in the evolutionary course. GMs evaluation of children with no known motor problems was normal, showing only slight and transient abnormalities at first months. CONCLUSION: GMs character of children with DS could be related to central nervous system and peripheral abnormalities characterizing this syndrome. The evaluation of GMs in children with DS could be an early marker of motor impairment and help in early management decisions making.

48. Garcia JM, Gherpelli JL, Leone CR.
The role of spontaneous general movement assessment in the neurological outcome of cerebral lesions in preterm infants..
J Pediatr (Rio J) 2004, 80: 296-304.

OBJECTIVE: To study the relationship among the quality, type, and trajectory of general movements in preterm infants and neonatal cranial ultrasonography findings and neurological outcome. METHOD: Forty preterm newborn infants, with gestational ages under 35 weeks, had their general movements recorded through video-tape during the preterm, term (37th - 42nd postconceptional weeks of age) and post-term (49th - 56th postconceptional weeks of age) periods, and were prospectively followed up to one-year conceptional age. RESULTS: Our results showed that the quality of general movements, particularly in the post-term period (p = 0.009), were related with the presence of severe cerebral lesions in the neonatal cranial ultrasonography and the neurological outcome. While the presence of severe ultrasonography lesions was associated with an adverse neurological outcome (p = 0.01), the finding of normal general movements patterns was associated with a normal neurological outcome, with negative predictive values of 100%, for the preterm, and 80%, for both term and post-term periods. CONCLUSIONS: When concurrently used, these evaluation methods may increase the specificity and sensitivity in detecting the group of preterm infants at high risk for neurological disturbances in long-term follow-up.

47. Palmer FB.
Strategies for the early diagnosis of cerebral palsy.
J Pediatr 2004, 145: S8-S11.

Strategies for the early detection and diagnosis of cerebral palsy include multiple measures of the underlying brain abnormalities and their neurodevelopmental consequences. These measures can be grouped into the categories of pathogenesis, impairment, and functional limitation. Neuroimaging techniques are the most predictive measures of pathogenesis of cerebral palsy in both the preterm and term infant. Measures of neurological impairment focusing on muscle tone, reflexes, and other features of the neurological examination are poorly predictive in the first months of life. Detection of functional limitations manifested by motor developmental delay is sensitive and specific for later cerebral palsy, but not until well into the second 6 months of life. Abnormal spontaneous general movements in the infant 16 to 20 weeks postterm and earlier reflect functional limitations in the first months of life and have been shown to predict later cerebral palsy. Recognition of abnormal spontaneous general movements may improve early detection and diagnosis of cerebral palsy if these techniques can be successfully incorporated into organized follow-up programs and developmental surveillance. Copyright 2004 Elsevier Inc.

46. Hadders-Algra M.
General movements: A window for early identification of children at high risk for developmental disorders.
J Pediatr 2004, 145: S12-S18.

Detection of children with a developmental disorder, such as cerebral palsy, at an early age is notoriously difficult. Recently, a new form of neuromotor assessment of young infants was developed, based on the assessment of the quality of general movements (GMs). GMs are movements of the fetus and young infant in which all parts of the body participate. The technique of GM assessment is presented and the features of normal, mildly abnormal, and definitely abnormal GMs discussed. Essential to GM assessment is the Gestalt evaluation of movement complexity and variation. The quality of GMs at 2 to 4 months postterm (so-called fidgety GM age) has been found to have the highest predictive value. The presence of definitely abnormal GMs at this age--that is, GMs devoid of complexity and variation--puts a child at very high risk for cerebral palsy. This implies that definitely abnormal GMs at fidgety age are an indication for early physiotherapeutic intervention. Copyright 2004 Elsevier Inc.

45. Zuk L, Harel S, Leitner Y, Fattal-Valevski A.
Neonatal general movements: an early predictor for neurodevelopmental outcome in infants with intrauterine growth retardation.
Child Neurol 2004, 19: 14-18.

Intrauterine growth retardation plays a significant role in neurodevelopmental outcome. The assessment of general movements during the first 20 weeks is a new method for early detection of brain dysfunction. General movements in 31 infants with asymmetric intrauterine growth retardation and their appropriate for gestational age-matched controls were examined. General movements were scored as normal or abnormal by sequential videotape recordings in the writhing (term to 2 weeks), early fidgety (9-11 weeks), and late fidgety (14-16 weeks) periods. Scores were compared between the groups and correlated with neurodevelopmental outcome at 2 years. The incidence of normal general movements was lower in the intrauterine growth retarded infants than in the controls (P < .001). Significant correlations were found between general movement quality and neurodevelopmental scores in the intrauterine growth retarded group. The fidgety movements were the most sensitive and specific for prediction of neurologic outcome. The general movement assessment can, therefore, serve as an additional tool for examining the neurologic status of the preterm and term intrauterine growth retarded infant.

44. Sival DA, Brouwer OF, Meiners LC, Sauer PJ, Prechtl HF, Bos AF.
The influence of cerebral malformations on the quality of general movements in spina bifida aperta.
Eur J Pediatr Surg 2003, 13: S29-S30.

43. Takaya R, Yukuo K, Bos AF, Einspieler C.
Preterm to early postterm changes in the development of hand-mouth contact and other motor patterns.
Early Hum Dev 2003, 75:S193-S202.

Hand-mouth contacts (HMCs) and other spontaneous movements of five low-risk preterm infants were studied longitudinally after their birth until 60 weeks postmenstrual age. For all infants, HMCs that emerged in the preterm period could not be observed transiently after 45 weeks, however, they re-emerged after 50 weeks postmenstrual age. In actograms of the infants' behaviors, the frequency of other spontaneous movements, such as head rotation, showed the same re-emerging pattern. Movements such as cloni, which were also observed in the preterm period, decreased after the term period, with no subsequent increase. Only general movements were continuously present throughout the entire observation period; these changed from writhing to fidgety in nature around the third month. These findings clarify which spontaneous movements of preterm infants are important for later behavioral development.

42. Dibiasi J, Einspieler C.
Load perturbation does not influence spontaneous movements in 3-month-old infants.
Early Hum Dev 2004, 77:37-46.

