DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE

Active head lifting from supine in early infancy: an indicator for

non-optimal cognitive outcome in late infancy
INGRID C VAN HAASTERT 1 | FLORIS GROENENDAAL 1 | MARIA K VAN DE WAARSENBURG 2 | MARIA J C
EIJSERMANS 3 | CORINE KOOPMAN-ESSEBOOM 1 | MARIAN J JONGMANS 1 , 4 | PAUL J M HELDERS 3 | LINDA S
DE VRIES 1

1 Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht. 2 Faculty of Medicine, University Medical Centre Utrecht, Utrecht.
3 Child Development and Exercise Center, Division of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht. 4 Faculty of Social Sciences,
Department of Special Education, Utrecht University, Utrecht, the Netherlands.
Correspondence to Dr Linda S de Vries at Department of Neonatology, Room KE 04.123.1, Wilhelmina Children's Hospital, University Medical Center Utrecht, Lundlaan 6, 3584 EA Utrecht,
the Netherlands. E-mail: l.s.devries@umcutrecht.nl

This article is commented on by Hadders-Algra on page 489 of this issue.

PUBLICATION DATA
Accepted for publication 13th December 2011.
Published online 14th March 2012.
ABBREVIATIONS
AHLS Active head lifting from supine
CUS Cranial ultrasonography
GMDS Griffiths Mental Development
Scales
BSID-II-NL Bayley Scales of Infant Develop-
ment (2nd edition), Dutch version
BSITD-III Bayley Scales of Infant and Tod-
dler Development (3rd edition)
AIM To explore whether active head lifting from supine (AHLS) in early infancy is associated with
cognitive outcome in the second year of life.
METHOD The presence of AHLS was always recorded in the notes of infants admitted to our ter-
tiary neonatal intensive care unit. Random sampling was used to pair infants with AHLS with two
comparison infants without AHLS whose sex, gestational age, birth year (1993–2009), time of
assessment, and developmental test (Griffiths Mental Development Scales, Mental Scale of the
Bayley Scales of Infant Development-II, or cognitive subtest of the Bayley Scales of Infant and Tod-
dler Development-III) were comparable. Brain injury identified from neonatal cranial ultrasound
scans was classified as no – mild or moderate – severe. Z-scores of cognitive test outcomes were
calculated for multivariable analysis.
RESULTS Eighty-seven preterm (34 males, 53 females) and 40 term (17 males, 23 females) infants
with AHLS were identified. AHLS was documented at a mean (corrected) age of 7.0 (SD 1.7) and
8.1 (SD 2.2) months respectively. The cognitive assessments were performed at a mean corrected
age of 15.7 (SD 1.7) and 23.9 (SD 1.6) months in preterm infants, and 19.1 (SD 2.3) months in term
infants. The mean cognitive outcome of preterm and term infants with AHLS was lower than that
of infants without AHLS (p=0.002 and p=0.004 respectively). This remained after excluding infants
with cerebral palsy with matching comparison infants (p=0.001 in preterm and p=0.001 in term
infants). The mean difference was highest (1.35SD) between term male infants and comparison
infants (p=0.001).
INTERPRETATION AHLS is associated with a less favourable cognitive outcome in the second year
of life in preterm as well as in term-born infants than in comparison infants.

