Neonatal Neurobehavioral Examination A New Instrument for Quantitative Analysis of Neonatal Neurological Status ANDREW M. MORGAN, VERA KOCH, VICKI LEE, and JEAN ALDAG

A new neonatal neurobehavioral examination (NNE) was designed in response to the need for a more quantitative assessment of neonatal neurological status. The NNE consists of 27 items divided into three sections: 1) tone and motor patterns, 2) primitive reflexes, and 3) behavioral responses. Each section consists of 9 items scored on a three-point scale. Fifty-four healthy full-term infants were examined at 2 days of age and demonstrated total NNE scores ranging from 70 to a maximum possible score of 81 ( = 76, s = 1.03). Mean section scores for these infants ranged from 25.3 to 26.6 (s = .59-1.79). Intertester agreement was 88% by item and 95% by total score in each section. Two hundred ninety-eight high-risk infants were then examined at 37 to 40 weeks conceptional age (gestational age plus chronological age) or at discharge from the neonatal intensive care unit, whichever occurred first. Total NNE mean scores for high-risk infants fell into discrete clusters by conceptional age at the time of exami­nation (37-42 weeks, mean score = 66.5; 34-36 weeks, mean score = 60.7; <34 weeks, mean score = 51.1). Similar clustering occurred for the three section scores. Highly significant differences existed between the three conceptional age groups for total scores and section scores. No clinically significant score differences were associated with severity of illness or gestational age at birth. The results of this study suggest that the NNE easily and reliably assesses infants' neonatal neurobehavioral status at a given conceptional age. Additional studies are in progress to determine the value of the NNE in predicting subsequent developmental disabilities.

Key Words: Child development; Pediatrics, evaluation; Tests and measurements, functional.

The field of neonatology has changed dramatically over the past 25 years, con­tributing to a steady decline in the mor­tality and morbidity of smaller low birth-weight infants.1,2 Despite ad­vanced technology, however, neonatal neurological deficits still occur.3,4 The ability to assess neonatal brain function and, thereby, to predict neurological

deficits remains rudimentary. Multiple risk factors associated with neurological impairment have been identified, but no method exists to determine whether a specific perinatal event has actually re­sulted in irreversible brain damage.5,6

Cranial sonography performed at var­ious times during the neonatal course has been shown to demonstrate struc­tural abnormalities such as periventric­ular leukomalacia or cystic changes,7

but the predictive significance of these findings in terms of irreversible injury is still uncertain.8

Clinical examination remains the most effective way to assess neonatal neurological status. The pioneer work of Thomas et al in the 1960s focused on a more classical neurological examina­tion that emphasized active tone, pas­sive tone, and primitive reflexes.9

Prechtl and Beintema10 and Amiel-Tison11 subsequently designed neuro­logical scales using the data of Thomas et al9 to assess neonatal maturity. With the introduction of the Brazelton Neo­

natal Behavioral Assessment Scale (BNBAS) in 1973, however, the focus shifted to a more behavioral orientation that emphasized sensory processing and interactive responses.12 As interest in early identification of developmental problems grew, new neonatal assess­ment scales emerged that combined both behavioral and neurological ap­proaches.13,14

Although many neonatal assessment scales are currently available to the cli­nician,15 almost all of them provide a descriptive, qualitative impression of neurobehavioral function that is de­pendent on the skill and experience of the examiner. This "gestalt" approach can identify areas of concern but is of limited value in predicting develop­mental outcome or assessing the success of treatment alternatives. Some scales have been modified to allow statistical interpretation, such as the "a priori clus­ters" of BNBAS items by Als et al16 or the "optimality" scoring of Prechtl,17 but none of the scales offer the concise nu-

A. Morgan, MD, is Chief, Section of Child De­velopment, and Assistant Professor, Department of Pediatrics, The University of Illinois College of Medicine at Peoria, 530 NE Glen Oak Ave, North Building, Peoria, IL 61637. Address correspondence to PO Box 1649, The University of Illinois College of Medicine at Peoria, Peoria, IL 61656 (USA).