BACKGROUND: The assessment of the quality of general movements (GMs) in young infants is a reliable and valid diagnostic tool for detecting brain dysfunction early in life. Of special interest is a type of GMs called fidgety movements (FMs) characteristic for 3- to 5-month-old infants. GMs are part of an infant's spontaneous motor repertoire and as such endogenously generated by the nervous system. Visual, acoustic and social stimuli hardly had any influence on FMs. AIM: Our main purpose was to find out whether FMs are sensitive to load perturbation. STUDY DESIGN: Spontaneous motility in supine position, with and without weighting was recorded on video and the data were semiquantitatively analysed. Weights were attached to the ankles and wrists of all four limbs; on one side of the body only; or without visual feedback of the weighted arm. SUBJECTS: We studied 29 healthy infants with normal FMs at the age of 12 weeks. RESULTS: Spontaneous motility remained symmetrical during all the experimental trails. Weighting had no influence on the quality or temporal organisation of FMs. CONCLUSION: This study demonstrated that the mechanisms responsible for FMs in 3-month-old infants are all but impervious to weight perturbation, at least not with the loads studied. FMs is the stable and predominant motor pattern of this age.

41. Guzzetta A, Mercuri E, Rapisardi G, Ferrari F, Roversi MF, Cowan F, Rutherford M, Paolicelli PB, Einspieler C, Boldrini A, Dubowitz L, Prechtl HF, Cioni G.
General movements detect early signs of hemiplegia in term infants with neonatal cerebral infarction.
Neuropediatr 2003, 34:61-66.

Background. Studies have reported that infants with hemiplegia of congenital origin may have a period between birth and up to 12 months when clinical signs of hemiplegia are not evident. The aim of this study was to establish whether the assessment of general movements (GMs) may help in the earlier detection of signs of hemiplegia. Subjects and Methods. Eleven infants with cerebral infarction on brain MRI, and eleven normal controls were enrolled in the study. Quality of GMs was assessed from videotapes between 3 and 6 weeks and between 9 and 16 weeks. Neurological outcome was evaluated at least at two years. Results. Seven of the 11 infants had an assessment performed between 3 and 6 weeks: abnormal GMs were observed in all the infants who developed hemiplegia, but one child had abnormal GMs and a normal outcome. All 11 infants had a scorable assessment between 9 and 16 weeks. In all a specific type of GMs, fidgety movements (FMs), were predictive of neurological outcome. The presence of early asymmetries at both 3 - 6 and 9 - 16 weeks was also significantly associated with later signs of hemiplegia. Conclusions. The assessment of GMs after the neonatal period appears to be very useful in the early identification of hemiplegia in infants with cerebral infarction. Whilst the prediction of hemiplegia should be possible from early neonatal MRI brain scans, this facility is not always available. Observation of GMs is a bedside clinical approach that allows confirmation of early prediction from MRI, early rehabilitation if needed and reassurance that neurological outcome will be good where that is appropriate.

40. Parisi P, Francia A, Vanacore N, Fiore S, Giallonardo AT, Manfredi M.
Psychomotor development and general movements in offspring of women with epilepsy and anticonvulsant therapy.
Early Hum Dev 2003, 74:97-108.

While the role of antiepileptic drug (AED) therapy in teratogenesis has widely been investigated, there are few prospective studies on later postnatal development in offspring of epileptic women in utero exposed. The aim of this study was a prospective investigation of the psychomotor development in a selected population of infant born to women with epilepsy on AED therapy during pregnancy. PATIENTS AND METHODS: Children were assessed at various times until 30 months of age by general movement (GMs) observation (at 7 days and 4 and 13 weeks), traditional neurologic examination (at 7 days and 4 and 13 weeks, 6, 9 and 12 months) and Brunet-Lezine (B-L) administration (at 30 months). We present the preliminary results of our study conducted on 11 children. RESULTS: Psychomotor delay in children was confirmed by traditional neurological examinations scores at 7 days, 4 weeks, 13 weeks and 6 months and by B-L score at 30 months. Between 9 and 12 months of age, traditional neurologic examination became "silent". GM assessment was found to be a better predictor of psychomotor development. In fact, GM analysis, particularly at 4 weeks, was strongly correlated with the Brunet-Lezine score at 30 months. In conclusion, on the basis of these data we suggest a psychomotor delay in the offspring of epileptic women and that GMs and neurologic evaluation provide complementary information concerning psychomotor development and later outcome of these children.

39. Bos AF, Dibiasi J, Tiessen AH, Bergman KA.
Treating preterm infants at risk for chronic lung disease with dexamethasone leads to an impaired quality of general movements.
Biol Neonate 2002, 82:155-158.

Mortality rates do not decline markedly after postnatal corticosteroid therapy and concern has been raised about its neurological sequelae. We studied 37 preterm infants with Prechtl's method for the qualitative assessment of general movements before, during and after dexamethasone therapy and found that the quality of general movements was impaired in 9 of 13 initially normal infants (p = 0.004, McNemar test). The quality of fidgety movements at 3 months was abnormal in the majority of the infants and correlated strongly with neurological abnormalities at 2 years (Spearman r = 0.785, p < 0.001). Prechtl's method may prove useful for the early neurological evaluation of alternative corticosteroid treatment strategies for the treatment of chronic lung disease.

38. Einspieler C, Cioni G, Paolicelli PB, Bos AF, Dressler A, Ferrari F, Roversi MF, Prechtl HFR.
The early markers for later dyskinetic cerebral palsy are different from those for spastic cerebral palsy.
Neuropediatr 2002, 33: 73-78.

Qualitative abnormalities of spontaneous motor activity in newborns and young infants are early predictive markers for later spastic cerebral palsy. Aim of this research was to identify which motor patterns may be specific for later dyskinetic cerebral palsy. In a large, prospectively performed longitudinal study involving four European hospitals we identified twelve cases with the relatively rare condition of dyskinetic cerebral palsy and compared their early motor development with twelve spastic cerebral palsy cases and twelve controls. From birth to the fifth month post-term, all infants were repeatedly videoed and their spontaneous motor patterns, including general movements, were assessed. Until the second month post-term, the infants that later became dyskinetic displayed a poor repertoire of general movements, "arm movements in circles" and finger spreading. Abnormal arm and finger movements remained until at least five months and were then concurrent with a lack of arm and leg movements towards the midline. Later dyskinetic infants share with later spastic infants the absence of fidgety movements, a spontaneous movement pattern that is normally present from three to five months. Qualitative assessment of spontaneous motor patterns enabled us to identify infants at high risk for dyskinetic cerebral palsy early in life. Additionally, we were able to discriminate them from those infants at high risk for later spastic cerebral palsy. This is a matter of significant clinical relevance because the two types of cerebral palsy ask for different management and early intervention.

