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• W2609920562 abstract "Original ArticlesNeurological Screening in a Cohort of Infants Born at King Khalid University Hospital Abdulrahman Al-Frayh, Facharzt Khalid N. Haque, FRCP, DCH Elisabet Norell, and MD Theresa Luine-SweenyMPH, DRPH Abdulrahman Al-Frayh Chairman, Department of Pediatrics and Vice Dean of Academic Affairs, College of Medicine, King Saud University, P. O. Box 2925, Riyadh 11461, Saudi Arabia Search for more papers by this author , Khalid N. Haque Associate Professor and Consultant, Department of Pediatrics, College of Medicine, King Saud University Search for more papers by this author , Elisabet Norell Formerly, Consultant Pediatric Neurologist, King Khalid University Hospital and King Abdul Aziz University Hospital Search for more papers by this author , and Theresa Luine-Sweeny Formerly, Assistant Professor, Department of Community Medicine, College of Medicine King Saud University Search for more papers by this author Published Online:1 Jul 1987https://doi.org/10.5144/0256-4947.1987.234SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutABSTRACTABSTRACTThe rate of neurological abnormality in infants varies not only internationally but also locally, depending on multifarious factors. By instituting a neurological screening program based on cumulative risk factors, we found a neurological abnormality rate at one year of 15/1,000 six-month examinations at our hospital. In this preliminary report we suggest the institution of such a screening program in other hospitals in the Kingdom.INTRODUCTIONMore than a hundred years ago, the relationship between adverse medical events in the perinatal period and later neurological handicap was documented.1 In the recent past, detailed incidence studies have been done in order to identify major risk factors for neurological abnormalities among various subgroups of newborns, such as premature infants.2Information about rates of early infant neurological abnormality are available from the developed world3 but are scanty for Saudi Arabia.4–6 The present study was undertaken to evaluate [1] the rate and types of neurological problems in the first year of life in a cohort of infants born at King Khalid University Hospital, Riyadh, Saudi Arabia, and [2] to identify obstetrical and postnatal complications which played a role in the etiology of these neurological abnormalities. On the basis of our results, we are making recommendations concerning screening of psychomotor development in Saudi Arabia.PATIENTS AND METHODSThe study population included all liveborn infants delivered at King Khalid University Hospital during a four-month period from the beginning of May to the end of August 1984 (cohort group). Six months after the birth of a ’cohort baby’ a pediatric neurologist screened each infant using the scheme shown in Table 1. To prevent observer bias, the neurologist did not take a history and had no access to the medical records of either the infant or the mother.Table 1. Scheme for infant neurological screening examination at six months of age.Table 1. Scheme for infant neurological screening examination at six months of age.Any infant with positive neurological findings was defined as a ’case.’ These case infants were then seen again by the same neurologist at 8-9 months and 12 months of age, uncorrected for gestational age. At these follow-up examinations, history was taken but, again to prevent bias, medical records were not accessed.Data on obstetrical and postnatal complications were subsequently extracted from the medical records of both the mother and the infant without prior knowledge of the status of the infant. Controls were obtained from those infants in the cohort group who were found not to have any neurological abnormality at the initial screening. Controls were pair-matched to cases for age of the mother (within three years) and nationality. Thus, this was a case/control study using pair-matching. Statistical analysis included chi-squared test for matched pairs, odds ratio with 95% confidence intervals, and the Mann-Whitney U test.Forty-two individual factors adapted from the obstetric and postnatal complications scales of Littman and Parmelee7 and Prechtl’s8 optimality scale were analyzed.RESULTSThe parents of 346 children were contacted (49.4% of total births in the study period). Of these parents, 262 (75%) brought their infants for a six-month neurological screening examination. Two hundred and fifty-three babies (97%) were screened from 24 up to 28 weeks of age (age of infants was not corrected for prematurity); two infants were screened at 23 weeks, and four at 29 weeks of age. Thirty-four (13%) infants were identified as ’cases’ on vital screening. Thirty-two (96%) of these infants were brought for follow-up visits. The remaining 312 infants were followed in well-baby clinic, and none of them were detected to have any neurological deficit by 1 year of age.Rate and Type of Neurological AbnormalityFour out of the 34 case infants had neurological deficit at one year (Table 2). Two showed moderate mental retardation. Both were born at term, with one having seven accumulated risk factors and the other having four accumulated risk factors. The third abnormal infant was born prematurely at 26 weeks with 11 accumulated risk factors. The fourth infant had Down’s syndrome which had been diagnosed at birth. This baby was included in rate calculations but was excluded from risk factor association analysis.Table 2. Neurological problems at one year of age in 34 infants with positive neurological findings at six months of age.Table 2. Neurological problems at one year of age in 34 infants with positive neurological findings at six months of age.The rate of neurological abnormality with 95% confidence intervals was 13 (9-18) per hundred screening examinations. On follow-up at one year, 12% remained with neurological handicap. The one-year rate for definite abnormality was thus 15 (6-54) per one thousand screening examinations. If the two infants without follow-up examinations are included, the rate for neurological handicap at one year was 23 (10-49) per one thousand screening examinations.Obstetrical and Postnatal Risk FactorsThirteen out of 42 individual complications occurred in sufficient numbers to allow calculation of 95% confidence intervals. These factors are summarized in Table 3. Case infants had a range of 2-14 accumulated risk factors, with a median of 5. Controls had a range of 0-10 accumulated risk factors, with a median of 3. High numbers of