Early Intervention and Monitoring for At-Risk Infants from a Neurological Perspective

What is an At-Risk Infant?

An at-risk infant refers to babies who may exhibit neurological delays in one or more developmental areas due to complications during pregnancy, at birth, or immediately after delivery. The term “at-risk infant” is primarily used to describe those at risk of developmental delays, weakness in postural muscles, deficiencies in sucking and swallowing skills in the early stages, delays in language development, inability to self-soothe, constant restlessness, avoidance of movement or the need for excessive stimulation, and hyperactivity, as well as sensory integration problems leading to behavioral and psychosocial issues. In other words, an at-risk infant is one who shows potential neurological delays due to problems encountered during pregnancy, at birth, or shortly after birth.

Who Are At-Risk Infants?

– Premature infants

– Infants who experienced hypoxia during birth

– Infants who have had a brain hemorrhage

– Other infants diagnosed with neurological diseases  

It is reported that 60-70% of all newborns exhibit at least one risk factor. 

When considering all risk factors, it is indicated that 60-70% of all newborns have at least one risk factor. Infants with risk factors can show completely normal development in all areas, but they may also exhibit lasting neurological defects and movement disorders. Therefore, regular monitoring and early intervention by a pediatric neurologist for at-risk infants is crucial, particularly because the capacity for neuroplasticity (the ability to reorganize) is at its maximum level during the 0-3 years age range, with the fastest development occurring in the first 6 months. Premature infants undergo neurological assessments based on their corrected age until they reach 2 years old. This capacity is maximally evaluated through the Bobath Neurodevelopmental Physiotherapy technique.

Problems Observed in At-Risk Infants TABLO*****

At-risk infants may exhibit the following neurological problems due to complications during pregnancy, at birth, or postnatally:

– Delays in developmental milestones

– Weakness in postural (body position) muscles

– Deficiencies in sucking and swallowing skills in the early stages

– Delays in language development

– Inability to self-soothe

– Constant restlessness

– Avoidance of movement or the need for excessive stimulation

– Hyperactivity, leading to sensory integration issues

– Behavioral issues and psychosocial problems

Motor coordination problems are seen in 50% of at-risk infants, while 5-15% may develop Cerebral Palsy (CP). 

Therefore, early detection of CP or other developmental disorders in at-risk infants is crucial for determining appropriate interventions, rehabilitation, and treatment options, and starting these supports as early as possible. Continuous neurological assessments during the first year are important, with evaluations every 1-3 months in the first year, every 4-6 months from 1-3 years, and annually after 3 years.

Risk Factors for Infants (According to Kliegman) TABLO***

1. Demographic-Social Risk Factors**

– Maternal age less than 16 or over 40, poverty, substance abuse (medications, alcohol, tobacco), emotional and physical stress.

2. Risk Factors Related to Maternal Medical History

– Genetic disorders

– Chronic diseases: Diabetes Mellitus (DM), Hypertension (HT)

– Rheumatological diseases

– Asymptomatic/symptomatic bacteriuria

– Issues in previous pregnancies

– Intrauterine fetal death, neonatal death

– Prematurity, intrauterine growth restriction

– Congenital malformations

– Cervical insufficiency

– Blood group incompatibility, neonatal jaundice, hydrops

– Neonatal thrombocytopenia, metabolic disorders

3. Risk Factors Related to the Pregnancy Process

– Vaginal bleeding, sexually transmitted infections

– Multiple pregnancies, preeclampsia

– Early membrane rupture, polyhydramnios/oligohydramnios

– Frequent births

– Acute or chronic internal or surgical diseases

– Inadequate prenatal care

– Coagulation disorders (hypercoagulability)

4. Risk Factors Related to Birth

– Premature birth (delivery before 37 weeks)

– Post-term birth (delivery after 42 weeks)

– Fetal distress, immature lecithin/sphingomyelin ratio

– Breech delivery, meconium-stained amniotic fluid

– Cord entanglement

– Cesarean delivery

– Forceps delivery

– Apgar score less than 4 at one minute

5. Risk Factors Related to the Neonatal Period

– Birth weight less than 2500 grams or more than 4000 grams

– Birth before 37 weeks or after 42 weeks

– Low/high birth weight according to gestational age

– Tachypnea, cyanosis, pallor, plethora, petechiae

– Congenital malformations

 What Neuromotor Assessment Methods Do We Use for At-Risk Infants TABLO***

– **Alberta Infant Motor Scale (AIMS)**

– **Neurosensory Motor Development Assessment Questionnaire (NSMDA)**

– **Hammersmith Infant Neurological Examination (HIMNE)**

– **Bayley-III Infant and Child Developmental Assessment Scale**

– **Test of Infant Motor Performance (TIMPS)**

– **Prechtl’s Assessment of General Movements (GMs)**

– **Denver Developmental Screening Test (Denver-II) or AGTE (Ankara Developmental Screening Inventory)**

– **Movement Assessment Battery for Children**

– **Peabody Developmental Motor Scales-2 (PDMS-2)**

– **Infant Motor Profile (IMP)**

– **Dubowitz Neurological Assessment**

– **Metropolitan School Readiness Test**

– **WISC-IV and CAS Test**

– **Moxo Attention Test**

Use of the General Movement Assessment in Evaluating At-Risk Infants

In following up with at-risk infants, along with neurological examinations, it’s essential to assess their general movement capabilities through the “General Movement Assessment.” This test helps predict motor and mental development based on the infants’ general movement abilities from 0 to 5 months. The General Movement Assessment (Prechtl Video Analysis Method) provides significant data for long-term prognosis. The strongest early indicator of a healthy human brain is its general movement abilities. In healthy human fetuses, general movements start in the 9th week of pregnancy and continue within a system until the 16th to 20th weeks after birth. Therefore, evaluating the movements of at-risk infants is particularly important.

The ideal time for conducting the General Movement Assessment is during Prechtl stage 4, which is the active alert state. Important considerations during this assessment include:

– Avoid assessing while the infant is sleeping or crying.

– The infant should have no clothing on besides a diaper.

– The ideal duration for capturing preterm infants is 30-60 minutes, and for term infants, it is 5-10 minutes.

– In the preterm period, three assessments should be conducted at two-week intervals, with one at three months.

– Video recordings should focus on assessing the fluidity, speed, midline positioning, and variability in timing of the movements. 

– This test is based on visual perception and should not be conducted when the infant is tired.

– The focus should be on the whole rather than details.

– There should be no auditory stimuli during observation.

– The environment should be devoid of a colorful blanket, mirrors, or excessive toys. 

If your child fits the definition of an at-risk infant, they should be evaluated by a pediatric neurologist. Therefore, dear parents, do not delay and risk your child’s development.