Rapid Communication

Improving the Identification of Neonatal

Encephalopathy: Utility of a Web-Based Video Tool
Autumn S. Ivy, MD, PhD1 Catherine L. Clark, PhD1 Sarah M. Bahm, MD2 Krisa P. Van Meurs, MD3
Courtney J. Wusthoff, MD, MS1,3

1 Division of Child Neurology, Lucile Packard Children’s Hospital, Address for correspondence Courtney J. Wusthoff, MD, MS, 750
Stanford University School of Medicine, Stanford, California Welch Road, Suite 317. Palo Alto, CA 94304
2 Department of Pediatrics, Lucile Packard Children’s Hospital, (e-mail: wusthoff@stanford.edu).
Stanford University School of Medicine, Stanford, California
3 Division of Neonatology, Lucile Packard Children’s Hospital, Stanford
University School of Medicine, Stanford, California

Am J Perinatol

Abstract Objective This study tested the effectiveness of a video teaching tool in improving
identification and classification of encephalopathy in infants.
Study Design We developed an innovative video teaching tool to help clinicians
improve their skills in interpreting the neonatal neurological examination for grading

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encephalopathy. Pediatric residents were shown 1-minute video clips demonstrating
exam findings in normal neonates and neonates with various degrees of encephalopa-
thy. Findings from five domains were demonstrated: spontaneous activity, level of
alertness, posture/tone, reflexes, and autonomic responses. After each clip, subjects
were asked to identify whether the exam finding was normal or consistent with mild,
moderate, or severe abnormality. Subjects were then directed to a web-based teaching
toolkit, containing a compilation of videos demonstrating normal and abnormal
findings on the neonatal neurological examination. Immediately after training, subjects
underwent posttesting, again identifying exam findings as normal, mild, moderate, or
severe abnormality.
Results Residents improved in their overall ability to identify and classify neonatal
Keywords encephalopathy after viewing the teaching tool. In particular, the identification of
► neonatal abnormal spontaneous activity, reflexes, and autonomic responses were most
encephalopathy improved.
► online teaching tool Conclusion This pretest/posttest evaluation of an educational tool demonstrates that
► neurological after viewing our toolkit, pediatric residents were able to improve their overall ability to
examination detect neonatal encephalopathy.

Neonatal hypoxic-ischemic encephalopathy (HIE)—brain
injury due to insufficient blood flow or oxygen delivery
around the time of birth—is a potentially devastating condi-
tion affecting up to 3 per 1,000 term infants. Therapeutic
hypothermia is a well-established treatment that can reduce
the risk of later disability when initiated within the first 6
hours after birth.1–3 Implementation of cooling within this
short time frame is challenging due to the difficulty of quickly
identifying neonates with moderate or severe encephalopa-
thy based on clinical examination. In one regional case series
from Ontario, nearly one-third of potentially eligible neonates
referred to their center were unable to receive cooling
treatment, with a primary reason being encephalopathy
had not been correctly identified within the time window.4

received Copyright © by Thieme Medical DOI http://dx.doi.org/

January 31, 2016 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0036-1593846.
accepted after revision New York, NY 10001, USA. ISSN 0735-1631.
September 22, 2016 Tel: +1(212) 584-4662.
Online Toolkit for Detecting Neonatal Encephalopathy Ivy et al.