accumulated risk factors were significantly associated with cases (Mann-Whitney U test, P <0.01). The remaining 29 factors occurred in too few numbers for meaningful analysis.Table 3. Obstetrical and postnatal complications associated with infant neurological problems: odds ratio for matched pairs.Table 3. Obstetrical and postnatal complications associated with infant neurological problems: odds ratio for matched pairs.DISCUSSIONThere are many factors which interact to affect the pregnant woman, her fetus and her infant. If many factors accumulate to act simultaneously on the fetus or the neonate, total effect can be synergistic. Touwen9 suggested that six or seven risk factors occurring together may cause a “risk of neurological disturbances being found in the baby.” In this study, risk factor accumulation occurred more often in cases than in controls (Table 3). There are few meaningful abnormal neurological signs at birth, and neurological deficit may not appear normal for several weeks. Therefore, the sooner such abnormalities are identified and a habilitation program is instituted, the more hopeful the prognosis of the child would be. It should be noted, however, that the presence of seven or more risk factors did not always predict poor outcome. One control infant with ten accumulated risk factors was found to be normal neurologically. As Nelson and Ellenberg10 pointed out, caution should be exercised in labeling infants with mild motor disorders and in predicting future motor impairment, as abnormal neurological signs disappear in some cases by one year or even later.In this preliminary study the most important factors associated with neurological abnormality at six months were: [1] microcephaly, [2] prematurity, and [3] low birth weight (Table 3). These findings are similar to published work which has suggested that microcephaly, low birth weight and prematurity are associated with higher rate of neurological abnormalities. We have also found that parity of four or more and a rapid second stage of labor are both significantly associated with poor neurological outcome.The rate of neurological abnormality found at one year (15/1,000 six-month examinations) compares well with the American rate of 16.0 to 17.3 per thousand examinations.11We recommend that the following categories of infants be followed from birth in a special clinic: (1) infants with very small or very large head circumference at birth; (2) infants born prematurely; (3) infants born at term but with low birth weight and low Apgar scores; (4) infants with problems in the neonatal period, such as convulsions, hyperbilirubinemia, and feeding difficulties; and (5) infants with several accumulated risk factors (Table 3). In such a clinic a neuropediatric developmental screening, such as the one used by us, could be applied, and if any abnormality is suspected, a multidisiplinary approach could be used to help the infant.Institution of such a program, however, demands adequate training of pediatricians in the techniques of neuropediatric developmental screening of infants. The doctor performing the screening needs thorough knowledge and experience to avoid overlooking the soft signs of neurological problems or overdiagnosing a normal infant as abnormal. Eventually, however, by introducing routine neuropediatric screening methods as suggested, Saudi Arabia will reach a stage where such screening runs like an important thread through all health care work with children. It will then be possible to detect almost all children with a neurological/developmental handicap and to apply neurodevelopmental habilitative measures beginning at an early age.For other infants it is our suggestion to implement routine infant screening of psychomotor development in well-baby clinics at nine or ten months of age and again at eighteen months of age. These ages are chosen because our results suggest that the six-month screening examination for infants is not specific in that most of the neurological abnormalities (soft signs) resolve between nine and twelve months. These key ages have also been found suitable in Sweden.Our findings are not unique, and the risk factors are well known. However, we feel that the results of this study clearly show that if institutions in the Kingdom would adopt a neurological screening program based on cumulative risk factors as suggested in Table 3, most infants with neurological deficit would be detected, thus leading to earlier institution of therapeutic regimens and possible reduction in long-term handicap.ARTICLE REFERENCES:1. Little WJ. On the influence of abnormal parturition, difficult labor, premature birth, asphyxia neonatorum, on the mental and physical condition of the child, especially in relation to deformities . Trans Obstet Soc (London). 1862; 3:293. Google Scholar2. Cruickshank WM. The problem and its scope . Cruickshank WM, ed. Cerebral palsy: a developmental disability. New York: Syracuse University Press, 1976:1–28. Google Scholar3. Hagberg B, Lundberg A. Neuropediatrisk utvecklings-diagnostik . Paediatricus. 1980; 2:15–31. Google Scholar4. Haque KN. Cerebral palsy in Riyadh, Saudi Arabia . Pakistan Paediatr J. 1986; 10(1):1–12. Google Scholar5. El-Rifai MR, Ramia S, Moore V. Cerebral palsy in Riyadh, Saudi Arabia: II. Associations between gestational age, birthweight and cerebral palsy . Ann Trop Paediatr. 1984; 4(1):13–7. Google Scholar6. Taha SA, Mahdi AH. Cerebral palsy in Saudi Arabia: a clinical study of 102 cases . Ann Trop Paediatr. 1984; 4(3):155–8. Google Scholar7. Littman B, Parmelee AH. Medical correlates of infant development . Pediatrics. 1978; 61(3):470–4. Google Scholar8. Prechtl HF. Neurological sequelae of prenatal and perinatal complications . Br Med J. 1967; 4:763–7. Google Scholar9. Touwen BC. Developmental neurology . Rose CF, ed. Pediatric neurology. Oxford: Blackwell, 1979:86–97. Google Scholar10. Nelson KB, Ellenberg JH. Children who 'outgrew' cerebral palsy . Pediatrics. 1982; 69(5):529–36. Google Scholar11. Solomons G, Solomons HC. Motor development in Yucatecan infants . Dev Med Child Neurol. 1975; 17:41–6. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 7, Issue 3July 1987 Metrics History Accepted26 November 1986Published online1 July 1987 KeywordsNeurological manifestationsNervous system diseases - in infancy and childhood - Saudi ArabiaACKNOWLEDGEMENTThe authors would like to thank Mr. Mohammad Iqbal Qureshi for secretarial assistance.InformationCopyright © 1987, Annals of Saudi Medicine" @default.
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