Acta Pædiatrica ISSN 0803-5253

REGULAR ARTICLE

Discriminant ability of the Infant Neurological International Battery

(INFANIB) as a screening tool for the neurological follow-up of high-risk
infants in Colombia
Nathalie Charpak (ncharpak@gmail.com)1, Ana Marıa de la Hoz2,3, Julieta Villegas1, Fabian Gil2,3
1.Fundacio n Canguro, Bogota, Colombia
2.Pontificia Universidad Javeriana, Bogota, Colombia
3.Hospital Universitario San Ignacio, Bogota, Colombia

Keywords ABSTRACT
Follow-up studies, Kangaroo Mother Care, Aim: The aim of this study was to assess the discriminative ability of the Infant Neurological
Low birthweight, Neurological examination,
Premature infant International Battery (INFANIB), applied at 3, 6 and 9 months of corrected age (CA), on
neurological outcomes at 1 year of CA.
Correspondence
n Canguro, Calle 56A
Nathalie Charpak, Fundacio Method: An observational analytic study was conducted on a cohort of 5857 infants,
No 50-36 Bloque A13, Apto 416, Pablo VI Azul. followed up to 1 year of CA in a Kangaroo Mother Care programme from 1993 to 2010 in
Bogota, Colombia.
Bogota, Colombia. Infants were included if they had two complete INFANIB results at 3 or 6
Tel: +57 1 2210731 |
Fax: +57 1 2210731 | or 9 months of CA and at 12 months of CA, including the Griffiths Scale. The outcome was
Email: ncharpak@gmail.com defined as the presence of a neurological abnormality, as evidenced by the results of both
Received the INFANIB and Griffiths Scale.
26 July 2015; revised 3 January 2016; Results: The sensitivity of the INFANIB at 3 months was 62.2%, and specificity was 76.1%,
accepted 18 February 2016.
with a receiver operating characteristic (ROC) area of 0.69. At 6 months, the results were
DOI:10.1111/apa.13377 77.5% for sensitivity and 74.4% for specificity (ROC 0.76), and at 9 months, they were
77.2% for sensitivity and 91.1% for specificity (ROC 0.84).
Conclusion: The INFANIB was an appropriate neurological screening test with regard to
determining which Colombian infants would benefit from a timely intervention for
neuromotor disorders.

INTRODUCTION neurodevelopment keeps evolving and infants that are

Advances in neonatal care during the last decade have
increased the survival of premature infants. Those surviving
prematurity and extreme prematurity are high-risk infants
facing significant risks for somatic growth and neuropsy-
chomotor development abnormalities, as well as the pres-
ence of chronic diseases during their lifetime (1). The most
frequently diagnosed neurological disorders are motor
impairments (1–4) such as cerebral palsy and developmen-
tal coordination disorders that can generate high levels of
disability and dysfunction in the life of affected infants and
their families.
Postdischarge high-risk follow-up during the first year
should systematically evaluate the neurological develop-
ment with the purpose of early identification of neuromotor
alterations, resulting in timely intervention and treatment
(3,5–6,8–11). Periodic evaluation is fundamental given that
Abbreviations
CA, Corrected age; INFANIB, Infant Neurological International
Battery; IVH, Intraventricular haemorrhage; KMC, Kangaroo
Mother Care; KMCP, Kangaroo Mother Care programme; LBW,
Low birth weight; NICU, Neonatal intensive care unit; ROC,
Receiver operating characteristic.
apparently normal at a given age can demonstrate abnor-
malities in future evaluations (7,10,11). A systematic
neurological evaluation by a neuropaediatrician is expen-
sive and not readily available, particularly in resource-
restricted settings. To ration resources and maximise ben-
efits for high-risk infants, it is necessary to identify a
simplified but effective and valid assessment tool that is able
to promptly detect abnormal results in the neurological
Key notes
 This study assessed the discriminative ability of the
Infant Neurological International Battery (INFANIB),
applied at 3, 6 and 9 months of corrected age (CA),
on neurological outcomes at 1 year of CA.
 An observational analytic study was conducted on a
cohort of 5857 infants in a Kangaroo Mother Care
programme in Bogota , Colombia.
 The INFANIB proved useful in determining which
infants would benefit from timely intervention for
neuromotor disorders.