The Vermont Oxford Network Collaborative targeted “timely
identification of at-risk infants” and “staff education for both
local and referring hospitals” as key best practices for centers
providing therapeutic hypothermia.5
In addition to meeting clinical and biochemical criteria,
identification of HIE largely relies on clinical examination skills.
A survey of California practices found that while neurologic
examinations were most often performed by a neonatologist or
referring physician, many centers relied on transport nurses or
pediatric residents for these assessments.6 The neonatal neuro-
logical examination can be intimidating for nonneurologists,
including the focused neurological examination to identify
neonatal encephalopathy. At the same time, it has been shown
that neurological examinations performed by pediatricians and
trainees without additional neurology training can accurately
identify newborns with abnormalities when a standardized
approach is used.7 For many clinicians, the particular challenge
in using a focused exam to identify neonatal HIE is uncertainty in
identifying features of encephalopathy, particularly when these
exam findings may not be frequently encountered. Although
there currently exist video and online resources for learning and
practicing the general pediatric neurological examination (most
neonates with various degrees of encephalopathy. After each
clip, subjects were asked to identify whether an exam finding
was normal or consistent with mild, moderate, or severe
abnormality in the specific domain tested (two clips/questions
were given for each domain). Two questions were also asked
about autonomic responses, based on written descriptions of
autonomic findings. Again, subjects were asked if these con-
ditions would be considered normal or consistent with mild,
moderate, or severe abnormality. Correct answers were not
revealed following the pretest. For the training sessions, sub-
jects viewed different video clips of neurological examina-
tions, along with written descriptions of exam findings and
diagnostic criteria. Immediately following the training
sessions, subjects completed a posttest consisting of the
same video clips and autonomic questions from the pretest,
presented in a different order. None of the training videos was
present in either the pretest or the posttest. Both pre- and
posttests were completed by the subjects using the Qualtrics
(Provo, UT) online survey tool.
Pre- and posttest scores were analyzed with paired t-tests
using GraphPad Prism software (La Jolla, CA). Specifically, we
examined improvement between the pretest and posttest scores

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notably through the University of Utah: http://library.med.utah.
edu/pedineurologicexam), no similar resource currently exists
for interpreting the neonatal neurological examination specifi-
cally for grade of encephalopathy. We developed a web-based
tool for training and review of the focused exam to identify
neonatal encephalopathy. This study tested the effectiveness of
that video teaching tool in improving identification and classifi-
cation of encephalopathy in neonates.
Methods
We developed a web-based video teaching tool to help
clinicians improve their skills in interpreting the neonatal
neurological examination for encephalopathy: https://peo-
ple.stanford.edu/wusthoff/neurologic-exam-neonates-sus-
pected-encephalopathy-0. This toolkit contains both text
descriptions and video tutorials of the five major domains
by overall score and by specific content domain (spontaneous
activity, level of alertness, posture/tone, reflexes, and autonomic
responses), using both paired t-tests and Mann–Whitney tests.
Results
All participants’ overall posttest scores improved over their
pretest scores. Their improvement ranged from 10 to 90%,
with a mean improvement of 38.1%. As shown in ►Fig. 1, the
overall posttest scores were statistically significantly higher
than the overall pretest scores. The paired t-test value (with
20 degrees of freedom) was 9.7, p < 0.001. The overall pretest
mean was 34.8, with a standard error of the mean (SEM) of 3.6
and a standard deviation (SD) of 16.6. The overall posttest
*
Mean percentages of correct responses

100
of the neonatal encephalopathy exam: spontaneous activity, * * pre-test
* post-test
across all respondents

level of alertness, posture/tone, reflexes, and autonomic

responses. The videos demonstrate how findings on the
neonatal neurological exam can be used to distinguish neu-
50
rologically normal newborns from those with mild, moder-
ate, and severe encephalopathy. Informed consent for
videotaping was obtained from each infant’s parent. The
Stanford University Institutional Review Board exempted 0
this study from review.
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To test the efficacy of our toolkit, we recruited 21 volunteer

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pediatric residents with no more than 2 months of neonatal

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intensive care unit (NICU) experience. In this pretest/posttest

evaluation of an educational tool, all participants reviewed the
online toolkit and completed 10 questions, video-based pre-
and posttests assessing their ability to correctly grade degree
of abnormality. The pretest consisted of eight 1-minute video
clips of an expert examiner demonstrating exam findings in
one of four domains: spontaneous activity, level of alertness,
posture/tone, and reflexes, from both normal neonates and
Fig. 1 Pediatric residents improved in their overall ability to detect
exam findings in neonatal encephalopathy after viewing the online
toolkit. In addition, accurate diagnoses of spontaneous activity,
autonomic responses, and reflexes were significantly improved after
viewing online teaching videos, whereas accurate detection of level of
alertness and posture/tone showed a nonsignificant trend toward
improvement.
indicates p < 0.05, and error bars represent standard
error of the mean.

