Assessment and Evaluation of the High Risk Neonate: The NICU Network Neurobehavioral Scale

The overall goal of this procedure is to evaluate the neurobehavioral status of the newborn infant. In particular, infants who may be at risk for poor developmental outcome because of medical conditions such as prematurity, prenatal, substance exposure, or stress. This is accomplished by first becoming certified in the administration and scoring of the exam by an established ends trainer.

The second step is to bring the infant while asleep into a quiet dimly lit room, typically in the hospital or at home. Next, conduct the ends examination as detailed in the manual and summarized below. The final step is to record the infant scores for each item and compute overall summary scales.

Ultimately, the NS is used to provide a quantified neurobehavioral assessment that can be used to identify which infants are most at risk for poor developmental outcome, help with the care of the infant in the hospital, help the parents understand the strengths and vulnerabilities of the infant, make recommendations for treatment by healthcare and early intervention providers. The main advantage of this technique over existing methods is that it provides an integrated, comprehensive, and quantified neurobehavioral assessment that has been proven to be successful in the identification of infants at risk for poor developmental outcome. Generally, some individuals new to this method will struggle because of the training and certification process.

We first had the idea for this method when we were asked by the National Institutes of Health to develop a special exam sensitive to the characteristics of high risk infants. Visual demonstration of this method is critical to understand and Correctly administer the items. My colleague, Dr.Andreas and I will be demonstrating the procedure with preterm babies in the neonatal intensive care unit Begin by observing the covered infant sleeping in sleep.

State one or two. Record the infant's initial state as quiet or active sleep drowsy, quiet, awake, active, awake, or crying. To test habituation, present the light to the infant.

Repeat this with the rattle and a bell. Next, gently unwrap and undress the infant and place him supine. Record his posture as total extension, partial flexion, total flexion or abnormal.

Then record the infant skin color as normal palate cyanotic or modeled. Be sure to also observe skin texture and record any abnormalities seen such as shedding or peeling excoriations, loose skin or deep creases around the eyes and nose. Now, observe the infant's baseline motor activity and record it as very little or none normal or excessive.

Next, press the heel of the infant gently and record the number of trials. It takes the infant to stop responding to the stimulus. Repeat this on the other heel.

To start testing lower extremity reflexes, place the infant supine and hold one of his relaxed legs just below the knee. Then press a thumb against the ball of the infant's foot to test plant our grasp. Record the response as no response, weak, normal, or exaggerated.

Next, test the Babinski reflex by scratching the lateral side of the infant's foot. Again, record the response as no response, weak, normal, or exaggerated. To test ankle CLOs, dorsiflex the ball of the infant's foot several times.

Record the response as no clones one, two, or more or sustained beats. Repeat the plant or grasp Babinski reflex and ankle clones with the opposite leg. To test leg resistance and recoil, hold both of the infant's legs near the ankles with one hand with the index finger between the infant's feet.

Next, fully extend the infant's hips and knees. Then extend the thighs and legs and release record resistance to extension as none, little, moderate, or strong. Be sure to note the speed and amount of thigh and lower leg recall.

Now test the infant's power of active leg movements. Start by grasping the infant's moving foot above the angle between index and middle fingers. Apply gentle resistance and record the active movements against gravity as none, minimal, moderate, or strong.

To check popliteal angle, grasp the bottom of the infant's heel. Bring the infant's knee to his belly and extend the leg in one fluid motion. Repeat this with the infant's other leg.

Then record the angle formed at the knee by the upper and lower leg for the left and right legs. Next, test the infant's upper extremity reflexes using one hand, place the infant's arm above his chest. Place the other hand on the infant's trunk to prevent trunk rotation.

Keep the thumb at the level of the infant's elbow. Now gently push the infant's elbow across his chest so that his arm comes across his neck like a scarf. Repeat this with the infant's other arm, and then record the point on the chest to which the infant's elbow moves easily.

Before encountering resistance to test forearm resistance and recoil, start by holding both of the infant's arms at the wrist and fully flex his arms at the elbow. Then extend his forearms and release one arm in one second, followed by the other arm. One second later, record the amount of forearm resistance and speed and amount of recoil.

Now test the power of the infant's active arm movements. Using the index and middle fingers grasp the wrist of the infant's moving hand. Apply gentle resistance to the infant's movement.

Record the movement against gravity as none, minimal, moderate, or strong. To check the rooting reflex, hold the infant's hands against his chest Using one hand with the other hand, stroke the skin at the corner of the infant's mouth. Record the response as none.

Turn away from weak, full or exaggerated head. Turn towards the stimulated side. Now, test the infant's ability to grasp a finger.

Begin by placing an index finger or thumb in the palm of the infant's hand and press the palmer surface without touching the back of the infant's hand. Repeat with the infant's other hand and then record the response as none weak, strong, or prolonged. To assess truncal tone, place one hand under the infant's buttocks.

Using the other hand hold the back of his head at the neck. Then lift the infant a few inches above the crib so that his buttocks do not touch the surface. Gently flex the infant's trunk by bringing the head forward and then bringing the infant to a sitting position.

Record the truncal tone as no tone. Some tone, good tone or exaggerated tone. Now hold the infant's wrists or forearms.

