Reduction of perinatal mortality has not been followed by a concomitant reduction of morbidity; on the contrary, there is a rise in the prevalence of motor and sensory deficiencies. Thanks to the technological progress in perinatal care of the premature infants or of those with a very low weight at birth, they survive indeed but there are a lot of cases with neurosensory deficit.
Anyway, in spite of its gestational age and of its weight, any new-born infant with severe or moderate pathology, requires attentive supervision by the neonatologist so that neuromotor assessments are performed first at birth, then at regular intervals, and the kinesiotherapist’ assessment may be performed starting with the corrected age of 34 weeks.
This assessment should not replace the medical examination (clinical, imagery, EEG, visual and auditory evoked potentials, etc.); on the contrary, they constitute an indispensable complement in the periodical supervision of the infant. The aim is to stimulate the infant early so as to reduce the possible handicap concomitant with the training of the parents for the positioning and the mobilization of the new-born infant.
It is well-known the fact that the decrease in infantile mortality was not followed by the concomitant decrease in morbidity, on the contrary, there was an increase in prevalence of neurosensory deficiencies. Due to technical progress concerning the care of premature babies or of those with a very low weight at birth, they survive but there are numerous cases with many neurosensory deficiencies.
The prevalence of these deficiencies (Larroque, Vohr):
|Babies born in term with weight > 2500g.||1/1000|
|Babies born between 32 and 36 weeks, weight: 1500-2500g.||1%|
|Babies born under 32 weeks, weight < 1500g.||6%|
The Surveillance of Cerebral Palsy in Europe (SCPE) collaborative group has concluded that at the age of 5 years old:
- 31% of the above cases do not walk independently;
- 16% walk only with help;
- 53% walk independently.
Intrinsic risk factors of the neurosensory deficiencies in the newborn baby:
- Prematurity < 32 gestation weeks,
- Weight at birth < 1500g ,
- Intrauterine growth delay,
- Gestational hypertension,
- Pre or perinatal infections,
- Multiple births, possibly followed by prematurity,
- Perinatal asphyxia,
- Rh incompatibility,
- Prevalence of the masculine gender in premature babies.
Irrespective its gestational age and weight, any newborn with a moderate or severe pathology will be supervised attentively from the following points of view:
- Neurosensory, psychomotor,
- Growth, respiratory and digestive pathology,
- Psychology – behaviour, sleep,
- Social – familial,
- Language – communication.
The poor motor activity fixes the muscles in shortened positions, thus they lose their extensibility.
For example, the “chandelier posture” of the lower limbs is due to the shortening of the superior trapeze muscle or the shearing of the lower limbs by hypertonia of the adductors. (Fig. 3 – “Chandelier posture”)
Examination of the child by the physician (Bournier):
- 0 – 1year: at birth, at 40 gestational weeks, at 3 months, at 4 months, 6 months, 9 months corrected age (CA);
- 1 – 2 years: 12 months, 18 months, 24 months CA;
- 3 – 6 years: annually.
The assessment of the kinetotherapist may begin starting with the 37th week of CA.
Whichever the case, after leaving the maternity hospital, it is very important that the family physician should assume the supervision of the child, and guide the family to the neurologist and to the centres specialised in rehabilitation treatments.
Clinical examination of the newborn.
The neurosensory development is the result of the combined influence of genetic factors and of the environment, which accomplish the most efficient patterns of movement. The motor skills of the full-term newborn baby are characterised by:
- axial hypotonia
- limb hypertonia
- archaic reflexes
- complex and variable spontaneous motor activity.
During the last trimester of gestation, the foetus, being positioned with its back to the uterine wall, has a tendency to flexion. The preterm, who does not experience this intrauterine period, is hypotonic, cannot regroup spontaneously (Bullinger, Rosé)
The absence of regrouping possibility has the following consequences:
Fig. 1 – “Frog-like posture” (after Amiel-Tisson)
- It favours an asymmetric posture, prevents the rotation of the chest and prevents the infant to look at his/her hands, too. (Ferraud)
- It is necessary to position the baby in flexion (foetal posture) in order to initiate a visual, auditory relationship and in order to calm down the infant.
- Extension as a pattern predominates, as well as the asymmetric posture, disturbing the neuro-motor acquisitions, especially the evolution towards symmetry.
- The body diagram evolves into the triad: plagiocephaly, false torticollis hemisyndrome, a situation that is aggravated in the case of neurologic lesions.