American Journal of Perinatology

 Online Toolkit for Detecting Neonatal Encephalopathy
mean was 72.9, with SEM of 3.2 and SD of 14.5. The Mann–
Whitney value was 19.5, p < 0.01.
Posttest scores were significantly higher than pretest scores
in three specific content areas: spontaneous activity, reflexes,
and autonomic responses. The paired t-test value comparing the
spontaneous activity pretest scores and the spontaneous activity
posttest scores (with 20 degrees of freedom) was 7.1, p < 0.001.
The spontaneous activity pretest score mean was 41.7, with
SEM of 6.3 and SD of 28.9. The spontaneous activity posttest
score mean was 86.9, with SEM of 3.3 and SD of 15.0. The Mann–
Whitney value was 41.0, p < 0.01. The paired t-test value
comparing the reflexes responses pretest scores and the reflexes
responses posttest scores (with 20 degrees of freedom) was
3.2, p < 0.01. The reflexes pretest mean was 66.7, with SEM of
10.5 and SD of 48.3. All respondents scored a perfect 100% on the
reflexes posttest; therefore, the mean was 100.0, with SEM of 0
and SD of 0. The Mann–Whitney value was 147.0, p < 0.05. The
paired t-test comparing the autonomic responses pretest scores
and the autonomic responses posttest scores (with 20 degrees of
freedom) was 4.7, p < 0.001. The autonomic responses pretest
mean was 35.7, with SEM of 7.8 and SD of 35.9. The autonomic
responses posttest mean was 81.0, with SEM of 6.4 and SD of
29.5. The Mann–Whitney value was 82.5, p < 0.01.
There was a trend toward improved scores in level of
alertness and posture/tone, but performance in these
domains did not reach significance. The paired t-test compar-
ing the level of alertness pretest scores and posttest scores
(with 20 degrees of freedom) was 1.8, p > 0.05. The level of
alertness pretest mean was 33.33, with SEM of 10.5 and SD of
48.3. The level of alertness posttest mean was 57.1, with SEM
of 11.1 and SD of 50.7. The Mann–Whitney value was 168.0,
p ¼ 0.21. The paired t-test comparing the posture/tone pre-
test scores and the posture/tone posttest scores (with 20
degrees of freedom) was 1.9, p > 0.05. The posture/tone
pretest mean was 14.3, with SEM of 5.1 and SD of 23.2. The
posture/tone posttest mean was 31.0, with SEM of 7.3 and SD
of 33.5. The Mann–Whitney value was 162.0, p > 0.05.
There were no clear patterns of over- or underidentification
of abnormality across all of the questions in the pretest.
However, for the video pretest question on tone, most respon-
dents incorrectly identified it as moderately or severely abnor-
mal when the neonate was actually demonstrating normal
tone. Level of NICU experience did not influence the overall
pretest scores, t-test (with 38 degrees of freedom) was 2.0,
p > 0.05. Level of NICU experience did not influence the
overall posttest scores, t-test (with 38 degrees of freedom)
was 1.3, p > 0.05.
Discussion
We have created a web-based video toolkit demonstrating
key exam findings that distinguish normal neonates from
those with encephalopathy and tested its efficacy on pediatric
residents at a large academic hospital. After reviewing this
toolkit, residents with no more than 2 months of NICU
experience were better able to identify physical exam find-
ings of neonates with signs of encephalopathy. The toolkit
was most beneficial in aiding correct identification of abnor-
Ivy et al.
malities in spontaneous activity, reflexes, and autonomic
responses. The domains of posture/tone and level of alertness
can be targeted both for refinement of our toolkit, and future
teaching and training efforts.
Rapid initiation of cooling in infants with suspected HIE
leads to improved neurodevelopmental outcomes.2 Animal
studies suggest that the sooner cooling begins after perinatal
hypoxia ischemia, the less neuronal injury that occurs.8 As
such, practitioners making the initial clinical assessment
should have tools available to them for timely examination
and triage to cooling therapy if indicated. We demonstrate
here that our online toolkit successfully improves recognition
of physical exam signs of encephalopathy, one component in
diagnosing neonatal encephalopathy. Once made widely
available, it has the potential to be a valuable online resource
to meet the needs of community physicians, trainees, and
nonphysicians who must quickly identify children with HIE
and initiate transport to tertiary NICUs. Ultimately, this novel
aid could significantly enhance identification of relevant
physical exam findings, as one step to facilitate referral of
children with HIE to receive cooling treatment within a brief,
critical window after birth.
Downloaded by: Cornell. Copyrighted material.
Conflict of Interest
None.
Acknowledgment
This research was supported by the Stanford Children’s
Health Research Institute Innovations in Patient Care grant
(C.J.W.).
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American Journal of Perinatology