37. Ferrari F, Cioni G, Einspieler C, Roversi F, Bos AF, Paolicelli PB, Ranzi A, Prechtl HFR. Cramped synchronised general movements in preterm infants as an early marker for cerebral palsy.
Arch Pediatr Adolesc Med 2002, 156:460-467

OBJECTIVE: To ascertain whether specific abnormalities (ie, cramped synchronized general movements [GMs]) can predict cerebral palsy and the severity of later motor impairment in preterm infants affected by brain lesions. DESIGN: Traditional neurological examination was performed, and GMs were serially videotaped and blindly observed for 84 preterm infants with ultrasound abnormalities from birth until 56 to 60 weeks' postmenstrual age. The developmental course of GM abnormalities was compared with brain ultrasound findings alone and with findings from neurological examination, in relation to the patient's outcome at age 2 to 3 years. RESULTS: Infants with consistent or predominant (33 cases) cramped synchronized GMs developed cerebral palsy. The earlier cramped synchronized GMs were observed, the worse was the neurological outcome. Transient cramped synchronized character GMs (8 cases) were followed by mild cerebral palsy (fidgety movements were absent) or normal development (fidgety movements were present). Consistently normal GMs (13 cases) and poor repertoire GMs (30 cases) either lead to normal outcomes (84%) or cerebral palsy with mild motor impairment (16%). Observation of GMs was 100% sensitive, and the specificity of the cramped synchronized GMs was 92.5% to 100% throughout the age range, which is much higher than the specificity of neurological examination. CONCLUSIONS: Consistent and predominant cramped synchronized GMs specifically predict cerebral palsy. The earlier this characteristic appears, the worse is the later impairment.

36. Dibiasi J, Einspieler C.
Spontaneous movements are not modulated by visual and acoustic stimulation in three months old infants.
Early Human Dev 2002, 68: 27-37.

Background: The assessment of the quality of general movements (GMs) in infants proves to be a reliable and valid diagnostic tool for detecting brain dysfunction early in life. Of special interest, particularly for the prediction of cerebral palsy, is the fidgety kind of GMs, the so-called fidgety movements (FMs) observable in 3- to 5-month-old infants. GMs are part of an infant's spontaneous motor repertoire and as such endogenously generated by the nervous system itself. Aim: The question was raised as to what extent the temporal organisation of FMs can be modulated by visual and acoustic stimulation. Study design: Spontaneous motility in supine position with and without stimulation was recorded on video and the data were semiquantitatively analysed. We studied the effect of visual stimulation (red ring, red puppet), unanimated acoustic stimulation (68, 77, 88 dB) and of the mother, approaching her infant in a talkative manner after an absence of a quarter of an hour. Subjects: Twenty-nine healthy infants at the age of 12 weeks who all showed normal FMs. Results: Visual stimulation demonstrated that only the presentation of a red puppet elicited a significant level of focussed attention and led to a decrease of FMs. A red ring, unanimated acoustic stimulation as well as the interaction with the mother had no influence on the temporal organisation of FMs. Conclusion: This study demonstrated that in 3-month-old infants, FMs is a predominant motor pattern and that it is possible to assess FMs during (playful) social interaction.

35. Prechtl HF, Cioni G, Einspieler C, Bos AF, Ferrari F.
Role of vision on early motor development: lessons from the blind.
Dev Med Child Neurol 2001 Mar;43(3):198-201

For a better understanding of the contribution vision makes to the development of other sensory systems and to movement and posture, we studied effects of early blindness by examining video recordings of 14 totally blind infants. Infants were born at term or preterm and showed no evidence of brain damage. During preterm and term periods no noticeable changes in motor activity were observed. Around 2 months postterm all infants showed clear delay in head control and abnormal, exaggerated type of 'fidgety movements'. Later, postural control was characterized by a prolonged period of ataxic features. Results indicate a lack of normal calibration exerted by vision on proprioceptive and vestibular systems. Early visuomotor coordination such as coordinated eye-head scanning and head orientating were present but disappeared after several weeks.

34. Prechtl HFR.
General movement assessment as a method of developmental neurology: new paradigms and their consequences. The 1999 Ronnie MacKeith Lecture.
Dev Med Child Neurol 2001; 43: 836-842.

33. Bos AF, Einspieler C, Prechtl HFR.
Intrauterine growth retardation, general movements, and neurodevelopmental outcome: a review.
Dev Med Child Neurol 2001; 43: 61-68.

32. Bos AF, Venema IMJ, Bergervoet M, Zweens MJ, Pratl B, van Eykern LA.
Spontaneous motility in preterm infants treated with indomethacin.
Biol Neonate 2000; 78: 174-180.

Objective: To determine in preterm infants with a patent ductus arteriosus (PDA) the effect of indomethacin treatment on spontaneous motor activity. Study Design: Motor activity was assessed from repeated videotape recordings in 32 preterm infants (less than or equal to 33 weeks gestation). Sixteen infants required indomethacin therapy for treatment of PDA, 16 were control infants, matched for gestational age. Indomethacin (0.2 mg/kg i.v. in 5 min) was given thrice, with an interval of 12 h. One-hour recordings were made immediately before and immediately after the first dose of indomethacin and 24 h later before and after the third dose. The same recording schedule was used for the control infants. The effects of indomethacin on quantity and quality of spontaneous motor activity were examined. Results: A significant reduction in the quantity of several spontaneous movement patterns and an increase in the occurrence of rest periods were found following the first indomethacin administration (p < 0.01). Concerning the quality of general movements, a reduction in the speed was found (p < 0.05). Both effects were not found after the third indomethacin administration. Conclusion: In preterm infants with a PDA, treatment with indomethacin leads to a transient reduction in the quantity of spontaneous movement patterns and to a decrease in the speed of general movements. We recommend a cautious use of bolus indomethacin for the treatment of PDA.

31. Cioni G, Bos AF, Einspieler C, Ferrari F, Martijn A, Paolicelli PB, Rapisardi G, Roversi MF, Prechtl HFR.
Early neurological signs in preterm infants with unilateral intraparenchymal echodensity.
Neuropediatrics 2000; 31: 240-251.