One of the objectives of neonatal follow-up is assessment of
the development of high-risk preterm and term-born infants
and children, following discharge from the neonatal intensive
care unit. Observation of spontaneous motor behaviour is an
important part of such an outpatient assessment.1
One example of spontaneous motor behaviour of an infant
that can be easily observed during the first year of life, particu-
larly between 6 and 9 months of (corrected) age, is active head
lifting from supine (AHLS). Although AHLS may occasionally
be seen in healthy infants, AHLS observed in our infants
occurred immediately the infant was put in a supine position
and tended to be sustained for long periods. Postural reactions
to hands-on manoeuvres like traction and vertical and
horizontal suspension have been described as diagnostically
relevant;2 however, AHLS as an example of spontaneous
motor behaviour has, to our knowledge, never been described
in relation to cognitive outcome.
Over the years, we have recognized AHLS and wondered
whether there could be a relation between this behaviour in
early infancy and cognitive outcome. The possible association
with cognitive development was suggested by suboptimal
behavioural performance at the time of AHLS and became
apparent during later follow-up.
When AHLS is seen as part of the spontaneous motor rep-
ertoire of an infant, this behaviour can offer information that
may alert clinicians to follow the child more carefully.
The aim of this study was, therefore, to explore whether
AHLS in early infancy is associated with cognitive outcome in
the second year of life. We also wanted to explore whether
neonatal brain lesions detected with cranial ultrasonography