Extend the infant's arms and pull him to a seated position as he is pulled to sit. Observe if there is any muscular resistance to stretching the neck, and if the infant attempts to move his head back into midline position parallel to his body, hold the infant upright by placing both hands under the infant's arms around his chest, using the thumbs to support the infant's head. Now, lift the infant so the top of his foot is stroked and gently pressed downward against the edge of the crib.

When finished, repeat with the other foot. Observe if the foot is lifted and then extends to place. To assess stepping, hold the infant upright with both hands under the infant's arms around his chest.

Use thumbs to support the infant's head. As before, let the soles of the infant's feet touch the surface of the crib or table and move the infant forward as stepping occurs. Record the response as none, some clear or exaggerated stepping if stepping was not elicited.

Note if the infant can support his weight, if his legs stiffen or if they cross in a scissor like motion. To assess ventral suspension, place a hand under the infant's chest and abdomen and suspend him in the air in a prone position over the crib. Record the final position of the infant's head, limbs, and trunk.

Then assess Inc. Curation while keeping the infant prone with a hand supporting his chest and abdomen, slowly tap or stroke a line a few centimeters from the vertebrae downward from the shoulders to the buttocks. Then repeat on the other side.

Record the truncal response as it flexes laterally in a concave curve on the stimulated side as none weak, fully developed or exaggerated to check for crawling. Make sure the infant is prone and then place his head in midline and arms near his head with his palms facing down. If he does not crawl spontaneously, stimulate the response by gently pressing palms on the soles of his feet.

Record the response as none weak, coordinated or prolonged crawling, and whether or not stimulation was needed. From the crawling position. Record the infant's head lifting as none.

Head turning brief lift, sustained lift or exaggerated response such as a hyperextended neck. Now hold the infant in a cuddled position, taking care not to rock or talk to the infant. Facilitate cuddling only if there is no active participation from the infant.

Then hold the infant in a cuddled position on a shoulder record his ability to relax or mold nestle and clinging, as well as if there is any resistance to cuddling. Rest the infant on your lap at a slight upward angle. Start by holding the red ball about 10 to 12 inches from the infant's eyes.

Jiggle the ball to find the infant's vocal range. Then slowly move the ball horizontally from one side to the other. If the eyes and head follow to at least one side, move the ball vertically and in an arc to see if the infant continues to follow.

Now grab the red rattle and gently shake it 10 to 12 inches from the infant's eyes. Slowly move the rattle horizontally from one side to the other. If the eyes and head follow to at least one side, move the rattle vertically and in an arc to see if the infant will continue to follow.

Take a position 12 to 18 inches in front of the infant's face. Slowly move from one side to the other. If the eyes and head follow to at least one side, move vertically and in an arc to see if the infant will continue to follow while still positioned 12 to 18 inches in front of the infant's face.

Speak in a soft, slightly high pitched voice and slowly move from one side to the other. If the eyes and head follow to at least one side, move vertically and in an arc to see if the infant will continue to follow. For the previous four exercises, record the infant's ability to become alert.

Focus on the object, follow with his and head horizontally or vertically, and ability to coordinate head and eye movements. To record auditory responses, shake the rattle continuously, six to 12 inches from the infant's ear and out of sight. Repeat this so there are two trials for each ear.

Repeat this exercise by substituting a voice for the rattle. Move away from the infant's line of vision and speak softly into one of the infant's ears.Repeat. So there are two trials for each ear.

Record the invincibility to become alert and to turn and or look towards the stimulus. Now, hold the infant upright using both hands to support him under his arms with thumbs across his chest and fingers around his back. Use fingers to support the base of his head.

Rotate your trunk in a half circle, then rotate in the other direction. Observe the infant's eye and head movements as well as the presence or absence of nystagmus. Begin by assessing the infant's defensive movements with the infant's head in midline.

Hold a small cloth in place over the infant's eyes and nose. But be careful not to occlude the nostrils. Record the activity level of the infant as well as the presence of non-directed or directed swipes of the infant's arms toward the cloth.

Then turn the infant's face slowly to one side and hold him briefly in that position with his jaw over his shoulder. Wait for the infant to settle and adjust his posture. Then repeat this on the other side.

Record the amount of extension of the infant's arm and leg on the side of his body. His face is resting on. Finally, score each sign of stress abstinence as yes if it was present during the exam.

Shown here are five profiles or types of infants based on their end scores from a sample of over 1, 200.At-risk. Infants analysis is based on previously established summary scores, measuring orientation need for handling, self-regulation, arousal, excitability, lethargy, hypertenicity, hypotenicity, non-optimal reflexes, asymmetric reflexes, quality of movement, and stress abstinence. Note that infants with Profile five depicted by the Black Line Show the most abnormal pattern seen here.

Infants with Profile five were more likely to develop abnormalities between the ages of two and a half to four and a half. With regard to the Bailey Scales, the Child Behavior checklist, school readiness as assessed by Dial R and Low iq. After watching this video, you should have a good understanding of the ENDS exam And its various applications.

Although this exam can provide insight into a broad spectrum of high risk infants neurobehavioral functioning, it can also be applied to direct care of the infant to inform developmental care practices in the neonatal intensive care unit. The implications of this technique extend toward treatment of the infant at risk because it identifies specific neurobehavioral abnormalities that are amenable to intervention. This method can help answer key questions in the child developmental field, such as what is the neurobehavioral repertoire of the normal newborn infant, and how can we identify neurobehavioral abnormalities.