The aim of the study was to document the early developmental course of neurological signs in a group of preterm infants at risk for hemiplegia, due to unilateral intraparenchymal echodensity (UIPE). Sixteen preterm infants with UIPE and sixteen controls were given serial neurological examinations, according to the protocols currently adopted in the different NICUs of the project. Moreover, the quality assessment of their general movements (GMs) was assessed subsequently from videotapes, from birth until around four months postterm. At two years, 12 of the UIPE infants showed hemiplegia and one suffered from asymmetrical diplegia. The findings of the traditional neurological examination were abnormal for the large majority of the UIPE group, although normal findings were also recorded, especially during the preterm period. Asymmetries were found after term age in nine UIPE and in two control infants. From the first observation onwards, all infants with UIPE showed bilaterally abnormal GMs and in those with unfavourable outcome fidgety movements (FMs) were absent. At the FMs period (9-16 weeks postterm), all infants with subsequent hemiplegia showed asymmetry of distal segmental movements which were reduced or absent on the side contralateral to the lesion.
Conclusions: Unilateral brain lesions induce clear neurological signs and abnormal GMs in particular, although these abnormalities are not initially asymmetrical. A reduction of segmental movements on one side of the body during the third month postterm is highly predictive of hemiplegia.

30. Bos AF, Einspieler C, Prechtl HFR, Touwen BCL, Okken-Beukens MD, Stremmelaar AF.
The quality of spontaneous motor activity in preterm infants as early predictive signs for minor neurological abnormalities at 2 years.
Newsletter Neonatal Neurology 1999; 8: 4-5.

Objective: To determine in preterm infants with a patent ductus arteriosus (PDA) the effect of indomethacin treatment on spontaneous motor activity. Study Design: Motor activity was assessed from repeated videotape recordings in 32 preterm infants (less than or equal to 33 weeks gestation). Sixteen infants required indomethacin therapy for treatment of PDA, 16 were control infants, matched for gestational age. Indomethacin (0.2 mg/kg i.v. in 5 min) was given thrice, with an interval of 12 h. One-hour recordings were made immediately before and immediately after the first dose of indomethacin and 24 h later before and after the third dose. The same recording schedule was used for the control infants. The effects of indomethacin on quantity and quality of spontaneous motor activity were examined. Results: A significant reduction in the quantity of several spontaneous movement patterns and an increase in the occurrence of rest periods were found following the first indomethacin administration (p < 0.01). Concerning the quality of general movements, a reduction in the speed was found (p < 0.05). Both effects were not found after the third indomethacin administration. Conclusion: In preterm infants with a PDA, treatment with indomethacin leads to a transient reduction in the quantity of spontaneous movement patterns and to a decrease in the speed of general movements. We recommend a cautious use of bolus indomethacin for the treatment of PDA.

29. Bos AF. Analysis of movement quality in preterm infants.
Europ J Obstet Gynecol Reprod Biolog 1998; 76: 117-119.

28. Bos AF, Martijn A, van Asperen RM, Hadders-Algra M, Okken A, Prechtl HFR.
Qualitative assessment of general movements in high risk preterm infants with chronic lung disease requiring dexamethasone therapy.
J Ped 1998; 132:300-306.

OBJECTIVE: The objective of this study was to determine in preterm infants at risk for severe chronic lung disease (1) the quality of general movements (GMs) and (2) the effect of dexamethasone treatment on spontaneous motor activity. STUDY DESIGN: In 15 very low birth weight infants the quality of GMs was assessed from repeated videotape recordings. Recordings were made at weekly intervals during the preterm period until term age and thereafter three times until the twentieth postterm week. All infants required dexamethasone therapy, and additional recordings were made a few hours before and 24 hours, 48 hours, and 7 days after dexamethasone was started. The relationship among movement quality, brain ultrasonographic abnormalities, and long-term outcome was explored. Acute effects of dexamethasone on motor activity were examined. RESULTS: After dexamethasone therapy was started, a significant transient reduction of the quantity of most spontaneous movements (p < 0.05) and a reduction of speed and amplitude of GMs was found (p < 0.05). A significant relationship was found between the severity of brain ultrasonographic abnormalities and the extent to which developmental trajectories of GMs were abnormal (p < 0.001). The development of cerebral palsy was related to the presence of cramped-synchronized movements near term (p < 0.02) and to the absence of fidgety movements at the age of 3 months after term (p < 0.05). CONCLUSION: In preterm infants with severe chronic lung disease and brain lesions, dexamethasone treatment leads to an acute reduction in motility and changes in the speed and amplitude of GMs. Until more is known about long-term neurologic sequelae, a cautious use of systemic dexamethasone therapy in preterm infants is recommended.

27. Bos AF, Martijn A, Okken A, Prechtl HFR. Quality of general movements in preterm
infants with transient periventricular echodensities.
Acta Paediatr 1998; 87: 328-335.

By means of sequential videotape recordings, the relevance of the quality of general movements for neurological outcome was determined in a group of 21 appropriate-for-gestational-age preterm infants with transient periventricular echodensities of variable localization and duration and in 6 infants without echodensities. Echodensities, especially in the parieto-occipital area, affected the quality of general movements. Echodensities persisting beyond 14d were associated with abnormal general movements; infants with echodensities up to 14 d had either normal or abnormal general movements. The developmental course of movement quality was correlated to neurological outcome (p < 0.005): normal outcomes were found in 11/12 infants with normal general movements throughout and in 9/11 infants with transient abnormal general movements; all 4 infants with persistent abnormal general movements had impaired outcomes. In infants with transient echodensities, longitudinal assessment of the quality of general movements helps to determine if there is brain dysfunction, either transient or persistent, and identifies infants at risk for impaired neurological outcomes.

26. Bos AF, van Asperen R M, de Leeuw DM, Prechtl HFR The influence of septicaemia on spontaneous motility in preterm infants.
Early Hum Dev 1997, 50: 61-70.

The qualitative assessment of general movements (GMs) in preterm infants is a sensitive method to investigate the integrity of the central nervous system. The question arises whether systemic infections affect the quality of GMs in a similar fashion to brain lesions. We were able to provide an answer to this problem in six infants (gestational age 24.4-32.4 weeks, birth weight 600-1660 grams), who had initially normal GMs as analyzed from sequential video-recordings. All infants sustained a proven septicaemia (Candida albicans in two, Staphylococcus aureus in three, a coagulase-negative staphylococcus in one infant). Unintentionally, recordings were also made during the acute phase. The complexity and variability of the GMs remained largely intact in five of the six infants; only one infant had transiently abnormal GMs. Compared with 1 week before the acute phase, the speed and amplitude of the GMs were diminished, giving the GMs a sluggish appearance. One to two weeks after the acute phase of septicaemia, the quality of GMs, i.e. speed and amplitude, had normalized in all infants. This study demonstrates that it is possible to discriminate between abnormal GMs due to cerebral lesions and sluggish GMs due to severe systemic infections, when the complexity of the GMs is considered as the main characteristic for judgement of normality of GM-quality.