538 DOI: 10.1111/j.1469-8749.2012.04259.x ª The Authors. Developmental Medicine & Child Neurology ª 2012 Mac Keith Press
(CUS) might act as a confounder on the relation between
AHLS and cognitive development.
METHOD
Design
In this retrospective case–control study, random sampling was
used to pair each infant with AHLS with two comparison
infants without AHLS whose sex, gestational age, birth year,
time of assessment, and developmental test used were compa-
rable. For this type of study, no informed consent or permis-
sion from the internal review board was required in our
hospital.
Participants
Infants born between April 1993 and December 2009 were
recruited from the neonatal follow-up programme. In this
programme, the (neuromotor) development of preterm and
term infants discharged from our level three neonatal intensive
care unit was assessed by experienced developmental special-
ists until 5 years 6 months of age. The presence of AHLS was
always separately recorded in the notes.
In total, 127 infants were identified: 87 preterm (34 males,
53 females) and 40 term (17 males, 23 females) infants; for
each study infant, two comparison infants were selected.
Measurements
AHLS is a spontaneous motor activity that infants may show
in the first year of life when placed in a supine position. The
head is raised forward with the shoulders and upper extremi-
ties off the surface, often in combination with extension and
adduction of the lower extremities off the surface, with the
ankles in plantar flexion and clawing of the toes. The upper
extremities may show variable postures or movements. The
infant is able to maintain this motor behaviour for minutes or
repeatedly during the time that is spent in supine (Fig. 1).
When present, AHLS is usually seen immediately when the
infant is put in a supine position.
We wanted to examine whether infants who were small for
gestational age are more prone to AHLS behaviour. Small for
gestational age was defined as a birthweight centile less than
10. Birthweight centiles were determined according to the
data of the Perinatal Registry of the Netherlands.3
Figure 1: Active head lifting from supine with simultaneous lifting of the
lower extremities in extension, adduction, plantar flexion of the ankles,
and clawing of the toes.
What this paper adds
• AHLS is mostly observed between 6 and 9 months in the first year of life.
• AHLS is associated with a less favourable cognitive outcome in the second
year of life in preterm as well as in term-born infants.
• Term-born male infants who show AHLS seem particularly at risk for poorer
cognitive outcome.
We also wanted to investigate the influence of brain injuries
detected by sequential CUS on AHLS. CUS was performed in
all infants during their stay in the neonatal intensive care unit and
a repeat CUS during the first visit at our neonatal follow-up
clinic (i.e. at term-equivalent age in infants born preterm and at
3 months of age in infants born at term). CUS findings were clas-
sified into two categories: 0, no or mild brain injury (preterm:
germinal layer haemorrhage, intraventricular haemorrhage
grade II, periventricular leukomalacia grade I; term: punctate
white matter lesions); and 1, moderate (preterm: intraventricular
haemorrhage grade III or cystic periventricular leukomalacia
grade II; term: watershed injury or focal infarct) or severe brain
injury (preterm: unilateral parenchymal haemorrhage, cystic
periventricular leukomalacia grade III, or cerebral artery infarc-
tion; term: basal ganglia ⁄ thalamic injury or large stroke).
Motor development in the first year of life was assessed by
observation and assessment of the spontaneous general move-
ment repertoire, postures, and postural reactions by use of the
motor assessment of the developing infant, according to the
Alberta Infant Motor Scale, and passive and active muscle tone
and responses deliberately to elicit primitive reflexes according
to Amiel-Tison.4–6 The surface on which the infant was lying
was always the same: a yellow, soft, but firm mattress of
110cm · 85cm · 5cm. This mattress was always in the same
room at the outpatient clinic, where the temperature was very
stable.
Cognitive outcome in the second year of life was assessed
using the Griffiths Mental Development Scales (GMDS), the
Mental Scale of the Bayley Scales of Infant Development (2nd
edition, Dutch version; BSID-II-NL), or the cognitive subtest
of the Bayley Scales of Infant and Toddler Development (3rd