©2016 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2016 105, pp. e195–e199 e195
Neurological screening of high-risk infants Charpak et al.

examination, leading to a timely intervention and referral to
a neuropaediatrician.
A number of reliable measurement scales used for
assessment, screening and diagnostic purposes for neuro-
logical disorders have been widely used in high-risk infants
(12–14). Most of these instruments are time-consuming and
need specialised training for application. However, the
Infant Neurological International Battery (INFANIB) is a
standardised neuromotor examination, which is less time-
consuming and easily fits into the routine of a paediatric
evaluation.
The INFANIB was developed by Ellison (15) and was
designed to provide information on age-specific motor
development impairment during the first 18 months of life
and to identify which infants could benefit from early
intervention. The INFANIB consists of the assessment of
five factors: spasticity, head and trunk, vestibular functions,
legs and French angles.
At the Kangaroo Mother Care programme (KMCP) in
Bogota , Colombia, the INFANIB has been used as a
neuromotor simplified evaluation tool since 1993 for
premature and/or low birthweight (LBW) infants (16). In
our KMCP, INFANIB scores were assigned according to
the corrected age (CA) for gestational age at birth.
During each INFANIB test administration, the infant was
classified as abnormal, transiently abnormal or normal.
Infants with abnormal and transient results subsequently
received physical therapy and additional care as needed,
such as diagnostic tests and images and referrals to
specialists.
To date, no comprehensive assessment of a strategy based
on the routine administration of the INFANIB has been
reported in the Colombian context. These results could be
used to inform decisions about the use of the INFANIB in
all follow-up programmes of high-risk infants in Colombia,
particularly in countries with similar profiles in the Latin
American and Caribbean region.
The objective of the study was to assess the ability of the
INFANIB test, performed at 3, 6 and 9 months of CA, to
discriminate neurological status at 1 year of CA in normal,
abnormal or transient preterm and/or LBW infants, allow-
ing for a timely intervention when needed.
Eligible subjects were preterm and/or LBW infants at a
KMC outpatient clinic in Bogota , from hospital discharge
up to 1 year of CA, between the years 1993 and 2009. The
patients had complete information regarding their neuro-
logical outcome at 1 year of CA, namely the Griffiths
Mental Development Scale and the INFANIB evaluation,
and information regarding at least two of three possible
neurological evaluations at 3, 6 or 9 months of CA with the
INFANIB.
The excluded patients were those with incomplete or
invalid information on their neurological evaluation at
1 year of CA or those with severe sensorial impairment,
such as blindness and deafness, which would hamper the
performance and interpretation of the gold standard
tests. On this basis, we excluded 624 infants. The sample
was composed of all eligible infants during the study
period.
This study assessed the performance of the INFANIB in a
KMC outpatient clinic in real-life circumstances in which
different paediatricians administered the test and different
providers undertook physical therapy. During the standard
KMC follow-up, all subjects had an INFANIB test admin-
istered by a paediatrician at the visits at 3, 6, 9 and
12 months of CA and the results were registered in their
clinical records. Infants were classified as normal, tran-
siently abnormal or abnormal, according to the obtained
INFANIB score for their CA, using the cut-off points
published by the test developers (15).
INFANIB can be used in children from 40 weeks of
gestational age onwards, evaluating global motor develop-
ment, tone and primitive reflexes and assessing up to 20
items in five factors (Table 1). Furthermore, during the
yearly visit, a properly trained infant psychologist applied
the Griffiths Scale for assessing psychomotor development,
which generated an overall score and specific scores for five
domains, most of which were affected by any motor
impairment (17).
Table 1 Factors and items evaluated by the INFANIB scale
Factors Items