25. Bos AF, van Loon A J, Hadders-Algra M, Martijn A, Okken A, Prechtl HFR. Spontaneous motility in preterm, small for gestational age infants. II. Qualitative aspects.
Early Hum Dev 1997, 50: 131-147.

In order to document in detail the developmental course of qualitative aspects of early spontaneous motility in intrauterine growth-retarded infants, sequential videotape recordings were made in 19 preterm infants with a birth weight below the 5th percentile. The quality of general movements (GMs) was studied longitudinally during the preterm and postterm period until approximately 20 weeks corrected age, using Prechtl's method of quality assessment. An abnormal quality of GMs was present in 15 out of 19 infants. Compared to a low-risk group, consisting of appropriate-for-gestational age preterm infants, the proportion of infants with normal findings on brain scans who had an abnormal quality of GMs was high. The presence of 'abrupt chaotic' GMs was related to late fetal heart-rate decelerations and ischaemic alterations of the placenta. The quality of GMs normalized before or during the third month postterm in most infants with abnormal GMs. In four infants, the GMs did not normalize during the study period. The quality of fidgety movements was, in particular, a marker for neurological outcome at 24 months. This study demonstrates that intrauterine growth retardation may cause prolonged, but in most cases transient brain dysfunction; the qualitative assessment of GMs may help to identify infants at increased risk for neurodevelopmental abnormalities.

24. Cioni G, Ferrari F, Einspieler C, Paolicelli PB, Barbani MT, Prechtl HFR.
Comparison between observation of spontaneous movements and neurological examination in preterm infants.
J Ped 1997; 130: 704-711.

OBJECTIVE: The Prechtl method of qualitative assessment of general movements (GMs) has been shown to be a good predictor of neurologic outcome in fetuses, preterm infants, and term infants. The aim of this study was to compare the results of this new technique with those of traditional neurologic examination and of cranial ultrasonography in preterm infants. METHODS: Serial videotape recordings (with off-line assessment of GMs), ultrasound examination of the brain, and neurologic examinations were performed from birth until about 6 months of corrected age, on a group of 66 preterm infants whose gestational age ranged from 26 to 36 weeks (mean 30.7 weeks). The agreement between the two techniques and their predictive power, with respect to the neurologic outcome at 2 years of corrected age, were evaluated for five different age groups from preterm age to 65 weeks of postmenstrual age. RESULTS: Overall agreement of the neurologic and GM findings was 80.3% and strongly age related (lower during the preterm and term periods and higher thereafter). At all ages the results of GM observation correlated highly with neurologic outcome; they showed higher sensitivity and specificity than the neurologic examination. This held true in particular before term age, when poor neurologic responses might be related to transient complications, and at term age, mainly because of infants with normal neurologic examination results but unfavorable outcome. During the preterm period the ultrasound results showed a better specificity and a lower sensitivity to outcome than GM findings. CONCLUSIONS: The results of this study indicate that quality assessment of GMs should be added to traditional neurologic assessment, neuroimaging, and other tests of preterm infants for diagnostic and prognostic purposes.

23. Cioni G, Prechtl HFR, Ferrari F, Paolicelli PB, Einspieler C, Roversi MF. Which
better predicts later outcome in fullterm infants: quality of general movements or neurological examination?
Early Hum Dev 1997, 50: 71-85.

The qualitative assessment of general movements (GMs) has been shown to be a better predictor of neurological outcome than the traditional neurological examination in brain-damaged preterm infants. The aim of this study was to compare the results of the two techniques in term infants. Off-line assessment of GMs from videorecordings and neurological examinations were carried out, from birth till about 6 months of postterm age, in a group of 58 term infants, the majority of which were affected by mild to severe hypoxic-ischaemic encephalopathy. The agreement between the two techniques and their predictive power, with respect to the neurological outcome at 2 years, were evaluated for four age groups. The range of agreement between neurological and GM findings was between 78 and 83%. At all ages the results of GM observation correlated highly with the neurological outcome; their sensitivity and specificity with respect to outcome were consistently slightly superior to those of neurological examination. In infants normalize after an initial period of transient abnormalities, GMs normalize earlier than the neurological results.

22. Einspieler C, Prechtl HFR, Ferrari F, Cioni G, Bos AF. The qualitative assessment of general movements in preterm, term and young infants - review of the methodology.
Early Hum Dev 1997, 50: 47-60.

We describe the state of the art of Prechtl's method for the qualitative assessment of general movements as a diagnostic tool for early detection of brain dysfunction. After discussing the optimal technique for video recording general movements in preterm, term and young infants, attention is focused on the proper analysis of this spontaneous motor pattern. Recently, a group of active researchers in the field reached consensus on the various qualities of normal and abnormal general movements. These definitions are reported here in full. Since it is a newly introduced method careful investigation into its reliability is required. Various groups of investigators have obtained data which demonstrate the robust character of the method (interscorer agreement: 78-98%). Finally, we discuss the validity of this early assessment method on the basis of the reports published so far. While the method's sensitivity is similar in all age groups studied (preterm, term, first month, second month, and third month age epochs), and averages 94.5%, the specificity of the method is age-dependent. It is low during the early ages, increases gradually and reaches 82 to 100% at 3 months post-term. This phenomenon is explained by spontaneous recovery of early dysfunction. In contrast, consistent abnormalities of general movements are linked to neurological deficits found at the 2 year follow-up.

21. Ferrari F, Prechtl HFR, Cioni G, Roversi MF, Einspieler C, Gallo C. Paolicelli PB,
Cavazutti GB. Behavioural states, posture and spontaneous movements in infants affected by brain malformation.
Early Hum Dev 1997, 50: 87-113.