edition; BSITD-III).7–9 Before 2003, all children up to 2 years
of age were assessed using the GMDS, consisting of five
subscales: locomotor, personal – social, hearing and speech,
eye–hand coordination, and performance. Information can be
obtained by testing or direct observation of the performance
of the child. In addition to quotients derived from the sub-
scales, an overall developmental quotient and a z-score can be
calculated. The mean (SD) developmental quotient for the
general population is 100 (12).7 From 2003 onwards, the
BSID-II-NL was used for children with a gestational age
younger than 30 weeks or a birthweight less than 1000g at
24 months corrected age, and from March 2008 onwards the
BSITD-III. All others were assessed using the GMDS. Items
within the Mental Scale of the BSID-II-NL are related to
memory and object permanence, problem solving, perceptual
organization, number concepts, language, and sociability.8
The cognitive subtest of the BSITD-III ‘includes items that
assess sensorimotor development, exploration and manipula-
tion, object relatedness, concept formation, memory, and
other aspects of cognitive processing’.9 Raw scores of the
Active Head Lifting and Cognitive Outcome Ingrid C van Haastert et al. 539
BSID-II-NL were converted into a mental development
index, and raw scores of the BSITD-III into a composite
score. Z-scores were also calculated. The mean (SD) in the
normative population for the Mental Scale of the BSID-II-
NL and for the cognitive subtest of the BSITD-III is 100 (15).
Normative values for the Dutch population are not yet avail-
able for the BSITD-III.
Statistical analysis
Data were analysed by the Predictive Analytic Software for
Windows version 17.0 (SPSS Inc., Chicago, IL, USA): t-tests
were performed for continuous variables, and v2 tests for cate-
gorical variables. A p value of <0.05 was considered significant.
Multivariable analysis using general linear modelling was per-
formed for z-scores of cognitive test outcomes as the depen-
dent variable, and AHLS, gestational age, birthweight (small
or appropriate for gestational age), and CUS abnormalities as
covariates.
RESULTS
Characteristics of the preterm and term samples are presented
in Table I.
Preterm infants
Slightly more female infants (60.9%) than male infants were
identified. The mean (SD) gestational age of infants and com-
parison infants combined (n=261) was 30.6 (2.4) weeks and
the mean (SD) birthweight 1470 (521) g. There were no sta-
tistical differences between the proportion of infants and the
comparison group for the total sample and subsamples for
these variables. AHLS was most often observed during the
second follow-up visit at a mean (SD) corrected age of 7.0
(1.7) months and at a mean (SD) chronological age of 9.2
(1.7) months.
In the second year of life, there were two follow-up appoint-
ments: at 15 (T1) and 24 (T2) months corrected age. At T1
(mean 15.7mo corrected age, SD 1.7, n=261), all but one infant
was assessed using the GMDS, and at T2 (mean 23.9mo cor-
rected age, SD 1.6, n=207), children were assessed using the
GMDS (n=151), the BSID-II-NL (n=37), and the BSITD-III
(n=19). Z-scores of case infants differed significantly from com-
parison infants for the total sample for neurodevelopmental
outcome (mean difference 0.40SD, p=0.004) at T1, as well as at
T2 (mean difference 0.58SD, p=0.001, see Table II). Male case
infants differed significantly from male comparison infants
(mean difference 0.58SD, p=0.023) at T1, as well as at T2 (mean
difference 0.94SD, p=0.001; see Table II and Fig. 2). Female
infants differed significantly from female comparison infants
(mean difference 0.35SD, p=0.031) only at T2.
Gross motor activities such as hand-to-foot contact, rolling
from supine to prone, and independent walking showed no
statistically significant differences between case infants and
comparison infants.
Term-born infants
Again, slightly more female (57.5%) than male infants were
identified. The mean (SD) combined gestational age of study
and comparison infants (n=120) was 40.1 (1.6) weeks and the
mean (SD) birthweight 3468 (574) g. AHLS was most often
observed during the second follow-up visit at a mean (SD) age
of 8.1 (2.2) months. For the total term sample, the mean age
at follow-up of infants in whom AHLS was observed was sig-
nificantly lower than of comparison infants (mean difference
0.9mo; Table I). However, this did not apply to the subsam-