- Many preterm babies maintain the “frog-like posture” due to muscular hypotonia and poor spontaneous movements. (Fig.1 – “frog-like posture”)
- In this situation, iliac, psoas and middle adductor muscles are shortened, favouring an internal rotation of femoral diaphysis and the possibility of anterior dislocation of the femoral head. The neonatologist’s duty is to assure a physiologic posture since the first day, with thighs in slight abduction, the knees in semi flexion, above the level of the bed. (Fig. 2 – Correct posturing of preterm baby)
Fig. 2 – Correct posturing of preterm baby – Amiel-Tisson
Fig. 3 – “Chandelier Posture” (according to Pinol B)
Thus, the preterm baby needs realignment in flexion in order to express its motility when it is positioned correctly.
Besides the examination performed by the neonatologist, the kinesiotherapist will perform a clinical examination of the infant when there are no longer critical problems.
It will be an examination:
- Additional to the medical one; It should first be performed in hospital starting with the age of 34 weeks CA.
- Re-examination at 3 months CA will confirm or infirm the neuromotor development anomalies (Pinol, Rosé)
- Further periodical re-examinations.
This assessment by the kinesiotherapist requires:
- Close contact with the child’s parents, instructing them to position the infant correctly and to mobilize it for improved mobility and feeding, namely
- a perioral stimulation that will improve the feeding difficulties, as well as the slight flexion of the head, which will facilitate cervical paravertebral muscle stress relieve and therefore the swallowing reflex. (Grenier)
- rocking the baby in a foetal position to be used up to 3 – 4 months CA. (Fig. 4 – Rocking the baby in foetal position.)
Fig. 4 – Rocking the baby in foetal position.
- positioning the baby in “Recamier” posture allows for the infant’s “liberation feeling” by giving support to its head. Thus, the motility loses its reflex character, the uncontrollable movements disappear, the child calms down. (Grenier) (Fig. 5 – “Recamier” Posture)
Fig. 5 – “Recamier” Posture
- Placing the infant in a hammock increases the sleep quality and reduces the risk of deformities and during the day it is advisable to place the infant in a “cocoon” made of sponge, to ensure flexion posture. (Ferraud. Pinol).
- attention should be paid to proper positioning during suckling
- position in supine for a long time can favour plagiocephaly and false torticollis by the preference of the child to maintain his/her head bent on a certain side, favouring a tonic hemicorporal asymmetry. (Captier) (False torticollis = loss of extensibility of sterno-cleido –mastoid muscle)
- asymmetrical posture in children can foster scoliosis attitudes in “C” when positioning the baby in a sitting posture.
Observation of posture and spontaneous motor activity (Amiel-Tisson)
What needs to be noticed in a newborn?
1. An abnormal posture:
- Excessive hyperextension of the head and sometimes of the trunk, too;
- A trunk inclination (scoliosis in “C”)
- Predominant active flexion of the head.
2. Upper limbs:
- Attitude in “chandelier” unilateral or bilateral;
- Wrist flexion and thumb adductor .
3. Lower limbs:
- Attitude in extension, internal rotation, possibly shearing;
- Imbalance of the pelvis in the frontal plane;
- Attitude in equinus of the feet ;
- Feet in “mirror”, one in valgus, the other in varus deformity;
- Metatarsus adductus;
- Permanent extension or permanent grasping of the hallux.
4. Abnormal motor activity:
- In supine position poor general movements, especially concerning the spatial variant (combinations of flexion-extension, adduction-abduction, internal-external rotation;
- Movements are stereotyped, monotonous.
- Simultaneous contraction of agonist and antagonist muscles – movements in block.
5. Sensory examination:
- Contrast white-black requires more attention from the preterm newborn than, so it will use the bull’s eye (white-black concentric circles)
- One can see the absence of fixation or of the tracking gaze
- Eyes in the sunset, strabismus, nystagmus
- Possible amimie.
- Mimicry does not change when a noise is produced.
6. Evaluation of space discovery hand – mouth:
- “Fencer” posture maintained for a long time, a leading to orthopedic risk:
- Risk of parietal-occipital plagiocephaly
- Risk of hemisyndrome and the preferential discovery of the occipital hand.
7. Evaluation of sucking and swallowing. (Larroque, Leroy)
Since the 34th gestation week, sucking and swallowing coordination matures in 3 phases: oral, pharyngeal and oesophageal.
- at 34 weeks AC one may examine the search of the breast reflex, holding the baby’s head slightly flexed and fingers touching the baby’s face in the area from the right ear lobe to the corner of mouth, causing orientation of the lips in that direction.