V. Koch, MS, is Clinical Associate, Division of Child Development, Department of Pediatrics, The University of Illinois College of Medicine at Peoria.

V. Lee, BS, is Clinical Assistant, Division of Child Development, Department of Pediatrics, The University of Illinois College of Medicine at Peoria.

J. Aldag, PhD, is Associate Professor of Medi­cine, Department of Medicine, The University of Illinois College of Medicine at Peoria.

This article was submitted April 24, 1987; was with the authors for revision 17 weeks; and was accepted March 15, 1988. Potential Conflict of In­terest: 4.

1352 PHYSICAL THERAPY

RESEARCH merical system necessary for quantita­tive analysis and true standardization.

We attempted to design and standard­ize a new assessment scale that would characterize the various aspects of neu-robehavioral fitness at a given concep-tional age (gestational age in weeks and chronological age from delivery in weeks) with objective, numerical scores. A quantitative rather than qualitative assessment of neonatal neurobehavioral status would be valuable in the identifi­cation of infants at risk for develop­mental disabilities and would also pro­vide a research tool for evaluating early treatment protocols.

METHOD

Design of the Neonatal Neurobehavioral Examination

After extensive review of existing ges­tational age scales and neonatal exami­nations, we selected 27 items for use in a neonatal neurobehavioral examina­tion (NNE) because of their ability to reflect the distinct changes in neurobe­havioral function that occur with in­creasing maturation. Alterations in arm recoil or prone suspension, for example, emerge as the infant's muscle tone grad­ually increases with gestational age. Grasp, positive support, and other prim­itive reflexes, and behavioral responses such as alertness and consolability also change in quality and intensity as the infant approaches full term. Almost all of the assessment items were taken from the previous work of Thomas et al,9

Brazelton,12 and Dubowitz and Dubo-witz.13 Other items, such as slip-through at the shoulders, were added to include areas of function not addressed in other assessment scales. Several traditional as­sessment items were eliminated because they were either redundant or inappro­priate when applied to a premature in­fant. For example, both heel-to-ear and popliteal angles are measures of hip and lower extremity tone, so only popliteal angle was included on the NNE. Be­cause all high-risk infants are exposed to the noxious lights and sounds in the neonatal intensive care unit and must habituate to them to some degree, we believed that the BNBAS response-decrement items were of questionable value and did not include them on the NNE. The 27 assessment items were organized into three sections represent­ing different aspects of neurobehavioral status: 1) tone and motor patterns, 2) primitive reflexes, and 3) behavioral re­

sponses. Each section consisted of nine assessment items.

A three-point scoring system was then applied to each item. A four- or five-point system was rejected because we believed it would result in more subtle differences in the performance choices and produce greater scoring indecision than a three-point scale. A three-point system simplified the assessment process and allowed the examiner to choose be­tween more obvious differences in the observed performance of each item. The longitudinal data of Thomas et al9 dem­onstrated that distinct changes in active tone, passive tone, and primitive re­flexes occur at about 32 weeks gesta­tional age and again at about 36 weeks gestational age. The resting posture of an infant, for example, shows absence of extremity flexion before 32 weeks gestational age, leg flexion between 32 and 36 weeks gestational age, and flex­ion of all extremities after 36 weeks gestational age. Similarly, grasp is weak before 32 weeks gestational age, reason­ably strong between 32 and 36 weeks, and strong enough to lift the infant off the bed (traction response) after 36 weeks gestational age. The natural evo­lution of tone and primitive reflexes, therefore, coincides nicely with a three-point scoring system.

