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ORIGINAL ARTICLE
Year : 2022  |  Volume : 20  |  Issue : 1  |  Page : 16-21

Trajectories of general movements in very preterm infants: An experience from South India, a prospective cohort study


1 Department of Neonatology, Christian Medical College, Vellore, Tamil Nadu, India
2 Developmental Pediatrics Unit, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission03-Jun-2021
Date of Decision25-Aug-2021
Date of Acceptance14-Oct-2021
Date of Web Publication04-Feb-2022

Correspondence Address:
Dr. Samuel Philip Oommen
Developmental Pediatrics Unit Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_58_21

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  Abstract 


Background and Objectives: The assessment of general movements (GMs), particularly fidgety movements, helps identify preterm infants likely to suffer from Neurodevelopmental deficits; less is known about preterm GMs. This study evaluates the predictive value of preterm GMs for normal fidgety movements. Methods: This prospective cohort study included 131 very preterm infants (gestational age - M (standard deviation) - 29.7 (1.3) weeks) who underwent 3 GM assessments in the preterm period (31–37 weeks postmenstrual age [PMA]), term age (38–44 weeks PMA) and fidgety movement age (48–58 weeks PMA). Results: The sensitivity of preterm GMs in predicting fidgety movements was 67.21%, the specificity was 44.4%, the positive predictive value was 94.25% and negative predictive value was 9.09%. The proportion of abnormal GMs decreased with increasing age, with 33.8% in the preterm age, 20% in the term age, and 7% in the fidgety movement age. Conclusion: This study confirms findings of other studies-specificity values of preterm GMs are poor, implying a high rate of false positives. Preterm GMs may be inadequate in predicting future Neurodevelopmental outcomes.

Keywords: Fidgety movements, general movements, neuro-developmental outcomes, preterm infants


How to cite this article:
John HB, Oommen SP, Kumar M. Trajectories of general movements in very preterm infants: An experience from South India, a prospective cohort study. Curr Med Issues 2022;20:16-21

How to cite this URL:
John HB, Oommen SP, Kumar M. Trajectories of general movements in very preterm infants: An experience from South India, a prospective cohort study. Curr Med Issues [serial online] 2022 [cited 2022 Jul 1];20:16-21. Available from: https://www.cmijournal.org/text.asp?2022/20/1/16/337306




  Introduction Top


The quality of a movement pattern observed in infants called general movements (GMs), is an excellent marker for early brain dysfunction.[1] These movements are spontaneously generated and not triggered by specific sensory input. They emerge around 9–12 weeks postmenstrual age and continue after birth. Adequate complexity, variability, and fluency are the core characteristics of GMs, which indicate the integrity of the infant's nervous system. The absence of these characteristics is associated with the presence of brain lesions and adverse neurological outcomes. The psychometric properties of GMs are the strongest among neonatal assessments in preterm infants.[2],[3]

GMs evolve over time and specific patterns of movements can be observed depending on the infant's gestational age. Three characteristic movement patterns have been described: (1) preterm GMs, (2) writhing movements or term GMs, and (3) fidgety movements or postterm GMs. [These are elucidated further in [Supplementary Table 1]].[1],[4]



Early identification of infants who are neuro-developmentally vulnerable is critical and could help prioritize and plan subsequent follow-up care. The nonintrusiveness and cost-effectiveness of the GM assessments make them ideal for early identification and for targeted developmental surveillance in our population. Abnormal fidgety movements are reported to have predictive values of up to 100% specificity for cerebral palsy at 12–24 months of age[2] and significant associations with fine manipulative disabilities, minor neurological dysfunction, attention deficit hyperactivity disorder, and cognitive problems in the school age.[5],[6] Similarly post-term GMs assessed at 3 months have very high predictive values for Neurodevelopmental outcomes at 18–24 months.[7] Few studies have looked at the ability of preterm movements to predict the neurodevelopmental outcome.

In this study, we (a) describe the trajectories of GMs from the preterm period (<32 weeks gestation) to writhing GM stage and finally to fidgety movements stage at 3 months, (b) look at the sensitivity and specificity of preterm GM in predicting normal fidgety movements, (c) explore associations between neonatal complications and GMs.