In premature infants we may see:
- Absence of reflex the search of the breast, or of sucking
- Sucking reflex is present, but the child does not swallow
- Sucking and swallowing are present, but with lack of pharyngo-esophageal coordination
- Disturbances of swallowing due to respiratory difficulties
- Hypo-motilit of the mouth area, the mouth is open permanently, with hypotonic tongue
- Oral stimulation determines opistotonus.
8. Motor and orthopaedic assessment (Pinol, Grenier)
In the preterm newborn one may notice:
- Absent or asymmetric grasping;
- At traction from supine position, the child throws itself in extension or it extends the lower limbs and it gets up in orthostatism
- At this manoeuvre there is an imbalance between the couple of agonist and antagonist muscles
- The head remains tilted on one side;
- Causing the baby to roll from supine position to prone position from the level of lower limbs the following are noted:
- tonic abnormalities of the lower limbs that prevent the manoeuvre;
- extension and asymmetry of head rotation
- attitude of the upper limbs “in chandelier”, extension of the trunk;
- one upper limb remains in interior rotation it does not get free.(Tisson, Metayer)
- From lateral decubitus, while attempting the reaction of lateral abduction, the abduction of the upper lateral thigh does not occur at the same time with the lateral flexion of the head. (Grenier) A normal Grenier reaction of the newborn has a very good prognosis from the motor point of view. (Fig. 6 – Grenier Lateral Abduction Reaction).
Fig. 6 – Grenier Lateral Abduction Reaction
- In vertical suspension (being held by the examiner, with his/her hands under the baby’s arms):
- The child cannot maintain itself, it “seems to slip from the examiner’s hands. The child is suspended with the feet on the table plane, its feet take the equinus posture or with one foot in varus, the other in valgus. (Fig. 7 – Positioning the feet in equinus)
Fig. 7 – Positioning of the feet in equinus
- Or, one may note a permanent grasping of the toes (Leroy, Pinol)
- in ventral suspension: – significant axial hypotonia.
- in sitting position on the edge of the table: – at side imbalances, the hand on the part of the bending does not take support on the table, and the collateral lower limb does not orient itself in abduction; the foot remains in varus equin or in talus valgus. (Fig. 8 – Incorrect side imbalance)
Fig. 8 – Incorrect side imbalance.
- In sitting position with lower limbs on the horizontal surface one may note:
- Asymmetries of lower limbs abduction or one lower limb is in internal rotation and adduction, the other in neutral position.
- The child sits asymmetrically, with more support on a buttock than on the other.
- Positioned in squat:
- the child does not support their weight
- the feet position asymmetrically and at the lateral movements induced by the therapist, the inversion-eversion is not normal (Metayer). (Fig. 9 – In squat position, deficiencies of the feet are assessed)
Fig. 9 – In squat position, deficiencies of the feet are assessed
Fig. 10 – Flexion of the pelvis on the stomach
- passive mobilization of the upper limbs in supine position:
- hyperpronation of the forearm with the fist closed
- adducted thumb
- passive mobilization of the lower limbs:
- hypertonia of the posterior pelvic muscles subsequently noted in the flexion of the pelvis. (Fig. 10 – Flexion of the pelvis on the stomach)
- From supine position, the 90 degrees flexion of the thighs with the extension of the knees reveals an asymmetry of the opening of the popliteal angle. At the same time, one may also note the varus or valgus position of the feet. (Fig. 11 – Assessment of the asymmetry of the popliteal angle)
- there is a malfunction of extensibility of the polyarticular muscle groups of the hips and knees
- one may note asymmetry at tilting the head to the right and to the left, with asymmetric lifting of the shoulder, too.
- Last but not least, the well-known Vojita postural reactions belong to the test battery used by the kinesiotherapist.
Fig. 11 – Assessment of the asymmetry of the popliteal angle
Orthopaedic deformities (Leroy, A. Tisson)
- hyperpronation of the upper limbs
- cubital flexion of the fists
- closed fist
- adducted thumb
- scoliosis attitude in “C”
- imbalance of the pelvic girdle in frontal plane
- coxofemoral instability
- genu flexum
- genu recurvatum
- equin clubfoot
- foot in varus or valgus
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- Le Metayer M. 1993. Le développement de l’enfant. In: Réeducation cérébro-motrice du jeune enfant. Education thèrapeutique, kinésitherapie pédiatrique, Fausser C et VinçonC. Ed. Masson Paris, p. 15-44.
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Correspondence address: Hospital ‘Prof. Dr. Al. Obregia’ Bucharest Clinic of Paediatric Neurology Berceni street, Sector 4 Bucharest