In the tone and motor patterns and primitive reflexes sections, a score of 3 reflected responses expected of a full-term infant (37-42 weeks gestational age), a 2 reflected responses expected at 32 to 36 weeks gestational age, and a 1 reflected responses expected at less than 32 weeks gestational age. Exaggerated responses that are generally considered to be signs of neurological injury (eg, shoulder retraction, fisting, or equinus) were included in a separate column and were assigned a score of 1. The behav­ioral responses section was divided into three subtests—responsiveness, temper­ament, and equilibration—with three items in each subtest. The three subtests represented three distinct aspects of be­havioral performance. Items in the re­sponsiveness section reflect the infant's general ability to process and respond to external stimuli, items in the tempera­ment section reflect the level of the in­fant's threshold to noxious stimuli, and items in the equilibration section reflect the ability of the infant to return to an emotional baseline after the stimulation threshold has been exceeded. The origi­nal Brazelton scales12 for the selected items were modified so that a score of 3 consistently represented optimal per­

formance, and a score of 1 consistently represented a deficient response. The original nine-point scoring system was condensed into a three-point system to conform to the design of the other NNE items and to reduce the likelihood of scoring indecision.

Scores of the 9 items in each section were summed to provide section scores in addition to a total score for all 27 items. The maximum total score possi­ble was 81, and the minimum total score possible was 27. In the behavioral re­sponses section, each subtest was also given a cluster score. The subtest was assigned a cluster score of 3 if two of the three items in the subtest were scored as 3, a score of 1 if two of the three items were scored as 1, and a score of 2 for all other combinations. This multivariate scoring system was used at the outset to improve the possibility of ultimately finding a marker or combination of markers predictive of outcome. A scor­ing sheet was designed with all instruc­tions and scoring mechanisms on the front and back of a single page to sim­plify administration of the NNE (Appendix).

Standardization

Full-term infants. We reviewed the records of all admissions to the newborn nurseries of two local hospitals from May 1983 to September 1983. Only in­fants with completely normal prenatal and perinatal courses were identified as potential subjects for the full-term infant standardization of the NNE. Infants were selected who satisfied the following criteria: 1) gestational age of 38 to 40 weeks as determined by dates and Du­bowitz scoring system, 2) serial prenatal care, 3) no maternal problems (eg, tox­emia, diabetes, medications), 4) spon­taneous vaginal delivery without com­plications, 5) 5- and 10-minute Apgar scores of 9 or 10, 6) no resuscitation needed, 7) normal newborn examina­tion results, 8) normal activity and sleep pattern in the nursery, and 9) no feeding problems. These infants were examined with the NNE at 48 hours postgesta-tional age midway between feedings in a quiet, dimly lit area adjacent to the nursery. Informed consent was obtained from the infants' parents. A subgroup of subjects was examined separately by two of the authors (V.K. and V.L.) within the same hour to determine intertester agreement.

High-risk infants. The NNE was sub­sequently standardized on a randomly

Volume 68 / Number 9, September 1988 1353

selected group of infants in the neonatal intensive care unit at Saint Francis Medical Center (Peoria, Ill) who were considered to be at greatest risk for de­velopmental disability. The criteria for inclusion in the standardization process were 1) birth weight less than 1,500 g, 2) respiratory difficulty requiring me­chanical ventilation, or 3) any neurolog­ical complication (eg, intraventricular hemorrhage, meningitis, seizures, or prolonged hypotonia). Infants with con­genital defects were excluded from the study. Infants selected to participate in the study were enrolled in a follow-up program to monitor their develop­mental outcome.18

Infants eligible for inclusion in the standardization process were monitored by the neonatal intensive care staff dur­ing their hospitalization. The infants were scheduled for examination by one of two therapists (V.K. or V.L.) as they approached conceptional term (37-42 weeks conceptional age) or at discharge, whichever occurred first. The examina­tion was performed as part of routine care, but informed consent was obtained from the infants' parents whenever pos­sible. Because the population included a combination of infants born in the hospital and infants admitted after birth, many infants were discharged or trans­ferred back to referring hospitals before they reached conceptional term or be­fore they could be examined. The NNE was performed at the infants' bedside midway between feedings with no spe­cial preparation. The examination was postponed if the infant was medically unstable or had recently experienced an invasive procedure.