Posture, quantity of spontaneous movement patterns, quality of general movements (GMs), and behavioural state organisation were studied in nine infants affected by documented brain malformations. A single 1 h video recording of five infants and two or more serial video recordings of another four infants were performed after birth. The graphic representation of single movement patterns (actogram) and of behavioural states of one video recording was performed in eight out of nine infants. The quality of GMs was assessed according to Prechtl's method in all video recordings. All nine infants showed a less variable posture than normal newborn infants and an unusual resting posture was detected in seven infants. Poor behavioural state organisation without sleep cycles was common to the nine infants and excessive wakefulness was observed in six infants. As for the quantity of single movement patterns, six infants lacked one or two movement patterns normally present in healthy newborn infants. An abnormal quality of GMs was noted in all nine infants and distinct motor abnormalities were observed in single infants. A monotonous and sometimes stereotyped sequence of different body parts involved in the movement (i.e. poor repertoire GMs) was common to all infants. In the four infants of whom two or more video recordings were available, initial poor repertoire GMs were followed by a further deterioration in movement quality. No relationship was found between the quantity of defective brain tissue, lack of a specific part of the brain, type and severity of GM and posture abnormalities.

20. Kainer F, Prechtl HFR, Engele H, Einspieler C. Prenatal and postnatal assessment of the quality of general movements in infants of women with type-I diabetes mellitus.
Early Hum Dev 1997, 50: 13-25.

The effect of type-I diabetes on the quality of general movements (GMs) was studied longitudinally in 12 human fetuses. GMs were analysed at two-weekly intervals from 16 weeks until delivery. A pregnancy optimality-score and a diabetes optimality-score were used to cover the course of the pregnancy and delivery and the severity of diabetes. GMs of infants were analysed 1, 4-6, and 12-18 weeks after birth and the Bayley developmental test was performed at 10 months. All fetuses showed normal GMs at 16 weeks. From 20 weeks onwards until delivery five fetuses developed abnormal GMs. The diabetes optimality-score was significantly lower in the group with abnormal GMs (P = 0.018) whereas the pregnancy optimality-score did not differ between fetuses with normal and abnormal GMs. Our results indicate that type-I diabetes can have a negative impact on prenatally observed GMs. Consistently normal GMs indicate normal neurodevelopmental outcome at 10 months whereas in the group with abnormal GMs reduced Bayley-scores may occur.

19. Prechtl H.F.R. (ed). Spontaneous Motor Activity as a Diagnostic Tool. Functional
Assessment of the Young Nervous System.
Early Hum Dev, Special Issue, 1997, Vol. 50 (1), pp:148.

18. Prechtl H.F.R. State of the art of a new functional assessment of the young nervous
system. An early predictor of cerebral palsy.
Early Hum Dev 1997, 50: 1-11.

The paper provides a survey of the state of the art of a new neurological diagnostic procedure in fetuses, preterm and term infant as well as in young infants. This method consists of a judgement of the movement quality of a particular type of spontaneous movements, the so-called general movements. At a very early age normal and abnormal general movement quality predicts the neurological outcome over 2 years, in particular cerebral palsy. The reliability of this method turned out to be very robust. Recent animal experiments on isolated parts of the central nervous system provide convincing evidence of endogenously generated neural activity. Similar neural mechanisms must provide the basis for spontaneous movements seen in the human at early ages. Those neural defects leading to qualitative changes of general movements are described in detail.

17. Prechtl HFR, Einspieler C. Is neurological assessment of the fetus possible?
Eur J Obstet Gynecol Reprod Biol 1997; 75: 81-84.

The possibility to assess the functional condition of the fetal nervous system is of great importance to the obstetrician, since a considerable part of early brain damage is of prenatal origin. Several attempts to develop such a technique are reviewed. In addition, a new method, the qualitative assessment of fetal general movements, is described as a successful tool to obtain reliable data on the fetal brain dysfunction. This new method is robust, non-intrusive and cost-effective. There is also the advantage that the same criteria for the diagnostic assessment can be used for the fetus as well as for the young infant.

16. Prechtl HFR, Einspieler C, Cioni G, Bos AF, Ferrari F, Sontheimer D. An early
marker for neurological deficits after perinatal brain lesions.
Lancet 1997; 349: 1361-1363

BACKGROUND: In normal awake infants, fidgety movements are seen from the age of 6 weeks to 20 weeks. The aim of the study was to test the predictive value of absent or abnormal spontaneous movements in young infants for the later development of neurological deficits. METHODS: In a collaborative study involving five hospitals we collected data on the normal and abnormal quality of fidgety movements of 130 infants and compared it with assessments of neurological development done longitudinally until the age of 2 years. On the basis of ultrasound scans infants were classified as at low-risk or at high-risk of neurological deficits. Infants were videoed for 1 h every week from birth to discharge and then for 15 min every 3 to 4 weeks; quality of general movements was assessed. Repeated neurological assessments were also done until 24 months of corrected age. FINDINGS: 67 (96%) of 70 infants with normal fidgety movements had a normal neurological outcome. Abnormal quality or total absence of fidgety movements was followed by neurological abnormalities in 57 (95%) of the 60 infants (49 had cerebral palsy and eight had developmental retardation or minor neurological signs). Specificity and sensitivity of fidgety movement assessment were higher (96% and 95%, respectively) than of ultrasound imaging of the infants' brain (83% and 80%, respectively). INTERPRETATION: Our technique of assessing spontaneous motor activity can identify and distinguish between those infants who require early intervention for neurological abnormalities and those who do not. Our technique is simple, non-intrusive, reliable, quick, and can be done on very young infants.

15. Albers S, Jorch G. Prognostic significance of spontaneous motility in very immature
preterm infant under intensive care treatment.
Biol. Neonate 1994; 66: 182-187.

Qualitative analysis of spontaneous motility was performed in 22 preterm infants (gestational age 25-31 weeks) on the intensive care unit. The infants were videorecorded once a week in the late afternoon during 1 h until 36 weeks of gestation. Quality of movement was analyzed by 8 observers using visual 'Gestalt perception' and compared with the neurological outcome 1 year after term. A normal quality of movement consistently predicted a normal neurological outcome with a probability of 90-100%. An abnormal quality of movement predicted an abnormal outcome with a probability of only 56% in the first, but with a probability of 82% in the third postnatal week. The average interobserver agreement was 78%. The analysis of spontaneous motility for the early diagnosis of neurological dysfunctions can reliably be applied on very immature preterms under intensive care conditions from the 3rd postnatal week on.