Factor I Hands Tonic Tonic Asymmetric

METHODS Spasticity held labyrinthine labyrinthine tonic neck
A historical cohort study was assembled to evaluate the open or in supine in prone reflex
closed
performance of the INFANIB, a neurological screening
Factor II Body All fours Pulled to Sitting
tool. All risk factors related to inadequate neurological
Head and derotative sitting
examination results at 1 year were collected: birth weight trunk
gestational age at birth; acute foetal distress, which was Factor III Body Sideways Forward Backwards
defined as abnormal monitoring before delivery; oxygen Vestibular rotative parachute parachute parachute
dependency, which was defined as more than 28 days of Factor IV Positive Dorsiflexion Foot grasp Standing
oxygen requirement; neonatal intensive care unit (NICU) Legs support of the foot
admission; length of NICU stay; intrauterine growth reflex
restriction, defined as a weight below the 10th percentile Factor V Abductor’s Popliteal Heel-to-ear Scarf sign
for the gestational age; asphyxia at birth, defined as an French angle angle
angles
Apgar score of less than three at five minutes, and
intraventricular haemorrhage (IVH) of any grade.

e196 ©2016 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2016 105, pp. e195–e199
Charpak et al. Neurological screening of high-risk infants

Data processing and analysis The neurodevelopmental outcome at 1 year of CA can be

The main outcome was the discriminant ability defined as seen by the distribution of both the Griffiths Scale and
the sensitivity, specificity and area under the receiver the INFANIB score results at 1 year of CA (Table 3).
operator characteristics (ROC) curve of the INFANIB test The discriminant ability of the INFANIB evaluations at
applied at 3, 6 and 9 months of CA, as compared to the 3 months was normal in 4326 of 5812 infants (73.9%)
neurological status, which is the gold standard, using the transiently abnormal in 1438 (24.6%) and clearly abnormal
results of both the Griffiths Scale and the INFANIB score in the remaining 48 (0.8%) subjects. At 6 months, 4185 of
obtained at the 1 year of CA visit. 5801 (71.5%) infants were normal and 1532 (26.2%) and
The Griffiths Scale overall score was dichotomised into 84 (1.4%) were transient and abnormal, respectively. At
normal (≥90) and abnormal (<90), and the INFANIB’s 9 months, normal, transient and abnormal results were
three categories were reduced to two, normal and abnor- 5142 of 5833 (87.8%), 609 (0.4%) and 82 (1.4%),
mal, the latter including both transient and abnormal respectively.
results. A neurological evaluation at 1 year of CA was A total of 256 infants (4.4%) had abnormal neurological
classified as normal when both tests were normal. Any results at 1 year of CA. NICU admission, IVH, birth
abnormal results in either test classified the subject as asphyxia, weight and gestational age at birth were indepen-
abnormal at 1 year of CA. dently related to the outcome (chi-square p = 0.000).
Data were analysed using Stata/MP version 11 (Stata The sensitivity of the INFANIB at 3 months was 62.2%,