Data Analysis

Full-term infants. Means and stand­ard deviations of the three section scores and the total score on the NNE were determined for full-term infants. Inter-tester agreement was established both by total score and by individual item.

High-risk infants. Visual inspection of the mean total scores (Figure) and the three section scores for high-risk infants examined at each conceptional age dem­onstrated three distinct conceptional age clusters: 1) 33 weeks of age or less, 2) 34 to 36 weeks of age, and 3) 37 weeks of age or more at the time of examination. The infants, therefore, were divided into these three conceptional age groups in the subsequent data analysis. We also divided the infants into three groups by severity of illness according to the

Figure. Mean total scores of high-risk infants on the neonate neurobehavioral examination by conceptional age (in weeks) at time of examination.

amount of ventilatory support they re­quired (<2 days, 2-7 days, or >7 days).

To study the NNE score differences associated with conceptional age and severity of illness, four two-way analyses of variance (ANOVAs) were performed for each measure (tone and motor pat­terns, primitive reflexes, behavioral re­sponses, and total score). Post hoc t tests were planned if a significant interaction effect occurred to determine the nature of the mean differences. If no interac­tion effect existed, the main effects were tested and post hoc t tests were used to determine where the group differences occurred for any significant main effect. Because four separate primary analyses were made, an alpha level of .05 with a Bonferroni correction19 (0.5/4) yielded an acceptable level of significance of .013. The SPSS-PCplus ANOVA and t-test programs were used.20,21

We also determined correlations be­tween conceptional age, gestational age, severity of illness, tone and motor pat­terns, primitive reflexes, behavioral re­sponses, and total score. Means and standard deviations were reported by conceptional age groups for all four measures. The SPSS-PCplus CORRE­LATION program was used.20

RESULTS

Full-term Infants Fifty-four full-term infants satisfied

the study criteria and were available for examination. The NNE was completed and scored for each infant within 15

minutes. A scorable response was ob­tained for each item on each infant. Mean age of testing was 46 hours (s = 6 hours) postgestational age.

Means, ranges, and standard devia­tions were calculated for the three sec­tion scores and the total score (Tab. 1). Limited variability in scores existed for these presumably "normal" full-term in­fants. Eighty percent of the section scores were between 25 and 27, with standard deviations ranging from 0.6 to 1.8. Variability in full-term infants' per­formance, as reflected by the range of scores and the standard deviation, was greatest for behavioral responses and al­most nonexistent for tone and motor patterns. No section scores were below 20, and no total scores were below 70. All behavioral subtests were rated 2 or 3.

Intertester agreement was established based on paired examinations of 20 chil­dren performed by two examiners (V.K. and V.L.) within an hour of each other (Tab. 2). We found an average of 88% item agreement and 95% section agree­ment between examiners.

High-risk Infants

Between May 1983 and June 1985, 298 high-risk infants who satisfied the inclusion criteria were examined with the NNE. As with the full-term infants, the NNE was completed and scored on all high-risk subjects within 15 minutes. A scorable response was obtained for each item on each infant examined.

The results of the two-way ANO VAs

1354 PHYSICAL THERAPY

RESEARCH

TABLE 1 Scores of Full-term Infants on the Neonatal Neurobehavioral Examination (N = 54)

Section

Tone and motor patterns Primitive reflexes Behavioral responses Total score

26.6 25.3 25.5 76.0

s

.59 1.45 1.79 1.03

Range

(25-27) (22-27) (20-27) (70-81)

TABLE 2 Intertester Agreement on the Neonatal Neurobehavioral Examination for Full-term Infants (N = 54)

Section

Tone and motor patterns Primitive reflexes Behavioral responses

Agreement (%)

Item by Item

93 88 83

Section Score

97 95 93

are reported in Table 3. No significant interactions existed for tone and motor patterns, primitive reflexes, behavioral responses, or total score. In addition, no significant differences were associated with severity of illness. For the concep-tional age groups, however, highly sig­nificant differences were found for each of the four measures. When t tests were conducted for each measure by concep-tional age group, significant differences (p < .001) existed between all three age groups for each measure. An inspection of the means by age group demonstrated that the youngest age group consistently had lower scores than the older age groups (Tab. 4).