  Methods Top


Study design

The study is a prospective follow-up of a cohort of preterm infants (<32 weeks gestational age). The infants were recruited in the neonatal intensive care unit (NICU) and followed up till their final neurodevelopmental assessment at 18–24 months. This report pertains to the period between recruitment and the postterm GMs (3–4 months postterm).

Setting

The study was conducted in a tertiary care teaching hospital in South India. The NICU has Level III facilities and acts as a referral center for four adjoining districts from three neighboring states.

Participants

The cohort consists of 170 very preterm infants (gestational age <32 weeks) admitted in the NICU, who were enrolled between October 2013 and August 2015. Infants with congenital abnormalities, those who were ventilated or sedated at the scheduled time of video recordings were excluded. This study was approved by the Institutional Review Board and Ethics Committee of Christian Medical College, Vellore, number 8390. Written informed consent was obtained from the parents.

The sample size was calculated using our previous study[8] where 13% of infants had abnormal fidgety movements. We assumed a 95% level of confidence (Z value) and precision of 5%. The sample size required was 174.

Measures

  1. GM assessment: Infants underwent video recordings of GMs in three age periods. Detailed description of the recording of GMs is given in our earlier article.[8] All video recordings were coded and identifying information removed. The classification of movements was done as described by Einspieler and Prechtl[1] and elucidated in [Supplementary Table 1] by the principal investigator who completed advanced certification in GM assessment. If the infant was crying or hypokinetic, GMs were not scored. The video recordings of the movements during preterm period-(henceforth referred to as GM1), writhing movements during the term period (henceforth referred to as GM2) and fidgety movements during the postterm period-(henceforth referred to as GM3) were scored on separate days for each infant, so the scoring of one key period would not influence scores of other key periods
  2. Mother's antenatal and perinatal details and infants' details were collected from medical records
  3. Definitions of various conditions are described in [Supplementary Table 2]
  4. Cranial ultrasound (CUS) scans were done at least on two occasions for each infant. The early scans were done within the first 10 days of life, late scans between 4 and 6 weeks. Intracranial hemorrhages were classified according to Papile et al.;[9] periventricular leukomalacia (PVL) was classified according to de Vries et al.[10]



Data analysis

Data were analyzed using the SPSS package for Windows, version 21.0 (SPSS Inc., Chicago, IL, USA). Data were summarized using descriptive statistics. Fisher's exact test was used to compare nominal data. Independent sample t-test was used to compare if the 2 groups-normal and abnormal GMs had different average values of gestational age and birth weight. Chi-square test was used to find the association between abnormal and normal GM1 and GM3 values. A P ≤ 0.05 was considered statistically significant. Sensitivity and specificity values were calculated using standard 2 × 2 tables where GM3 was used as a gold standard against GM1.


  Results Top


Of 170 preterm infants who were initially recruited, the data of 131 infants who had complete assessments were included for the analysis [Figure 1]. There were no significant differences in the clinical characteristics of the 131 infants who comprised the final cohort and the 39 infants who were excluded [Table 1].
Table 1: Clinical characteristics of study group and infants lost to follow up

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Figure 1: Flow chart of the study – Depicts the flow of the study. All 170 infants recruited for the study, underwent GM1, 144 infants underwent GM2 and 147 infants underwent GM3. 39 infants were excluded from the analysis since they had missed the GM2 or GM3 assessment. The reasons were not being able to come to the follow-up clinic (n = 20), attempted assessment, and failed (n = 1), and 2 infants had expired. The final number of infants included for analysis was 131.

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Objective 1: General movement trajectories

The distribution of normal and abnormal GMs during the three periods is shown in [Table 2] and [Figure 2]. Of the 131 infants, there were eight trajectories of progression of the GMs as shown in [Table 3] and [Figure 2]. The proportion of abnormal GMs decreased with increasing maturity of the infants and during the fidgety movement period. In the majority of infants 122 (93%), movements had normalized and only 9 (6.9%) remained abnormal.
Table 2: Distribution of the normal and abnormal general movements

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Figure 2: Trajectories of general movements in GM1, GM2, and GM3 – Depicts trajectories of General Movements in GM1, GM2, and GM3. The proportion of abnormal GMs decreased from GM1 to GM3. In GM1, 87 (66.4%) infants had normal movements and 44 (33.4%) infants had abnormal movements. In GM2, 105 infants (80%) had normal movements and 26 infants (20%) had abnormal movements. In GM3, 122 (92%) infants had normal movements, and 9 infants (8%) had abnormal movements.

