This article is a commentary on Guzzetta et al., pp 767-772 of this issue.
The role of observation of spontaneous movements at 3 months in infants at risk of developing hemiplegia
Article first published online: 5 JAN 2010
© The Authors. Journal compilation © Mac Keith Press 2010
Developmental Medicine & Child Neurology
Volume 52, Issue 8, page 698, August 2010
How to Cite
SPITTLE, A. J. (2010), The role of observation of spontaneous movements at 3 months in infants at risk of developing hemiplegia. Developmental Medicine & Child Neurology, 52: 698. doi: 10.1111/j.1469-8749.2009.03528.x
- Issue published online: 8 JUL 2010
- Article first published online: 5 JAN 2010
There is a growing body of evidence demonstrating that that the first year of an infant’s life is critical to recovery or compensation from injury to the developing brain.1 Thus it is imperative that appropriate early intervention is commenced as soon as possible in an infant’s development to promote neural and functional plasticity of the brain.1,2 Identifying which children are at greatest risk of motor impairments is a challenging component of paediatrics, as it is not only important for ensuring that these infants get appropriate services but also for counselling parents. On the other hand, it is important that we do not over-identify children as having problems and causing unnecessary concern. The study by Guzzetta et al.3 investigates the relationship between Prechtl’s general movements assessment, along with observation of hand movements at 3 months of age in term infants with neonatal cerebral infarction and development of later hemiplegia.
This small study which involved 13 infants with cerebral infarction and 13 comparison infants has several important findings. The first finding demonstrated that general movements at 3 months, known as fidgety movements, are highly predictive of hemiplegia. This is yet another study that provides evidence for the high predictive value of Prechtl’s general movements assessments for later cerebral palsy, highlighting the significance of a very important, cost-effective, and easily accessible skill of observation using standardized techniques.4,5 However, it is also important to note that the accuracy is not 100% and in this study two of the eight children who went on to have a diagnosis of hemiplegia were not detected with this assessment.
The unique aspect of this study is that Guzzeta et al.3 also investigated bilateral hand movements, by assessing global hand movement, segmental movements of the wrist, and independent digit movement. The degree of symmetry of wrist movements was the most predictive of these three measures, as there was a significant reduction of symmetry of wrist movements with infants who had a stroke who went on to develop hemiplegia, compared with children who had a stroke and a normal neurological outcome and the comparison groups. Furthermore, the researchers demonstrated that infants who went on to develop hemiplegia showed a significantly lower frequency of digital movements.
Whilst the findings of this study demonstrate that there is motor impairment present at 3 months postterm in infants who had a neonatal stroke, the small sample limits the interpretation of some of these findings into clinical practice and it is essential that more work is done in this area. Neonatal stroke is relatively uncommon and often not detected at birth, therefore it is difficult to get large participant numbers for a study and highlights the importance of collaborations between multiple centres. Owing to the small numbers, the authors are not able to make recommendations about what a clinically important reduction or asymmetry in hand movements would be to predict later hemiplegia. Nonetheless, this study has demonstrated even in a small number of infants with neonatal infarctions who go on to develop hemiplegia that movement deficits are present as early as 3 months postterm and it is important as clinicians that we closely observe infants spontaneous movements from a very early age, rather than waiting until there is a problem with upper limb function when the child would be expected to be using their hand more in everyday activities. While the techniques described in this paper would not be used to diagnose hemiplegia, children who demonstrate differences in their motor behaviour, particularly absent fidgety movements, should be closely monitored and appropriate support provided.