Consistent with the findings of the two-way ANOVAs, the Pearson corre­lation matrix showed that the correla­tion of conceptional age with each of the four test measures was significant (Tab. 5). Similarly, there was no corre­lation of severity of illness with any of the four measures. A mild correlation of gestational age with scores on the tone and motor patterns section was found. Although this correlation was not clini­cally significant, it did reach statistical significance because of the large sam­ple size. No other significant correlation of gestational age with test measures occurred.

Correlations among the three sec­tional scores (tone and motor patterns, primitive reflexes, and behavioral re­sponses) varied from .498 to .630, indi­cating a modest amount of overlap be­tween the scores varying from 24% to 40% (correlation squared) of the vari­ance. These modest correlations indi­cate that although some overlap existed

between the section scores, a reasonable amount of variance was unique to each one. Substantial correlations existed be­tween each section score, with the total scores varying from .804 to .862. The variance in total scores was not unex­pected because the total score is a sum­mation of the three section scores.

DISCUSSION

The results of the initial phase of standardization demonstrate that the NNE provides a quantitative represen­tation of the multiple aspects of full-term infants' neurobehavioral status. The high numerical scores obtained in­dicate that the actual performance of the healthy full-term infants coincides with the theoretical design of the instru­ment; that is, healthy full-term infants obtained a score of 3 (the score expected of a full-term infant) on almost all of the NNE items. Behavioral responses, in general, appeared to be more diverse than the more neurological items. Very little score variability, nevertheless, was shown overall.

Analysis of the data on high-risk in­fants yielded similar encouraging re­sults. The total means and section means for all high-risk groups were lower than those established for full-term infants. These results are consistent with growing evidence that even rela­tively healthy premature infants do not perform as well when they reach con­ceptional term as do their full-term counterparts.19

A very distinct pattern of distribution for the high-risk scores created three significantly different conceptional age clusters (37-42 weeks, 34-36 weeks, and <34 weeks conceptional age). These clusters approximated the design of the three-point scoring system, theoretically representing performance at greater than 36 weeks, 32 to 36 weeks, and less than 32 weeks gestational age. This find­ing suggests that the NNE as designed does reflect gestational maturation and is a quantitative representative of neu­robehavioral status at a given concep­tional age.

Additional analysis of the high-risk

infants' data demonstrated that the scores appear to depend primarily on conceptional age at the time of the ex­amination; gestational age at birth and severity of illness do not appear to be major contributing factors to NNE score. The correlation matrix indicates a reasonable amount of variance unique to each section score and supports the importance of including all three neu­robehavioral sections on the NNE. No one developmental area is representa­tive of neonatal neurological status, and items assessing these three areas should be included in any neonatal evaluation tool.

The NNE, therefore, appears to be an efficient and accurate assessment of neurobehavioral status at the time of the infant's discharge from the nursery. The NNE is easy to administer to both full-term and premature infants and has good intertester agreement. It has an advantage over previously published scales in that it offers a numerical rep­resentation of neurobehavioral status rather than a gestalt impression. Addi­tional studies are in progress to deter­mine the potential clinical applications of the NNE.

CONCLUSION

The NNE was developed in response to the need for a more quantitative as­sessment of neonatal neurobehavioral status. The 27-item examination meas­uring tone and motor patterns, primi­tive reflexes, and behavioral responses was standardized on a sample of 54 healthy full-term infants and 298 high-risk infants. The total score and three section scores varied primarily by con­ceptional age at examination (gesta­tional age and chronological age) inde­pendent of gestational age or severity of illness. Full-term infants scored higher on all measures than preterm infants examined at conceptional term.

