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The Neurological Assessment of the Preterm and Full-term Newborn Infant.L Dubowitz. (Pp 167; £35.00). Cambridge University Press, 2000. ISBN 1898683158.
Progress in the management of disease in the newborn has carried with it a recognition of the substantial risk of injury to the immature nervous system. The aspiration to localise and prognosticate from neurological signs in the early newborn period is easily understood. The problem is that the signs available to be discerned are in themselves usually insufficient to allow precision. In addition, the child grows and develops, the range and complexity of skills are constantly changing, and the manifestations of the lesion(s) alters, or may become silent, often to reappear later as a different but nevertheless highly significant impairment.
The evaluation of the newborn nervous system was originally based upon concepts learnt from adult neurology. The baby was seen as demonstrating little or no cortical or cerebellar activity and the study of primary reflexes predominated. The approach of adult neurology, with emphasis on localisation of the lesion, becomes less applicable in the younger child. In the newborn period, focal insults to the brain will often give rise to generalised disturbances and, contrarily, generalised disturbances may show focal deviations. Recognition of these phenomena has led to a progression from the concept of a localisation based neurology to one which sees the infant displaying a neurological/behavioural repertoire. Over the past several decades Saint Anne Dargassies, Prechtl, Amiel Tison, Brazelton, Dubowitz, and others have, through meticulous study, done much to illuminate this area. Through these studies, awareness of the importance of the behavioural state of the baby, as well as the more detailed neurological items has evolved.
A second problem in this area, particularly in relation to research studies, has been the development of a systematic newborn neurological examination which is reliable and repeatable. This has been the subject of the two editions of this work. The first, published in 1981, gave a detailed, easily understood and applied system for the neonatal neurological examination. The current edition brings that work up to date. New material is presented, refinement of the scheme has occurred, and the examination is described. Items which were less discriminatory of pathology from the 1981 version have been withdrawn and, following the work of Prechtl, more emphasis is placed on the analysis of general movements. There is a further post neonatal to two year old infant neurological examination proforma presented briefly at the end of the text.
The text is essentially a manual on the application of this neurological examination scheme. It is easy to follow and the segments of the examination are presented clearly with excellent photographs and line drawings of each manoeuvre. There is also a useful addendum (“cautionary tales”) to each section of the examination, giving guidance on possible pitfalls and sources of error. There is a lot of very useful information on the variations in findings in term and preterm infants, and particularly the changes in the neurological features of preterm infants as they grow towards term. There follows a section on the development of an optimality score from the observed items of the assessment. This section deals with the results of a survey of 224 normal term infants. In this study each item of the scheme was plotted, and centile values (and thereby optimality scores) were computed. This provides quantification of the assessment, a sense of the range of findings to be expected, and can be useful in correlating lesions observed on neuro imaging with clinical findings. Chapter six deals with the scheme in relation to findings in infants with recognised brain lesions.
The book is not designed to be a text of neonatal neurology and readers looking for discussion of neurological disease states will be disappointed. As a description of a comprehensive and easily applied system of neonatal neurological examination the new edition succeeds admirably.