Table I: Characteristics of preterm (n=261) and term (n=120) infants with and without active head lifting from supine (AHLS)

Male Female Total sample

Infant Comparison p Infant Comparison p Infant Comparison p

Preterm, n 34 68 53 106 87 174

GA mean (SD), wk 31.0 (2.6) 30.9 (2.6) 0.972 30.2 (2.3) 30.3 (2.2) 0.775 30.5 (2.4) 30.6 (2.4) 0.855
BW mean (SD), g 1595 (594) 1670 (560) 0.534 1312 (425) 1381 (469) 0.367 1423 (514) 1494 (524) 0.297
CA AHLS mean 7.4 (1.8) 6.8 (1.1) 0.046 7.2 (2.0) 6.9 (1.7) 0.346 7.3 (2.0) 6.9 (1.5) 0.062
(SD), mo
CHR age AHLS 9.5 (2.0) 8.8 (1.1) 0.070 9.4 (2.1) 9.2 (1.8) 0.382 9.5 (2.1) 9.0 (1.6) 0.081
mean (SD), mo
SGA, n (%) 5 (14.7) 0 (0) 0.003 5 (9.4) 0 (0) 0.004 10 (11.5) 0 (0) 0.001
CUS, n (%) 5 (14.7) 1 (1.5) 0.015 10 (18.9) 4 (3.8) 0.003 15 (17.2) 5 (2.9) 0.001
CP, n (%) 3 (8.8) 0 (0) 0.035 3 (5.7) 0 (0) 0.036 6 (6.9) 0 (0) 0.001
Term, n 17 34 23 46 40 80
GA mean (SD), wk 40.1 (1.7) 40.2 (1.7) 0.799 40.0 (1.7) 40.1 (1.5) 0.856 40.1 (1.7) 40.2 (1.6) 0.758
BW mean (SD), g 3257 (837) 3556 (432) 0.181 3418 (684) 3507 (480) 0.577 3349 (747) 3528 (458) 0.171
Age AHLS 8.0 (2.2) 8.7 (1.8) 0.227 7.1 (2.1) 8.2 (2.4) 0.069 7.5 (2.2) 8.4 (2.1) 0.030
mean (SD), mo
SGA, n (%) 6 (35.3) 0 (0) 0.001 4 (17.4) 1 (2.2) 0.039 10 (25) 1 (1.3) 0.001
CUS, n (%) 10 (58.8) 1 (3)a 0.001 7 (30.4) 1 (2.2) 0.001 17 (42.5) 2 (2.5) 0.001
CP, n (%) 3 (17.6) 0 (0) 0.033 5 (21.7) 0 (0) 0.003 8 (20) 0 (0) 0.001

a
Cranial ultrasound (CUS; moderate or severe abnormalities) of one comparison infant is missing. GA, gestational age; BW, birthweight; CA,
corrected age on which AHLS was observed or not; CHR age, chronological age on which AHLS was observed or not; SGA, small for gestational
age; CP, cerebral palsy.

