Original article
Neonatal neurological examination in a resource-limited setting: What defines normal?

https://doi.org/10.1016/j.ejpn.2020.08.010Get rights and content

Highlights

  • Neonatal neurological profiles differ notably for high- and low-resource settings.

  • Neonatal tone patterns are more consistent across high- and low-resource settings.

  • Distinct cut-off scores for high- and low-resource settings will increase utility.

Abstract

Objective

To describe the results of the Hammersmith Neonatal Neurological Examination (HNNE) in a low-risk, term-born, contemporary sample in Ghana. Of particular interest was to compare these findings with the original British study that validated the HNNE, and published data from other low- and middle-income countries.

Study design

In a nested substudy of a larger prospective study (IMPRINT: Impact of Malaria in Pregnancy on Infant Neurodevelopment), 140 low-risk, term-born neonates (39.3 ± 1.4 weeks gestation) at Korle Bu Teaching Hospital in Accra, Ghana were administered the 34-item HNNE from birth to 48 h of age by trained physicians. Neonates’ performance was compared with previously published normative data from the United Kingdom (1998), and published data from Thailand, Myanmar, Vietnam, and Uganda.

Results

Ghanaian neonates demonstrated lower scores on 29/34 HNNE items relative to normative data from the United Kingdom (P < .05), with only 5% of Ghanaian neonates in our sample classified as neurologically optimal. There were significant differences in the proportion of neonates scoring optimally per HNNE item between our Ghanaian sample, compared with published data from other settings (Thai [13/16 items], Burmese [14/16 items], Vietnamese [7/9 items], and Ugandan [22/34 items] neonates). Raw scores were markedly different between Ghanaian and British neonates, with Ghanaian neonates demonstrating lower median and wider range of scores. These differences were less prominent between Ghanaian and Ugandan neonates.

Conclusion

Our findings raise questions as to whether or not the thresholds for optimality for the HNNE based on data from the United Kingdom are applicable to Ghanaian newborns. Our study could not fully resolve whether the differences in scores were due to genetic differences in developmental pathways, the implementation of the assessment, or the characteristics of our sample. Low proportions of neonates scoring optimally from other low- and middle-income countries suggest the need for further research to determine the clinical utility of the HNNE in resource-limited settings, including the predictive value for neurodevelopment later in infancy.

Section snippets

Sample

This is a nested substudy of a larger single-center, hospital-based, prospective observational study (IMPRINT: Impact of Malaria in Pregnancy on Infant Neurodevelopment). The IMPRINT study aimed to compare neonatal neurological outcomes of infants exposed to malaria in pregnancy with those of unexposed infants. Participants were recruited from Korle Bu Teaching Hospital in Accra, the largest tertiary teaching hospital in Ghana, with approximately 10,000 live births annually. This hospital is

Ghanaian sample vs. normative data from the United Kingdom

There were no significant differences in maternal demographic characteristics between the infants included in this nested substudy and the remaining infants included in the larger IMPRINT study, though significantly more excluded mothers had a history of a sexually transmitted infection (P < .001). In total, 140 low-risk, term-born neonates (136 Ghanaian, 2 Nigerian, 1 Ivorian, 1 Malian ethnicity) were assessed; 35 neonates were not in the correct state and could not be administered all items,

Discussion

This study described the results of the HNNE in a sample of low-risk, term-born Ghanaian neonates born in a tertiary care referral hospital. Neonates were scored using the HNNE optimality scoring system, published in 1998 and developed using normative data from a sample of 224 neonates born in the United Kingdom. The extent of similarities and differences in the HNNE scores in Ghana and other LMICs were also documented. The profile of HNNE scores of neonates in Ghana and published results from

Funding

This work was supported by a Mater Foundation Principal Research Fellowship to Dr. Samudragupta Bora and The University of Queensland Research Training Program and Frank Clair scholarships to Ms. Harriet L.S. Lawford. The funding sources had no role in the writing of the manuscript or in the decision to submit it for publication.

Financial disclosure

The authors have no financial relationship relevant to this study to disclose.

Declaration of competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

Dr. Akomah Kennedy, Dr. Godwin A. Awuni, Dr. Newton E. Ofosu, Dr. Oyeronke S. Oyawoye, Dr. Temitope Akinyemi, Dr. Vida Akrasi-Boateng, and Mr. Hanson G. Nuamah at the University of Ghana for assistance with data collection. Most importantly, we would like to thank the children and their families who participated in the IMPRINT study.

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