Recent federal and state legislation has mandated that every infant at risk for possible developmental disabilities must be identified and referred for ap­propriate intervention services from the nursery.22 This identification process would be enhanced by an examination capable of assessing neonatal neurobe­havioral status as a predictor of subse­quent disabilities. The NNE has been shown to be an effective and reliable method of quantifying the neurobehav­ioral abilities of infants at the time of examination. Additional studies of the NNE are needed to establish its predic-

Volume 68 / Number 9, September 1988 1355

TABLE 3 Two-way Analysis of Variance by Age Group and Severity of Illness for High-risk Infants on the Neonatal Neurobehavioral Examination (N = 298)

Main effect Age group Severity of illness

Interaction Age group x sever­

ity of illness

df

2 2

4

Tone and Motor Patterns

<.001 <.153

<.419

P

Primitive Reflexes

<.001 <.086

<.535

Behavioral Responses

<.001 <.229

<.264

Total Score

<.001 <.098

<.462

TABLE 4 High-risk Infants' Mean Scores and Standard Deviations by Conceptional Age Group for Each Neonatal Neurobehavioral Examination Section (N = 298)

Section

Tone and motor patterns

s Primitive reflexes

s Behavioral responses

s Total score

s

Conceptional Age (wk) at Time of Examination

<34 (n = 21)

17.43 3.25

17.38 3.53

16.33 3.94

51.14 9.49

34-36 (n = 138)

20.51 2.98

20.28 3.06

20.09 3.82

60.65 8.00

>36 (n = 139)

22.57 2.90

22.01 3.10

21.84 3.31

66.45 7.45

TABLE 5 Correlation of Conceptional Age with Neonatal Neurobehavioral Examination Section (N = 298)

Conceptional age (CA) Gestational age (GA) Tone and motor patterns

(TMP) Primitive reflexes (PR) Behavioral responses

(BEH) Total score (TS) Severity of illness (SI)

CA

1.000

GA

.427a

1.000

TMP

.413a

.161b

1.000

PR

.337a

.038

.573a

1.000

BEH

.291a

.137

.498a

.630a

1.000

TS

.412a

.139

.804a

.862a

.847a

1.000

SI

.243b

-.222a

.020

.061

-.029 .007

1.000

tive value and ability to measure change in response to intervention protocols. We currently are conducting a detailed item-by-item analysis of the NNE and a

correlation of the NNE with develop­mental outcome to determine the clini­cal value of the NNE in the follow-up of high-risk infants.

REFERENCES

1. Shapiro S, McCormick M, Crawley B, et al: Changes in infant morbidity associated with decreases in neonatal mortality. Pediatrics 72:408-415, 1983

2. Caron B, Hack M, Rivers A: The very low birthweight infant: The broader spectrum of morbidity during infancy and early childhood. J Dev Behav Pediatr 4:343-349, 1983

3. Kitchens W, Keir E, Keith C, et al: Changing outcome over 13 years of very low birthweight infants. Semin Perinatol 6:373-387, 1982

4. Ross G: Morbidity and mortality in very low birthweight infants. Pediatr Ann 12:32-44, 1983

5. Siegal L, Saigal S, Rosenbaum P: Correlates and predictors of cognitive and language de­velopment of low birthweight infants. J Pediatr Psychol 7:135-148, 1982

6. Nelson K, Ellenberg J: Neonatal signs as pre­dictors of cerebral palsy. Pediatrics 64:225-231,1979

7. Weindling A, Rochefort M, Calvert S, et al: Development of cerebral palsy after ultraso­nographic detection of periventricular cysts in the newborn. Dev Med Child Neurol 27:800-806,1985

8. Graziani L, Pasto M, Stanley C, et al: Neonatal neurosonographic correlates of cerebral palsy in the preterm infant. Pediatrics 78:88-94, 1986

9. Thomas A, Chesni Y, St. Anne Dargassies S: The Neurological Examination of the Infant. London, United Kingdom, Spastics Interna­tional Medical Publications, 1960