540 Developmental Medicine & Child Neurology 2012, 54: 538–543

 Table II: Outcome of preterm (n=261) infants at 15mo follow-up (T1) and 24mo corrected age follow-up (T2) and term (n=120) infants at 19mo follow-up with
and without active head lifting from supine (AHLS)

Male Female Total sample

Infant Comparison p Infant Comparison p Infants Comparison p

Preterm
T1, n 34 68 52a 106 86a 174
CA mean (SD), mo 15.3 (1.9) 15.4 (1.6) 0.784 16.1 (1.9) 15.7 (1.5) 0.183 15.8 (1.9) 15.6 (1.6) 0.395
DQ mean (SD) 100 (16) 107 (8) 0.023 103 (12) 106 (9) 0.056 102 (14) 106 (9) 0.004
Z-score, mean (SD) )0.03 (1.36) 0.55 (0.66) 0.023 0.25 (1.0) 0.53 (0.76) 0.056 0.14 (1.15) 0.54 (0.72) 0.004
T2, n 28 56 41 82 69 138
CA mean (SD), mo 23.5 (2.4) 23.8 (1.7) 0.500 24.1 (1.8) 24.1 (0.9) 0.959 23.8 (2.1) 24.0 (1.3) 0.585
Z-score, mean (SD) )0.54 (1.14) 0.40 (0.81) 0.001 )0.09 (0.92) 0.26 (0.76) 0.031 )0.27 (1.03) 0.31 (0.78) 0.001
Term, n 17 34 23 46 40 80
Age mean (SD), mo 20.2 (2.7) 19.4 (2.5) 0.276 18.9 (2.4) 18.7 (1.8) 0.688 19.5 (2.5) 19.0 (2.2) 0.286
DQ mean (SD) 91 (15) 107 (8) 0.001 98 (16) 110 (9) 0.001 95 (16) 109 (8) 0.001
Z-score, mean (SD) )0.77 (1.3) 0.58 (0.63) 0.001 )0.19 (1.3) 0.82 (0.73) 0.001 )0.44 (1.3) 0.72 (0.69) 0.001

a
One female infant was too ill to be tested during the follow-up visit. CA, corrected age; DQ, developmental quotient.

a b
4.00

2.00
Z-scores at 24mo CA

2.00
Z-scores at 19mo

0.00
0.00

–2.00

–2.00
–4.00
*
–4.00 –6.00
Males with Males without Females with Females without Males with Males without Females with Females without
AHLS AHLS AHLS AHLS AHLS AHLS AHLS AHLS
Preterm born infants with and without AHLS Term-born infants with and without AHLS

Figure 2: Z-scores based on scores of the Griffiths Mental Development Scales, the Bayley Scales of Infant Development second (Dutch) version, and the
Bayley Scales of Infant and Toddler Development (3rd edition) for preterm born infants (n=207) and term born infants (n=120). The circles (infants) represent
outliers (1.5–3 interquartile distance from the box), the asterisk an extreme (interquartile range >3). Preterm male infants differ significantly from male com-
parison infants (p=0.001); preterm female infants differ significantly from female comparison infants (p=0.031); term male infants differ significantly from male
comparison infants (p=0.001); and term female infants differ significantly from female comparison infants (p=0.001). AHLS, active head lifting from supine.

ples of term males and females. In the second year of life, there vs 69% of 87.5% of available data, p=0.001). Finally, infants
was one follow-up appointment at about 18 months of age. without AHLS (n=70) walked 3 months earlier on average
The GMDS was administered at a mean (SD) age of 19.1 than those with AHLS (n=30): mean (SD) 14 months (2) and
(2.3) months. Z-scores of study infants differed significantly 17 (5) months respectively (p=0.002; data available for 87.5%
from comparison infants for the total sample for neurodevel- of infants).
opmental outcome (mean difference 1.15 SD, p=0.001). The
mean difference between male infants and male comparison Multivariable analysis
group was 1.35 SD (p=0.001), and between female infants and Multivariable analysis showed that only AHLS and CUS were
female comparison group 1.01 SD (p=0.001; Table II and independently associated with cognitive test outcomes at a
Fig. 2). mean age of 24 months corrected age in infants born preterm,
Term infants with AHLS tended to have less hand-to-foot and at a mean age of 19 months in infants born at term
contact compared with those without AHLS (71% vs 80% of (Table III).
65% available data), but this did not reach statistical signifi- Because six preterm born infants were later diagnosed to
cance. However, almost all infants without AHLS rolled over have cerebral palsy (CP), the same analysis was performed
from supine to prone compared with those with AHLS (97% excluding infants with CP and their matching comparison