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Table 3: Trajectories of the general movements from preterm to postterm period

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Objective 2: Predictive values of preterm general movements for normal fidgety movements

Among the 131 study infants, 82 infants had normal preterm movements and subsequent normal fidgety movements (true positives). In another four infants, both preterm movements and fidgety movements were abnormal (true negatives). Forty infants (30.5%) had abnormal preterm GMs but fidgety movements were normal (false negatives) and five infants (6.8%) had abnormal fidgety movements although the preterm movements were normal (false positives). Thus the sensitivity of preterm GMs in predicting fidgety movements was found to be 67.21% and the specificity was 44.4%, the positive predictive value (PPV) was 94.25% and negative predictive value (NPV) was 9.09% [Table 4].
Table 4: Sensitivity and specificity of general movements 1 and general movements 3

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Objective 3: Relationship between general movements and neonatal complications

Analyzing the associations of GM1 and GM3 and clinical characteristics of infants, it was found that chronic lung disease showed significant associations with abnormal preterm GMs. Pneumonia and major brain lesions on late CUS showed significant associations with abnormal Fidgety movements. Writhing movements showed no significant associations with neonatal complications [Supplementary Table 3]. The early CUS was done between day 1 and day 20 of life (M-6.1, standard deviation [SD]-3.39). The late CUS was done between day 21 and day 80 of life (M-44.06, SD-11.31).




  Discussion Top


This is the first study describing the preterm GMs of infants in India. We describe the trajectories of GMs from the preterm period to the postterm period, the ability of preterm movements in predicting fidgety movements, and the association between GMs and perinatal and neonatal complications.

In this study, the proportion of abnormal GMs decreased with increasing age. In the preterm period, 33.8% of infants had abnormal movements, which decreased to 20% in the term writhing movement stage and further decreased to 7% in the postterm fidgety movement stage. Other longitudinal studies in preterm infants have also shown that a large proportion of abnormal GMs in the preterm period.[11],[12] The lowest proportion of abnormal GMs is observed in the fidgety movement age.[13],[14],[15] Abnormal GMs in the preterm period may indicate instability and immaturity of the infant's central nervous system (CNS) than CNS injury.[16] Preterm GMs are often associated with acute perinatal complications and early ultrasound abnormalities which resolve as the CNS matures.[16] Abnormal writhing movements are also transient in many cases and normalize between 8 and 20 weeks postterm age.[7] This study showed a lower percentage of continuous normal GMs (55%) when compared to a study by Porro et al.[17] which reported more than 90% of infants to have continuous normal GMs.

In this study, two infants with normal movements in the preterm age developed abnormal fidgety movements. Both infants had a normal early CUS, but abnormal late CUS, implying that the insult occurred after the preterm GM stage. Other studies have also reported deterioration of GMs with late abnormalities in neuroimaging.[18],[19]

Predictive value of preterm general movements

Since fidgety movements have reported predictive values of up to 97% sensitivity for Cerebral Palsy at 12–24 months of age,[20] we looked at the ability of preterm GMs to predict fidgety movements. In this cohort, preterm GMs had a sensitivity of 67.21%, specificity of 44.4%, PPV of 94.25%, and NPV of 9.09% in predicting fidgety movements. This showed that if the preterm movements were normal, then they were likely to remain normal in the fidgety period. Since preterm movements evolve over time, the ability of abnormal preterm movements to predict abnormal fidgety movements (F-and abnF) was poor. Another study showed a single assessment of preterm GMs at 34 weeks to be only moderately associated with motor development at 14 months.[21] The predictive ability of GMs for abnormal neurological outcomes at 1 year, increases as infants mature-a study showed that the ability to predict abnormal neurologic outcomes increased from 56% in the first postnatal week to 82% in the third postnatal week.[12]

Neonatal complications and general movement assessment

In this study, infants with abnormal preterm GMs had lower mean birth weight than those with normal movements. Chronic lung disease was significantly associated with preterm movements, maybe because of restricted movements, since the infants were oxygen dependent during the assessment. Other studies also found that preterm movements are associated with chronic lung disease.[16],[22] Bronchopulmonary dysplasia had no association in the fidgety movement period probably because most infants had recovered by this time.

