Tone assessment in neonates

Presented by: Moderator:

Dr. Pranaya Kumar Mall Dr. Swati upadhyay
SR, Neonatology Asst. Prof. Neonatology

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 Contents
❑ Development of tone
❑ Important tools for assessment
❑ Amiel tison method
❑ HNNE
❑ HINE
❑ Conclusion
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 Background
• Muscle Tone- state of relaxed muscle under the spontaneous
excitation by the central nervous system.

• Human fetus extended posture in very early phase &

progresses to flexed posture.

• Rule is same whether develops intrauterine or extra uterine.

• Progression caudocephalad and centripetal.

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 Progression of tone with age

Gosselin J, Gahagan S, Amiel-Tison C. The Amiel-Tison Neurological Assessment at Term: conceptual and methodological
continuity in the course of follow-up. Ment Retard Dev Disabil Res Rev. 2005;11(1):34-51
 Tone assessment tools in neonates
Tools Applicable age Tone Time Normative data
items required
APGAR At birth 1 (5) In instance -

APIB (Assessment of preterm infant behavior) 0-1 month 6(280) 60min -

37-42 weeks corrected age -
ATNAT 9(35) 5min
(CA)
ENNAS (Einstein neonatal neurobehavioral
37-42 weeks PMA 5(20) 30-45min 118 LBW & 76 full term
assessment scale)

HNNE 37-42 11 (34) - 224 Term

KNES (Kathmandu neonatal encephalopathy scale) 0-24 hr 1(7) - -

NAPI (Neurobehavioral assessment of the preterm
32 weeks CA-term 7 (41) 30min 521 preterm
infant)

125 full term healthy,344

30 weeks GA-<46-48 Weeks
NNNS (NICU network neurobehavioral scale) 10 (115) 20min healthy,
CA
1388 opiate exposed
Premie Neuro 23-37 Weeks PMA 8 (24) 30-60min -

Goo, M., Tucker, K. and Johnston, L.M. (2018), Muscle tone assessments for children aged 0 to 12 years: a systematic review. Dev Med Child Neurol, 60: 660-671 .
 Tone assessment tools in babies < 2 years
Tools Applicable age Tone Time Normative data
items required
ATNAT (0-1) 0-1 year 17 (55) - -

92 infants at 12 mo,43
HINE 2-24 months 8(37) 5-10 min
infant at 18 mo (no risk)

412 term
HINT (Harris infant neuromotor test) 2.5-15.5 months 2(21) 15-25 min

INFANIB (infant neurological international battery) 4-18 months 6(20) - -

MAC (movement assessment in children) 2-24 months 3 (53) 30 min -

MAI (movement assessment in infant) 0-12 months 5(65) 30 min -

TINE (touwen infant neurological exam) 1 year 1 (50) 15-20min 521 preterm
 Tone assessment tools in babies >2 years

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Hammersmith Neonatal Neurological Examination 
(HNNE)
 Background
• Quick, practical and easy.

• Initially developed by Dr Lilly Dubowitz and Prof Victor

Dubowitz in 1981.

• Updated later by Dr Eugenio Mercuri, in 1998.  

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 • Tone

• Tone patterns
HNNE contains
• Reflexes
34 items divided
in 6 categories
• Movements

• Abnormal signs/patterns

• Orientation & Behaviour

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 HNNE
• Takes about 10–15 min.
• No formal training required
• Inter-rater reliability - 96%
• Each individual item gets a score of 0, 0.5, or 1.Compound score is
calculated by simple summation of the optimality scores of individual items.
• Score < 30.5 – Suboptimal for term
• For Preterm at term equivalent age <26 suboptimal

https://hammersmith-neuro-exam.com
• Video HNNE

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 HNNE : Score
• Raw score (1-5)

• Optimality score for individual items (0,0.5,1)

– Optimal >10thcentile----------------------score =1
– Borderline >5th centile ------------------score=0.5
– Suboptimal <5th centile ------------------score= 0

Dubowitz L, Mercuri E, Dubowitz V. An optimality score for the neurologic examination

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of the term newborn. J Pediatr. 1998 Sep;133(3):406-16
• Compound optimality score for a group

• Total optimality score

<30.5 suboptimal for term
<26 suboptimal for preterm at TEA

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 Dubowitz L, Mercuri E, Dubowitz V. An optimality score for the neurologic
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examination of the term newborn. J Pediatr. 1998 Sep;133(3):406-16.
 Dubowitz L, Mercuri E, Dubowitz V. An optimality score for the neurologic examination of the
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term newborn. J Pediatr. 1998 Sep;133(3):406-16
 Dubowitz L, Mercuri E, Dubowitz V. An optimality score for the neurologic examination
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of the term newborn. J Pediatr. 1998 Sep;133(3):406-16.
 FAQs
• Whom to use- Any neonate
• How often to repeat- Depends upon clinical scenario. But one
shortly before discharge and at term gestation is most reliable
• If items are missing- Acceptable up to 5 items (for research
purpose) and up to one (for clinical purposes).
• Min gestation to use- Any ( But prior to 34 weeks only assess
change in pattern, no normative data)
• How long- 2-3 months post term