Active Head Lifting and Cognitive Outcome Ingrid C van Haastert et al. 541

Table III: Predictors of cognitive outcome (based on z-scores) for preterm
infants (n=207) at 2y corrected age and term infants (n=120) at 19mo using
multivariable analysis
Coefficient SEM p 95% CI
Preterm
Constant 0.34 0.07 0.001 0.20
AHLS )0.42 0.13 0.002 )0.68
CUS-2 )0.70 0.22 0.002 )1.14
Term
Constant 0.75 0.10 0.001 0.55
AHLS )0.65 0.22 0.004 )1.09
CUS-2 )0.92 0.27 0.001 )1.44
SEM, standard error of the mean; AHLS, active head lifting from
supine (0, no; 1, yes); CUS-2, cranial ultrasound scans in two
categories (0, no or mild; 1, moderate or severe brain injury).
infants. AHLS remained associated with cognitive outcome
(p=0.001), whereas CUS did not reach statistical significance
any more (p=0.051). Similarly, we repeated the analysis with
the term-born sample where eight infants were later diagnosed
as having CP. Again, AHLS remained associated with cognitive
outcome (p=0.001), but CUS did not reach statistical signifi-
cance anymore (p=0.12).
DISCUSSION
AHLS noted during the first year of life in infant graduates
from neonatal intensive care units appears to be associated with
a less favourable cognitive outcome in the second year of life
than in those who do not show AHLS. This applies to preterm
as well as to term infants and supports our hypothesis. In addi-
tion, the term infant with AHLS is less inclined to roll over
from supine to prone, and starts to walk independently at a later
age. Moreover, AHLS is often sustained and repeated by the
infant when lying in supine. The infant seems unable to use
other movement strategies when supine or to move out of this
position. It is our experience that parents interpret AHLS as
the intention of their child to come to a sitting position and that
they tend to be proud of the strong abdominal muscles of their
child, or to interpret AHLS as being an expression of curiosity.
We do not know of any explanation for the underlying
mechanism or neural substrate for this behaviour. Transitions
from variable, non-adaptive behaviour to adaptive selection
strategies occur at specific ages for different motor functions.10
Interestingly, AHLS is most often observed between 6 and
9 months in the first year of life, the same period in which
‘selection of the most efficient postural adjustment in which
all direction-specific neck, trunk, and proximal leg muscles are
activated’ occurs, according to Hadders-Algra.11 One can
speculate about the potential influences of factors associated
with the environment, parent–infant interactions, and the neu-
ronal development related to AHLS. It is possible that an
infant is curious to see what is happening in the environment
and in the absence of other motor strategies uses AHLS to
interact socially. De Groot12 postulated that the influence of
the environment and spontaneous motility both play an
important role in the fine-tuning of postural control. As such,
stereotypic postural control in early infancy may interfere with
542 Developmental Medicine & Child Neurology 2012, 54: 538–543
further motor development, social interactions, and later
cognitive development. Although there is not much evidence
about the influence of positioning while awake on motor
development, AHLS may result from too much time spent in
supine position or in a device like an infant seat, with fewer
possibilities to experience a variety of play positions and motor
strategies.13–15 Until now, we have had no exact information
0.48
)0.16
about these aspects.
)0.26 Another assumption is that AHLS is based on reduced cere-
bral connectivity due to diffuse or overt brain injury, and that
0.95
)0.22
this stereotypic behaviour is ‘the motor correlate of impaired
)0.40 cognitive function’.16,17 The present study shows that not only
did AHLS make a unique contribution to the prediction of a
less favourable cognitive outcome in the second year of life in
preterm and term-born infants compared with comparison
infants, but also moderate or severe CUS abnormalities when
infants with CP were included. No interaction between these
and the other aforementioned variables could be detected in
the analyses.
McPhillips et al. showed ‘how the educational functioning
of children may be linked to interference from an early neuro-
developmental system (the primary-reflex system)’. The sym-
metrical tonic neck reflex is one of the more than 70 reflexes
known within the primary-reflex system, which can be nor-
mally observed between 4 and 6 months of age.18,19 AHLS
partly mirrors the symmetrical tonic neck reflex at which
infants not only show flexion of the head but also extension of
the legs, often combined with plantar flexion in the ankles and
a tendency to adduct the feet or cross them, as we show in
Figure 1. However, the position of the upper extremities may
be variable.
The strength of this study is that it is the first to show a
relation between AHLS and cognitive development in pre-
term and term infants who were at high risk for developmen-
tal difficulties. However, owing to the nature of the design of
this study, data cannot immediately be generalized, not even
to graduate populations from neonatal intensive care units.
For instance, in this retrospective study, we were only able to
use information that was available to us. As the infants were
seen at about 6 months corrected age (preterm) or at about
9 months (term), we cannot exclude the possibility that
AHLS was more common than noted by us. Another limita-
tion is that the GMDS and BSITD-III are not yet standard-
ized for Dutch children.7,9 Judging the results of the preterm
comparison infants on the GMDS, BSID-II-NL, and
BSITD-III, it is noteworthy that although the start of life of
these infants was not optimal, the mean values corrected for
the degree of preterm birth were higher than expected at T1
as well as at T2, with the mean developmental quotients and
z-scores well above the normative mean and the SD lower
than the norm values (Tables II and III). This applied also to
the term-born comparison infants. The question of whether
normative values for cognitive development in the general
Dutch population are different from other populations has
not yet been answered.7,9 However, our findings are in accor-
dance with those of Anderson et al.,20 who compared the
results on the BSITD-III of extremely preterm, low birth-
weight infants with those born at term with a normal birth-
weight, and detected higher mean values than expected for
the comparison group.
It is challenging to unravel the underlying mechanism or
neural substrate of AHLS. In the meantime, parents should be
provided with information on how to handle and position
their child. Children who show AHLS, especially those with
moderate to severe CUS abnormalities, need a long-lasting
follow-up to detect possible special needs in time. Whether an
intervention programme may be beneficial to improve the
cognitive development of a child who shows AHLS in early
infancy remains to be seen. A systematic review and meta-
analysis could not detect long-term benefits in cognitive
outcome of developmental intervention programmes for pre-
term-born infants.21 Koldewijn et al. showed, in a multicentre,
randomized, controlled trial in which parents of 83 infants of
very low birthweight received a post-discharge intervention
programme, that groups did not differ on the mental develop-
ment index and other variables at 24 months corrected age.
However, subgroup analyses revealed that motor and mental
outcomes of intervention in infants with bronchopulmonary
dysplasia and combined biological and social risk factors
improved.22
In conclusion, this study provides provisional evidence of a
relation between AHLS and subsequent consequences for
cognitive outcome, an interference that may result from an
underlying developmental deficit. Within the present study,
AHLS in the first year of life was significantly associated with
a less favourable cognitive outcome in the second year of life,
in preterm as well as term-born infants. Further research is
needed about the prevalence and neurodevelopmental conse-
quences of infants showing this remarkable clinical sign.
ACKNOWLEDGEMENTS
We are grateful to L. F. Sinnecker who performed some of the data
collection, and I. Janssen who created the drawing (Fig. 1) of an infant
who actively lifts the head from supine.

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