In this study, pneumonia and invasive ventilation were associated with GM3. One study showed the correlation between pneumonia and absent fidgety movements,[23] and ventilation with a deterioration of GMs.[24] A study by Hempenius et al.[16] found the duration of mechanical ventilation associated with GMs in the first 2 weeks of life. Majority of studies reported no associations between GMs and perinatal and neonatal variables.[19]

Cranial ultrasound and general movement assessment

In this study, there was no association between abnormal early CUS and GMs. This finding is similar to what has been reported by de Vries and Bos, who showed a weak relationship between GMs and IVH in the first 10 days of life.[25] However, in this study, abnormal late CUS was significantly associated with abnormal fidgety movements.[23] Several other studies found associations of abnormal fidgety movements with ultrasound findings such as PVL or echo densities in the parieto-occipital area.[16],[24],[26]

Limitations

Although this is the first study with an adequate sample size, on preterm GMs from this country, there are some limitations. About a quarter of the infants (22.8%) did not complete all assessments and were excluded from the study. The scoring of GMs was done by a single assessor since no one else in the study site was trained in GMs. This study only reports the relation between preterm movements and fidgety movements and cannot be extrapolated to make definitive conclusions about the eventual neurodevelopmental outcome.


  Conclusion Top


GM assessment in the preterm age may have limited value as a single assessment tool since movements at this age are influenced by perinatal morbidities and brain immaturity. Preterm GMs tend to normalize or deteriorate as the infant matures and therefore, they cannot substitute the fidgety movement assessment and continued developmental monitoring of premature infants.

Acknowledgments

The authors would like to thank all babies and their families who were part of this study. A special thanks to Ms. Indira Balan and Meenakshi Papanasam who helped in organizing follow-up appointments for this study and Mr. Selvakumar G for his technical support.

Ethical statement

This study was approved by the Institutional Review Board and Ethics Committee of Christian Medical College, Vellore. Written informed consent was obtained from the parents of all participants.

Financial support and sponsorship

This research was funded by the Fluid Research Grant of Christian Medical College Vellore Association.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Noble Y, Boyd R. Neonatal assessments for the preterm infant up to 4 months corrected age: A systematic review. Dev Med Child Neurol 2012;54:129-39.  Back to cited text no. 2
    
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Hadders-Algra M. General movements: A window for early identification of children at high risk for developmental disorders. J Pediatr 2004;145:S12-8.  Back to cited text no. 4
    
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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;83:521-5.  Back to cited text no. 5
    
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Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: A study of infants with birth weights less than 1,500 gm. J Pediatr 1978;92:529-34.  Back to cited text no. 9
    
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de Vries LS, Eken P, Dubowitz LM. The spectrum of leukomalacia using cranial ultrasound. Behav Brain Res 1992;49:1-6.  Back to cited text no. 10
    
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Albers S, Jorch G. Prognostic significance of spontaneous motility in very immature preterm infants under intensive care treatment. Biol Neonate 1994;66:182-7.  Back to cited text no. 12
    
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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;27:225-9.  Back to cited text no. 15
    
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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.  Back to cited text no. 18
    
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22.
Hitzert MM, Benders MJ, Roescher AM, van Bel F, de Vries LS, Bos AF. Hydrocortisone vs. dexamethasone treatment for bronchopulmonary dysplasia and their effects on general movements in preterm infants. Pediatr Res 2012;71:100-6.  Back to cited text no. 22
    
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25.
de Vries NK, Bos AF. The quality of general movements in the first ten days of life in preterm infants. Early Hum Dev 2010;86:225-9.  Back to cited text no. 25
    
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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