From the Department of Pediatrics, M.S. Ramaiah Medical College, Gokula, Bangalore 560 054, India.

Reprint .requests: Dr. P.P. Maiya, Professor and Head, Department of Pediatrics, M.S. Ramaiah Medical College. Gokula, Bangalore 560 054, India.

Manuscript received: April 6, 1998; Initial review completed: May 12, 19Y8;
Revision accepted: September 22, 1998.

With modern methods of neonatal care there is increased survival amongst asphyxiated babies. It is therefore becoming impor- tant to keep a close watch on the neuro-development of these babies. Vojta's system of kinesiological diagnosis is one of the available methods of assessing motor function in newborn and infants. It is based on the evaluation of 7 postural reactions(1). However, there is limited experience using this technique for neurodevelopmental predictions.

This study was undertaken to assess the predictive value of Vojta's neurokinesiological examination at 3 months of age as a screening test to predict neurodevelopmental outcome. in babies with hypoxic ischemic enchephalopathy (HIE) at one year of age.

Subjects and Methods

This prospective study was conducted at the Neonatal Intensive Care Unit (NICU) of M.S. Ramaiah Medical Teaching Hospital, Bangalore, between October 1994 and January 1997. There were 167 babies with HIE who were discharged alive and were enr01led for the follow-up. However, only 91 infants completed the follow-up till 1 year of age and only these infants were used for the final analysis.

The staging of HIE, in the NICU was done according to Saranat and Saranat's classification(2) by one of the authors. Neurodevelopmental assessment was done at an interval of 6 weeks during toe first 6 months and then once in 8 weeks till one year of age. At each visit the neuro-developmental assessment was done by both the authors. The authors were not blinded to earlier Vojta's assessment, or the initial HIE staging.

At each visit the Trivandrum Developmental Screening Chart(3) was used to screen for developmental delay, routine anthropometric measurements were taken and neurological assessment was done by using Vojta's neurokinesiological examination.

Vojta' s neurokinesiological examination is based on 7 postural reactions for early diagnosis of abnormal motor function(1). These reactions include traction reaction, Landau reaction, axillar hanging reaction, lateral tilt reaction, C01lis horizontalis reacton, Peiper Isbert reaction and Collis verticalis reaction.

Each of the reactions is read as normal or abnormal depending on the postural signs observed and the motor handicap is graded as below: (i) Lightest Central Co-ordination Disorder (CCD): If 1-3 reactions are abnormal; (ii) Light CCD: If 4-5 reaction are abnormal; (iii) Moderate CCD: If 6-7 reactions are abnormal; (iv) Severe CCD: All 7 reactions are abnormal plus an abnormal muscle tone.
The sensitivity and specificity of the Vojta's examination were calculated, and proportions evaluated by Chi-square test.
Results

There were 91 term babies with HIE followed for a period of 1 year who were included for the final analysis. There were 28 in HIE Stage I 37 in HIE Stage. II and 26 in HIE Stage III. At one year normal development was seen in 94.6% of HIE Stage I, 62.2% of HIE Stage II and 23% of HIE Stage III.

Table I provides the details of 3 months Vojta assessment and HIE in the neonatal period. The proportion of infants with significant abnormal Vojta reactions (>3) increased significantly with increasing HIE staging. (p <0.001).

Table II presents the association between 3 month Vojta assessment and I year neuro- developmental outcome. There was a significant (p <0.001) association between the two.

The sensitivity, specificity, positive and negative predictive values were 100% when >3 abnormal Vojta reactions of 3 months were used to detect I year neuro-developmental outcome.

Discussion

It is important to closely follow the neurodevelopment of neonates with HIE as they carry a high risk of developing neurological abnormalities(4-6). In the present study, 3.6% of the infants with HIE II and 77% with HIE III were found to be abnormal at 1 year. Our observations also confirm with Saranat and Saranat(2) in that there is a demonstrable relationship between severity of HIE and out- come. Early diagnosis, in these infants is imperative as the handicap can be reduced to a great extent by early intervention.

Vojta's neurokinesiological examination was found to be a sensitive screening procedure for early detection of neurological abnormalities. Though, Vojta's method is strictly a neurological examination and does not take into account the mental development of the baby, it was still a sensitive predictor of neuro-developmental outcome as a certain percentage of children having abnormal motor function are likely to have delayed mental developmental too( I). There was a strong association between the assessment at 3 months of age and the neuro-development at I year. All normal and abnormal infants at 1 year were correctly predicted when Vojta reactions of >3 were used as screening criteria. However, 76 infants (45%) who were discharged alive with HIE were not included as they did not attend regular followup. As the number excluded is significant, this may explain the 100% sensitivity and specificity observed in this study.
 

Trend Chi-square 30.71; p<0.001)

In a study comparing Amiel-Tison and Baileys screening for infant development in high risk infants, the former test proved more sensitive in picking up abnormalities below 9 months, but this advantage was lost for those beyond 12 months of age(7).

Chaudhari et al.(8). reported 26.6% pre- diction using abnormal Amiel Tison test at 3 months of age while our results' show 100% positive predictive value with Vojta's method at 3 months when more than 3 reactions were abnormal. Vojta's method is extremely, simple and can be completed in 1-2 minutes with practice. To the best of our knowledge, there are no articles published in English literature regarding early diagnosis by Vojta's neuro- kinesiological examination and therefore we can't compare out results with similar studies.

Vojta's system of kinesiological diagnqsis enables one to identify infants at risk for neurodevelopment delay as early as 3 months of age. Based on this early diagnosis the child can be referred for early intervention in order to prevent a life long handicap.