Corporation, College Station, TX, USA). with a 95% confidence interval (CI) of 55.8–68.2, specificity
The study was reviewed and approved by the Scientific of 76.1% (74.9–77.2) and an ROC area of 0.69 (0.66–0.72).
Committee of the Kangaroo Foundation. The study was At 6 months, sensitivity and specificity were 77.5%
considered to pose minimal risk, and anonymity of the data (71.8–82.5) and 74.4% (73.2–75.5), respectively, with an
was guaranteed. ROC area of 0.76 (0.73–0.78). At 9 months, sensitivity was
77.2% (71.5–82.2), specificity was 91.1% (90.4–91.9), and
the ROC area was 0.84 (0.81–0.87). The sensitivity of the
RESULTS INFANIB increased at the expense of specificity at three,
The analysis included 5857 study participants who had a six and most notably at 9 months in high-risk groups: at
complete neuromotor evaluation at 1 year of CA and who 9 months, IVH rose to 96%, neonatal anoxia to 97.4%,
had information on at least two INFANIB evaluations at 3, birthweight under 1000 g to 93% and gestational age of up
6 or 9 months visits. There were 5812 (99.2%), 5801 (99%) to 30 weeks to 87%. The discriminant ability of test results
and 5833 (99.5%) INFANIB tests available at 3, 6 and at each test age is described in Table 4.
9 months, respectively. The main characteristics of the
study participants are described in Table 2.
DISCUSSION
The results of the present study appear to confirm that early
evaluation with INFANIB may have an acceptable discrim-
Table 2 General characteristics of study participants inant ability to classify neurological outcome at 1 year of
Characteristic No (%) Mean (Min–Max) age.
Soleimani et al. (18) reported the evaluation of the
Birthweight (g) 1795.5 (500–2687)
INFANIB as a screening tool for the early detection of
Categorical birthweight (g)
<1000 g 269 (4.6) gross motor developmental delay in Iran. The study
1000–1500 g 1085 (18.5) reported 90% sensitivity and 83% specificity in infants of
1501–2000 g 283 (48.4) four to 18 months, and it concluded that the INFANIB was
>2000 g 1668 (28.5)
GA at birth (week) – 33.7 (25–41)
Categorical GA at birth (weeks)
<30 738 (12.6) Table 3 Classification of neurodevelopmental status according to the results of
31–32 860 (14.7) INFANIB and Griffiths Scale at 1 year of CA
33–34 1748 (29.8) Characterization of adverse outcome at 1 year CA No/total (%)
35–36 1922 (32.8)
>37 534 (9.1) Normal result in both tests 5601/5857 (95.6)
C section 4448 (75.9) Infants with abnormal result in the 256/5857 (4.4)
Male 2878 (49.1) neurological evaluation
Acute foetal distress 2044 (34.9) Abnormal result in both tests 45/256 (17.6)
Oxygen dependency 1293 (22.1) Abnormal and a transient result 56/256 (21.9)
Neonatal intensive care unit (NICU) 1495 (25.5) Abnormal and normal result 59/256 (23.0)
Intrauterine growth restriction (IUGR) 1537 (26.2) Griffiths abnormal – INFANIB normal 50/256 (19.5)
Anoxia 759 (32.9) Griffiths normal – INFANIB abnormal 9/256 (3.5)
Intraventricular hemorrhage (IVH) 300 (5.1) Transient result INFANIB – Griffiths normal 96/256 (37.5)