14. Einspieler C. Abnormal spontaneous movements in infants with repeated sleep apnoaes.
Early Hum Dev 1994; 36: 31-49.

Infants with repeated apnoea during sleep have received great attention for the assumed reason of being at-risk for sudden infant death. The present paper reports findings which indicate a different risk, namely for neurological impairment during infancy due to repeated hypoxia. A very strong correlation exists between the respiratory measurements based on a polygraphic all-night recording (PtcO2 drops and apnoea incidence and duration) and the impairment of the spontaneous movement repertoire in 114 infants, aged between 3 and 26 weeks. All infants have been video recorded at the same day as the registration of the sonogram. As there was a gradient of respiratory abnormalities from absent to severe, a similar gradient was present in the degree of motor deviations in these infants. A variety of qualitative changes in the spontaneous movement patterns was found which was similar to those previously described in cases with documented brain damage. These abnormalities could not be attributed to pre- and perinatal complications. It is concluded that infants with repeated sleep apnoea need special attention for prevention of neurological impairment irrespective of the supposed risk for sudden infant death.

13. Einspieler C. Prechtl HFR, van Eykern L, de Roos B. Observation of movements during sleep in ALTE and apnoeic infants.
Early Hum Dev 1994; 40, 39-50.

Fourteen infants of 2 months or 6 months of age were video-recorded during polysomnography. Four were normal infants, five had a history of ALTE (apparent life threatening event) and five had repeated and prolonged apnoea during sleep. Two ALTE infants have been recorded at 2 months as well as at 6 months of age. Movements during sleep could be classified into general movements, isolated movements of the upper extremity, startles, head rotations, and trunk rotations. In the ALTE cases at 2 months of age, the motility was quantitatively not different from the control infants but was markedly reduced at 6 months of age. (All cases had their event before 8 weeks of age.) In contrast to these findings, infants with repeated apnoea did not show a clear change in the quantity of their movements. With the exception of one ALTE case at 2 months, all observed cases of ALTE and apnoeic infants showed an abnormal quality of their spontaneous movements during sleep. As reported in a previous study, all these cases had also been found moving abnormally during wakefulness. It is suggested that the abnormal motility is a sequelae of the event (ALTE or repeated apnoeas) with as a consequence, an impairment of neural functions.

12. Prechtl HFR. Abnormal movements are a marker of brain impairment in fetuses and
preterm and fullterm infants. In: HC Lou, G Greisen, J Falck-Larsen (eds). Brain Lesions in the Newborn.
Copenhagen: Munksgaard. Alfred Benzon Symp 1994; 37: 314-321.

11. Prechtl HFR, Ferrari F, Cioni G. Predictive value of general movements in asphyxiated fullterm infants.
Early Hum Dev 1993; 35: 91 - 120.

The developmental course of spontaneous motility was investigated in a group of 26 fullterm infants, affected by mild to severe hypoxic-ischaemic encephalopathy. Serial 1-h videorecordings were carried out from birth to 15-22 weeks and a quality assessment of general movements (GMs) was made from a replay of the videos. Neurological follow-up of the infants were continued until at least 18 months of age; neonatal EEG and neuro-imaging techniques (US-scan, CT or MRI) were also carried out in all cases. The results indicate that perinatal asphyxia has important effects on the spontaneous motility of fullterm infants. Hypokinesis occurred very frequently during the first days of life, followed by a transient or prolonged (lasting longer than 15-22 weeks) abnormal quality of GMs. In the first 2 weeks the results of GM assessment did not correlate with the simultaneous findings of neurological examination, neuro-imaging and EEG, whereas they did when the results at 15-22 weeks were considered. The changes in spontaneous motility and especially GM developmental trajectories were good predictors of the neurological outcome. The predictive value of GM assessment was found to be similar to that of EEG and neuro-imaging, and better than neurological examination.

10. Hadders-Algra M, Prechtl HFR. Developmental course of general movements in early infancy. I. Descriptive analysis of change in form.
Early Hum Dev 1992; 28: 201-213.

In order to describe the developmental changes of general movements (GM) in early infancy and to relate them to changes in other aspects of the neurological repertoire, the spontaneous motility in supine position was recorded on video tape at 4-week intervals in a group of twenty-two full-term healthy infants aged 2-18 weeks. Each follow-up session included a neurological examination. In newborn infants GM have a 'writhing' quality. The movements are characterized by a tight appearance, a relatively slow speed and a limited amplitude. The 'writhing' character of the GM is gradually broken down into a so-called 'fidgety' quality. These GM are typified by an ongoing flow of small movements occurring irregularly all over the body. The transformation of GM from a 'writhing' character into a 'fidgety' character was related more closely to postmenstrual than to postnatal age. 'Fidgety' GM were almost constantly present at the age of 8-12 weeks. In the third month very rapid arm movements ('swipes' and 'swats') occurred. The developmental changes in the form of the GM and those of the neurological repertoire showed no significant correlation. This demonstrates that within the normal CNS the various functional modules develop autonomously.

9. Hadders-Algra M, van Eykern LA, Klip van den Nieuwendijk AW, Prechtl HFR.
Developmental course of general movements in early infancy. II. EMG correlates.
Early Hum Dev 1992; 28: 231-251.

In order to study developmental changes in muscle co-ordination during the first postnatal months, simultaneous polymyographic recordings and video-recordings were made during spontaneous movements of 22 healthy infants, who were followed from birth onwards. During the first 2 months general movements (GM) change from movements with a so-called 'writhing' character, which have a tight appearance, a relatively slow speed and a limited amplitude, into GM with a 'fidgety' character, which consist of an ongoing flow of small, elegant movements. We hypothesized that this transformation would coincide with a change from a pattern of co-contraction of antagonistic muscle groups into a pattern of reciprocal activation. This was not the case, a pattern of co-activation of antagonistic muscle groups remained the prevailing pattern. With increasing age, we found shorter burst durations of phasic activity, an attenuation of burst amplitude and a decrease of tonic background activity. These changes were attributed to a reduction of the sensitivity of the motor units due to spinal and supraspinal reorganization. It is hypothesized that the so-called 'bistable' properties of motoneurones play a central role in the observed phenomena: in neonates motor units are apt at displaying sustained activity, at 2 months of age the threshold for reaching this maintained activity increases, resulting in a low level of excitation of motor units during spontaneous movements. In the third month rapid arm movements ('swipes' and 'swats') develop. The 'swats' are characterized by a consistent pattern of reciprocal activity of antagonistic (shoulder) muscles.