10. Prechtl H, Beintema D: The Neurological Ex­amination of the Full Term Newborn Infant, ed 2. Philadelphia, PA, J B Lippincott Co, 1984

11. Amiel-Tison C: Neurological evaluation of the maturity of newborn infants. Arch Dis Child 43:89-93,1968

12. Brazelton TB: Neonatal Behavioral Assess­ment Scale. Philadelphia, PA, J B Lippincott Co, 1984

13. Dubowitz L, Dubowitz V: Assessment of the Preterm and Full Term Infant. Philadelphia, PA, J B Lippincott Co, 1981

14. Kurtzberg D, Vaughn H, Daum C, et al: Neu­robehavioral performance of low birthweight infants at 40 weeks post-conceptional age: Comparison with normal full term infants. Dev Med Child Neurol 21:590-607, 1979

15. Gorski P, Lewkowicz D, Huntington L: Ad­vances in neonatal and infant behavioral as­sessment: Toward a comprehensive evaluation of early patterns of development. J Dev Behav Pediatr 8:39-53, 1986

16. Als H, Tronick E, Lester B, et al: The Brazelton Neonatal Behavioral Assessment Scale (BNBAS). Abnormal Child Psychology 5:215-231,1977

17. Prechtl H: Assessment methods for the new­born infant: A critical review. In Stratton P (ed): Psychobiology of the Human Newborn. New York, NY, John Wiley & Sons Inc, 1982, pp 21-52

18. Cohen H, Morgan A: Neonatal follow-up: A regional program. IMJ 170:23-26, 1986

19. Godfrey K: Comparing the means of several groups. N Engl J Med 313:1450-1456, 1985

20. SPSS Incorporated Staff, Norusis MJ: SPSS-PCplus. Chicago, IL, SPSS Inc, 1985

21. SPSS Incorporated Staff, Norusis MJ: SPSS-PCplus Advanced Statistics. Chicago, IL, SPSS Inc, 1985

22. Nondiscrimination on the basis of a handicap. Federal Register March 48:9630, 1983

a p < .001. b p < .01.

1356 PHYSICAL THERAPY

RESEARCH APPENDIX

Neonatal Neurobehavioral Examination Scoring Sheet

Name

Date of Birth Gestational Age

Date of Exam Chronological Age

Timing of Exam Corrected Age

1 (<32 wk.) 2 (32-36 wk.) 3 (>36 wk.)

STATES 1. Deep sleep, no movement, regular breathing 2. Light sleep, eyes shut, some movement 3. Dozing, eyes opening and closing 4. Awake, eyes open, minimal movement 5. Wide awake, vigorous movement 6. Crying

A (Abnormal)

A. TONE AND MOTOR PATTERNS

POSTURE (Predominant)

ARM RECOIL Infant supine; take arms and extend parallel to the body; hold several secs and release.

SCARF Infant supine. Head in midline. Bring arm across chest until resistance is met.

POPLITEAL ANGLE Infant supine. Approximate knee and thigh to abdomen; extend leg by gentle pressure with index finger behind ankle.

ANKLE DORSIFLEXION Infant supine. Flex foot against shin until resistance is met.

PRONE SUSPENSION Hold infant in ventral suspension; observe curvature of back and relation of head to trunk.

SLIP-THROUGH Hold infant in vertical suspension under axillae. Observe amount of support required to prevent infant from "slipping."

PULL-TO-SIT Pull infant toward sitting posture by traction on both arms.