©2016 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2016 105, pp. e195–e199 e197
Neurological screening of high-risk infants
Table 4 Discriminant ability of INFANIB at 3, 6, 9 months of CA
Neurologic status at
1 year CA
Abnormal Normal
INFANIB result n n
3 months
Non normal (transient + abnormal) 156 1330
Normal 95 4231
6 months
Non normal (transient + abnormal) 193 1423
Normal 56 4129
9 months
Non normal (transient + abnormal) 196 495
Normal 58 5084
an appropriate screening test in developing countries such
as Iran.
Liao et al. (19) reported the reliability and predictive
validity using the Chinese version of the INFANIB at three,
seven and 10 months for at-risk infants. They assessed
55 preterm and 49 full-term infants with a high risk of
neurodevelopmental delay, which led them to conclude
that the INFANIB can be useful for screening infants with a
high risk of neuromotor abnormality in Chinese primary
care settings.
Sensitivity of the INFANIB was low at 3 months (62%)
and statistically significantly different from sensitivities at
6 and 9 months, which were almost identical (77%).
Specificity increased steadily with age, which is a clearly
significant trend. The overall discriminating ability – area
under the ROC curve – also increased steadily with
corrected age.
These observations are consistent with the fact that
abnormalities in neurodevelopment might originate early,
for instance due to asphyxia at birth, but manifestations
become evident when the affected structures or functions
should develop. As a consequence, the more mature the
infant when the evaluation is performed, the better the
discriminant ability of the INFANIB test.
The ideal sensitivity of a screening test should be as close
as possible to 100%. According to this, the INFANIB could
be judged as insufficient. Even if the sensitivity of the
INFANIB was higher at 9 months than at 3 months, it is
still not sensitive enough to capture all motor outcomes at
1 year. Specificity at 9 months was very high (>90%),
meaning that an abnormal result was very likely to be a
true positive finding.
The issue is that one cannot diagnose a problem that has
not appeared yet. Neurodevelopment keeps evolving, and
therefore, there are abnormalities that are not present and
are impossible to detect at certain times using screening or
confirmatory tests. For example, one cannot evaluate
vocabulary and numerical reasoning or walking ability at
3 months of age.
e198
Charpak et al.
Area under the Positive Negative
Sensitivity % Specificity % ROC curve Predictive Predictive
(95% CI) (95% CI) (95% CI) Value (PPV) Value (NPV)
62.2 (56; 68) 76.1 (75; 77) 0.69 (0.66; 0.72) 10% 98%
77.5 (71.8; 82.5) 74.4 (73.2; 75.5) 0.76 (0.73; 0.78) 12% 98%
77.2 (71.5; 82.2) 91.1 (90.4; 91.9) 0.84 (0.81; 0.87) 28% 99%
The apparent inability of the INFANIB to fully discrim-
inate between subjects with and without an abnormal
neurodevelopment status at 1 year of corrected age can be
explained by three factors. Firstly, neurodevelopment
impairment becomes apparent when a function that should
mature and appear at a given time falls short when
compared to a standard. Any clinical test, regardless of its
discriminant ability, will fail to identify a sign or symptom
that cannot be present when evaluated. Secondly, in our
study, infants with an abnormal or transient result at any
age were referred for early intervention. Successful inter-
ventions would improve findings at 1 year, and the appro-
priate transient or abnormal result made by the INFANIB
would be incorrectly classified as a false positive. Lastly,
this was a real-life 15-year study on the performance of
the INFANIB in a healthcare system in which observers
changed frequently and those who remained improved their
performance during the study period. This source of intra-
observer and inter-observer variability may explain some of
the lack of concordance between the INFANIB classifica-
tion and outcome at 1 year. It may also explain why our
estimation of sensitivity was consistently lower than other
reports in the literature, but reflects the usefulness in
clinical practice in a busy facility.
A normal INFANIB result means that the infant should
continue under close clinical monitoring, while abnormal
or transient results prompt intervention. Therefore, the
proper use of the INFANIB is not to screen or diagnose, but
to identify infants who are likely to benefit from early
intervention in a timely fashion. In particular, the INFANIB
results at 3 and 6 months helped us to identify infants in
need of early intervention, which was reflected in a sharp
decrease in the observed number of abnormal INFANIB
results between 6 months (n = 1616) and 9 months
(n = 691).
One limitation of the study was that we only carried out
the follow-up until 1 year of CA and this meant that we
were not aware of other possible outcomes that might have
occurred after the last follow-up. There was also a high
©2016 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2016 105, pp. e195–e199
Charpak et al.
rotation of paediatricians in the KMCP, typical of a
developing country setting. Nevertheless, the INFANIB
was shown to be an easily applicable neurological screening
test for high-risk premature infants.
CONCLUSION
Periodic INFANIB testing was informative and was easily
included into the routine physical examinations carried out
the paediatricians in the Kangaroo follow-up programme.
If the INFANIB is used as a screening test, a normal
result does not guarantee a normal neurological examina-
tion in the future, given that sensitivity is not high enough.
That is why the INFANIB must be repeated regularly during
the first year of life. On the contrary, the good specificity of
the test means that an abnormal or transient result will
enable clinicians to carry out timely interventions to try and
prevent neuromotor disorders. Therefore, the proper use of
the INFANIB is to identify infants likely to benefit from
early intervention in a timely fashion.
ACKNOWLEDGEMENTS
We are grateful to Dr Juan Gabriel Ruiz for his advice and
comments on this article.
FINANCIAL DISCLOSURE
There are no financial statements to disclose.
COMPETING INTERESTS
The authors have no conflict of interests to declare.
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