8. Cioni G, Prechtl HFR. Preterm and early postterm motor behaviour in low-risk premature infants.
Early Hum Dev 1990; 23: 159-193.

The development of spontaneous motility and posture was studied longitudinally in 14 carefully selected low-risk preterm infants. The aim of this investigation was to provide a set of data suitable for comparison with fetuses and with neurologically abnormal preterm infants. The infants were videorecorded weekly, for one hour in a supine position, from birth until their discharge from the hospital. Ten of them were thereafter also observed at home at 3-week intervals from 3 to 18 weeks of corrected age, together with 10 healthy fullterm infants. Occurrence and duration of motor patterns and postures in periods of rest and activity were obtained by off-line analysis of the videotapes. Few significant changes were found from birth until term age in the composition and quantity of the spontaneous movement patterns. Only twitches and stretches during activity periods showed a small decline approaching term age. However, notable inter-individual differences and intra-individual fluctuations from week to week were observed. Postterm development of preterm infants was similar to that of the fullterms. Both showed considerable changes in the qualities of general movements after the first postterm weeks. Only fidgety character movements occur earlier in preterm infants. No age-specific preference postures of the limbs were found in the preterm period. Midline position of the head in supine was observed at about the same postterm age in preterm and fullterm groups. Asymmetrical tonic neck postures were very inconsistently present before term age and rapidly disappeared after term, earlier so in preterm infants.

7. Ferrari F, Cioni G, Prechtl HFR Qualitative changes of general movements in
preterm infants with brain lesions.
Early Hum Dev 1990; 23: 193-233.

The aims of the study were (1) to replicate previous quantitative studies of motor activity in low-risk and high-risk preterm infants and (2) to apply a new method of systematic analysis of the qualitative characteristics of general movements in these two groups of infants. Sequential one-hour videorecordings of the unstimulated infants in the incubator were made during the preterm period and then continued during the postterm period until about 20 weeks. The high-risk group consisted only of infants with signs of haemorrhage and/or leucomalacia in the repeated ultrasonograms of the brain. The neurological follow-up continued up to a minimum of one and a maximum of three years of corrected age. The quantification of the various motor patterns in 12 matched pairs of low-risk and high-risk preterm infants revealed a slight but significant (P = 0.05) excess of isolated arm movements in the low-risk cases during the activity phase. No other movement pattern differed significantly. The qualitative assessment of general movements during the preterm period resulted in all but one of the 14 low-risk cases having a normal quality of general movements. In the lesion-group (N = 29) all the infants had an abnormal quality during the preterm period. Eight cases later became neurologically normal although 1 of them had strabism. In addition, one infant was blind (ROP) and retarded and one other had mental retardation. Nineteen infants later developed cerebral palsy (two monoplegia of a leg, three hemiplegia, 5 diplegia and 9 quadriplegia). Strabism was present in 48.3% of the whole group of 29 cases. A semi-quantitative estimation of various aspects of the abnormal general movements made a typology of abnormal patterns possible. A graphic display of developmental trajectories of individual cases, depicting the course of abnormal aspects along the time axis, helps document the evolution of abnormal signs. Their course is a better predictor of the neurological outcome than the nature and localization of the lesion, detected by imaging techniques. The qualitative assessment of general movements from videorecordings is a reliable, quick, cheap and totally non-intrusive method in neonatology for the early detection of functional impairment of the nervous system.

6. Prechtl HFR. Qualitative changes of spontaneous movements in fetus and preterm infants are a marker of neurological dysfunction.
Early Hum Dev 1990; 23: 151-159.

5. Cioni G, Ferrari F, Prechtl HFR. Posture and spontaneous motility in fullterm infants.
Early-Hum Dev 1989; 18: 247-262

Posture and spontaneous motor patterns during the first days of life were studied in ten healthy fullterm infants by direct observation and videorecording. The aim of the study was to provide a description of motor and postural characteristics of normal newborns. The infants were recorded for 1 h on their first and fourth day of life, when unstimulated in an incubator. Incidence and duration of the different body postures and motor patterns were scored during the replay of the videorecordings. The preference for the fully flexed posture of arms and legs described in the literature could not be confirmed. There was a large intra- and inter-individual variability in the postural repertoire. No particular posture, characteristic for each behavioural state, existed. Similar postures rarely occurred in the same infant on the first and fourth day. Extended postures more often occurred on the fourth day. Spontaneous motility consisted of several distinct movement patterns, the occurrence of which in states 1 and 2 was computed for day 1 and day 4. Motor patterns were differently related to the states. No differences were noted in the motor activity between the first and fourth days. Large inter-individual differences, but an intra-individual consistency, were found in the rates of specific motor patterns: infants who showed a low or high rate of particular movements on day 1 maintained the same characteristic on day 4. There was no overall low or high motor activity.

4. Prechtl HFR. New perspectives in early human development.
Eur J Obstet Gynecol Reprod Biol 1986; 21: 347-355

A new hypothesis is presented concerning the maturation of the human nervous system and the duration of pregnancy. It has been found that many neural functions characteristic of the fetus continue after birth until a major transformation takes place at the end of the second postnatal month. From a comparative perspective the duration of pregnancy in man is relatively short among primates. An explanation may be found in metabolic constraint. The special energy demands of a large fetal nervous system and the build-up of a subcutaneous fat deposit may have prevented a proportional prolongation of pregnancy during evolution of hominids.

3. Prechtl HFR, Hopkins B. Developmental transformations of spontaneous movements in early infancy.
Early Hum Dev 1986; 4: 233-238.

One component of the major transformation of neural functions at the end of the second postnatal month is concerned with a change in the appearance of general movements. These endogenously generated complex movements lose their writhing character and are replaced by a transient form, termed 'fidgety' movements. There are individual differences in the age of onset and duration as revealed by longitudinal observations. It is speculated that 'fidgety' movements may be related to a postnatal calibration of the proprioceptive system.

2. Prechtl HFR. (ed.) Continuity of Neural Functions from Prenatal to Postnatal Life.
Oxford: Blackwell Scientific Publications. Clin Dev Med 1984; 94.

1. Hopkins B, Prechtl HFR A qualitative approach to the development of movements during early infancy. In: HFR Prechtl (ed.) Continuity of Neural Functions from Prenatal to Postnatal Life.
Oxford: Blackwell Scientific Publications. Clin Dev Med 1984; 94: 179-197.