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https://hammersmith-neuro-exam.com/faq/
 Hammersmith Infant Neurological Examination 
(HINE)
 •Cranial nerve function

• posture
HNNE contains 26 items divided in 5
categories along with assessment of
motor milestones and behavior
• Reflexes & reactions
separately

• Movements

• Tone

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 HINE
• Aimed to be used between 3 to 24 months of age.
• No formal training required

https://hammersmith-neuro-exam.com/
• Video HINE

Assisted ventilation of the neonate, Sixth

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edition, 2017
 Haataja L, Mercuri E, Regev R, Cowan F, Rutherford M, Dubowitz V, Dubowitz L. Optimality score for the neurologic examination of
the infant at 12 and 18 months of age. J Pediatr. 1999 Aug;135(2 Pt 1):153-61.
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 < 5 months > 5 months
MRI 86-89% Sensitive MRI 86-89% Sensitive

GM 98 % sensitive Developmental assessment of

young children 83 %
sensitive
HINE 90 % Sensitive HINE 90 % Sensitive

Novak I, Morgan C, Adde L, et al. Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy: Advances in Diagnosis and Treatment [published correction appears in

JAMA Pediatr. 2017 Sep 1;171(9):919]. JAMA Pediatr. 2017;171(9):897-907 . https://www.cerebralpalsy.org.au/

 Why HHNE and HINE
• Easy to use
• Minimum resources needed
• No training required
• Freely available
• Objective scoring and quantification possible
• Good sensitivity to diagnose CP even below 5 months of
age
• Important especially in low resource settings.

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Amiel-tison neurological assessment at
term (ATNAT)
 ATNAT : History
• Andre Thomas (1952) first assessed brain status in infants by
using passive and active tone.

• Saint Anne-Dargassies (1960) added primitive reflexes.

• Amiel Tison (1985) added vision and hearing.

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 ATNAT
• Valid for both term and preterm (at term equivalent).

• Depends on the individual development of an upper and lower motor control

systems

• Lower system (brainstem and cerebellum) matures early (begin at 24 weeks) in

an ascending pattern to maintain posture against gravity and flexor tone in the
limb.

• Upper system (cerebral hemispheres and basal ganglia) matures later (begins at
32 weeks) in a descending pattern to control the lower system, with relaxation of
limb & finally allowing for fine motor skills, erect posture, and walking.

Gosselin J, Gahagan S, Amiel-Tison C. The Amiel-Tison Neurological Assessment at Term: conceptual and methodological
continuity in the course of follow-up. Ment Retard Dev Disabil Res Rev. 2005;11(1):34-51
 Physiological basis for exam development

• Brain injury (HIE & PVL) in neonate most commonly affects

the upper system.
• Best predictors of injury should be found in responses that

depend on the upper control system.

Gosselin J, Gahagan S, Amiel-Tison C. The Amiel-Tison Neurological Assessment at Term: conceptual and methodological
continuity in the course of follow-up. Ment Retard Dev Disabil Res Rev. 2005;11(1):34-51
 ATNAT
• Takes about 5 min.
• Full-term should be assessed in the first week of life.
• Preterm at 40 ± 2 weeks.
• 35 items clustered in to 10 domains
• Scoring system for each involves a non quantitative three-point scale

(0 normal, 1 mod abnormal, and 2 abnormal, X abnormal not gradable)

• Do not add items to get a total score.

Gosselin J, Gahagan S, Amiel-Tison C. The Amiel-Tison Neurological Assessment at Term: conceptual and methodological
continuity in the course of follow-up. Ment Retard Dev Disabil Res Rev. 2005;11(1):34-51
 ATNAT
• An optimal status defined by the absence of abnormal
neurological signs
• Non- optimal status for full-term infants can be graded into
mild, moderate and severe
• For preterm infants only two categories – mild to moderate
and severe to avoid effect of prolonged extra uterine life.
Gosselin J, Gahagan S, Amiel-Tison C. The Amiel-Tison Neurological Assessment at Term: conceptual and methodological
continuity in the course of follow-up. Ment Retard Dev Disabil Res Rev. 2005;11(1):34-51
 ATNAT
1. Cranial assessment
2. Neurosensory function and spontaneous motor activity
3. Passive muscle tone
4. Axial motor activity (active tone)
5. Primitive reflexes
6. Palate and tongue
7. Adaptation to manipulation
8. Feeding autonomy
9. Medical status
10. Unfavourable circumstances at the time of exam
 Paro-Panjan D, Neubauer D, Kodric J, Bratanic B. Amiel-Tison Neurological Assessment at term age: clinical application, correlation
with other methods, and outcome at 12 to 15 months. Dev Med Child Neurol. 2005 Jan;47(1):19-26.
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 Paro-Panjan D, Neubauer D, Kodric J, Bratanic B. Amiel-Tison Neurological Assessment at term age: clinical
11-01-2021 application, correlation with other methods, and outcome at 12 to 15 months. Dev Med Child Neurol. 2005 60
Jan;47(1):19-26.
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 Take home message
• Repeated neurological examination is the key for
early suspicion of neurological abnormality in later
ages.

• Early suspicion: early intervention: better outcome.

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 Thank You!!
Thank you

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