The value of the clinical examination revisited

It was common teaching in the 1990s that one of the best markers of long-term outlook for term asphyxiated infants was if they were feeding well by the end of the first week. Those still with abnormal neurological signs at discharge were likely to fair less well. This was based upon the work and observations from the 1970s and 1980s of such authors as Sarnat and Sarnat (1976), summarized in Levene’s textbook1 and the review article of Amiel-Tison and Ellison.2 The value of the neurological examination seems in recent times to have been less well appreciated. The article by Murray et al.3 is a timely and welcome reminder. Their paper is a well constructed study employing the detailed, systematic, and repeated examination expounded by Amiel-Tison. Why has the neurological examination taken rather a back seat in recent times? There have probably been quite specific reasons. Hypoxic-ischaemic encephalopathy is a devastating insult. All neonatal practitioners will have witnessed the normal term infant who has suffered hypoxia at birth who may rally immediately after resuscitation but who then sinks into the deepest phase of encephalopathy at around 72 hours of age, before either dying or recovering to a greater or lesser extent. Some make remarkable recoveries. All parents will ask if their infant will be damaged. Hypoxic-ischaemic encephalopathy is one of the most studied events in neonatal practice. Numerous sophisticated and illuminating studies by many groups have gradually elicited an insight into the underlying pathophysiological events.4 In so doing they have revealed time windows and strategies for potential therapeutic actions after the insult has occurred to stop the cascade of neurotoxic substances resulting in cell necrosis and apoptosis.4 The most successful to date is body cooling.5 The time window of potential therapeutic value is short; therefore, early, reliable markers of a high risk of secondary cell death have been needed for interventional studies. Low Apgar scores at 5 or 10 minutes and acidosis have been used but further objective tests were also sought. This is where the integrated electroencephalograph (EEG) became so useful.6 EEGs and magnetic resonance imaging have found very specific and important roles in this field especially in combination.7 The results of ‘machine’ tests are undoubtedly seen as objective. One also suspects a trend to believe in the imperative of having a machine-driven ‘test’. Clinical examination is often seen as more subjective. Some, however, would say that the machine tests are not without their subjectivity. They can be expensive and cumbersome to perform. They are not without risk of artefact8 and they are not available to all. They work well in the hands of a few. The paper by Murray et al. illustrates that the examination can be quite specific. The well-known modified Sarnat examination scores the infant in its most neurologically abnormal phase. The Amiel-Tison examination is detailed and observes as the infant goes through the recovery phase. Infants with a severe encephalopathy (Sarnat Grade 3) will do badly, those with a mild encephalopathy (Grade 1) will on the whole, but not universally, do well. Those with Grade 2 have a more uncertain prognosis – which is where the examinations over the following days/weeks to discharge are helpful. Further, the examinations can be performed by any trained physician in any clinical setting and involves direct engagement between physician, infant, and family. Although a combination of all tests – imaging and neurophysiological and clinical examination – will give a useful prediction of outcome, more subtle alterations in educational performance and IQ will need testing much later on to be truly representative of longer-term deficits.9 However, for any neonatologist, anywhere in the world, at the cot side of a newborn whose parents will be asking what they might expect and what follow-up will be needed for their infant, there is a great deal to be said for a detailed neurological examination which will give a pretty reasonable assessment of what the future may hold.