HEAD RIGHTING Place infant in sitting position; allow head to fall forward; wait 30 sec.

total extension

no flexion within 5 sec.

no resistance

180-135°

limited 60-90°

complete

complete

complete head lag

no attempt to raise head

LE flexed, UE extended

partial flexion at elbow >100° within 4-5 sec.

limited resistance past midline

90-135°

partial 30-60°

partial

partial

partial flexion

unsuccessful attempt to raise head upright

total flexion

arms flex at elbow to <100° within 2-3 sec.

at or before midline

90-60°

complete <30°

near horizontal

none

occasional alignment

occasional alignment

opisthotonus tonic extension

difficult to extend jerky flexion

tonic flexion shoulder retraction

<60°

equinus >90°

tonic extension

shoulder retraction

tonic extension shoulder retraction

head cannot be flexed forward SC

OR

ING

1.

to

tal r

espo

nses

to th

e 9

item

s in

eac

h ar

ea;

A sc

ored

as

1 2.

be

havi

oral

sub

test

sco

red

3, if

2 o

f thr

ee it

ems

are

scor

ed 3

3.

be

havi

oral

sub

test

sco

red

1, if

2 o

f thr

ee it

ems

are

scor

ed 1

4.

be

havi

oral

sub

test

sco

red

2, if

nei

ther

of t

he a

bove

crit

eria

are

met

5.

sc

ore

num

ber o

f abn

orm

al p

atte

rns

A.

Tone

& M

otor

Pat

tern

s A

bnor

mal

Pat

tern

s B.

Pr

imiti

ve R

efle

xes

Abn

orm

al P

atte

rns

C.

Beh

avio

ral R

espo

nses

R

espo

nsiv

enes

s Te

mpe

ram

ent

Equ

ilibra

tion

Volume 68 / Number 9, September 1988 1357

APPENDIX Neonatal Neurobehavioral Examination Scoring Sheet (Continued)

1 (<32 wk.) 2 (32-36 wk.) 3 (>36 wk.) A (Abnormal)

B. PRIMITIVE REFLEXES

ROOT

SUCK

GRASP

POSITIVE SUPPORT

WALKING

CROSSED EXTENSOR

MORO

TONIC NECK

CRY

absent

weak

absent

astasia

no response

no response

no response

no response

absent

C. BEHAVIORAL RESPONSES

mouth opening, partial head turning

inconsistent, irregular

sustained flexion

inconsistent, partial

some effort but not continuous with both legs

withdrawal and flexion

abduction only

legs only

whimpering

full head turning with mouth opening

strong regular sucking in bursts of 5 or more movements

traction

full extension

at least two steps

flexion & extension

abduction & adduction

arms & legs respond

sustained cry

tongue thrust

clenching-tonic bite

thumb adduction

equinus

scissoring

tonic extension

tremor only

obligate

high-pitched

RESPONSIVENESS

ALERTNESS

ORIENTATION to face & voice

DEFENSIVE REACTION to cloth over face

TEMPERAMENT

IRRITABILITY

PEAK OF EXCITEMENT

CUDDLINESS

EQUILIBRATION

SELF-QUIETING

CONSOLABILITY

TREMORS

1

inattentive or brief responsiveness (4 or less)

does not focus or follow stimulus, brief following (4 or less)

no response: nonspecific activity with long latency

1 - flat

no cry

low level of arousal never > state 3

no molding

1

cannot self-quiet

unconsolable

tremors in all states

1 - labile

cries to 6 stimuli

insulated crying in response to stimuli

resists, arches

2

moderately sustained alertness, may use stimulation to come to alert state (5,6)

inconsistent or jerky following horizontal 30° (5,6)

rooting, head turning

2

cries to 4 or 5 stimuli

predominantly state 4, may reach state 5 with stimulation

molds with movement and handling

2

occasional success, no sustained crying

consoles with holding and rocking; consoling not needed

tremors occasionally with aversive stimuli

3

sustained and continuous attentiveness (7-9)

sustained smooth following 60° horizontally and occasionally vertically (7-9)

swipes with arms

3

cries to 1-3 stimuli

predominantly state 5, reaches state 6 with stimulation

molds and nestles spontaneously

3

quiets on two or more occasions

consoles with talking or handling in crib

no tremors or tremors only with crying C

OM

MEN

TS:

1358 PHYSICAL THERAPY