|Year : 2021 | Volume
| Issue : 2 | Page : 229-235
The lacey assessment of preterm infants: Predictive validity in early infancy
Thanooja Naushad1, Meena Natarajan2
1 Clinical Support Services - Rehabilitation Section, Latifa Women and Children Hospital, Dubai, United Arab Emirates
2 Department of Physical Medicine & Rehabilitation, Annamalai University, Chidambaram, Tamil Nadu, India
|Date of Submission||10-Jun-2021|
|Date of Decision||19-Sep-2021|
|Date of Acceptance||23-Sep-2021|
|Date of Web Publication||29-Dec-2021|
Dr. Thanooja Naushad
Latifa Women and Children Hospital, P. O. Box 9115, Dubai
United Arab Emirates
Source of Support: None, Conflict of Interest: None
Background and Aim: The Lacey Assessment of Preterm Infants (LAPI) is reported to have low sensitivity but high specificity to predict neurological function. The study objective was to find the predictive validity of the LAPI of preterm infants (LAPIs) to predict neuromotor outcomes of infants born preterm at the corrected age of 3–4 months. Materials and Methods: In this prospective cohort study, infants born below 35 weeks' gestation were assessed using the LAPI before their discharge from the neonatal intensive care unit. Data were collected from Latifa Hospital, Dubai. Outcome assessment was done between 3 and 4 months corrected age using Prechtl's general movement assessment (GMA) and the Test of infant motor performance (TIMP). Results: A total of 125 infants completed the tests (45.6% females); their mean gestational age was 30.28 (standard deviation 2.59) weeks. LAPI showed 87.50% sensitivity (95% confidence interval [CI] =47.35%–99.68%), 96.58% specificity (95% CI = 91.48%–99.06%), and 99.12% negative predictive value (95% CI = 94.75%–99.86%) in predicting fidgety movements in the GMA. The specificity and negative predictive value of the LAPI to predict the motor outcome in the TIMP was 98.06% (95% CI = 93.16%–99.76%) and 88.60% (95% CI = 84.57%–91.67%) respectively whereas sensitivity was 40.91% (95% CI = 20.71%–63.65%). Developmental score in the LAPI showed a weak correlation (P = 0.02, r = 0.20) with the TIMP score. Conclusion: The results suggest that the LAPI can be used to reliably predict neurological function for infants born preterm at 3–4 months corrected age. LAPI can be used as a discharge assessment tool in neonatal units to identify candidates for early intervention services.
Keywords: Neonatal intensive care unit, predictive value of tests, preterm infants
|How to cite this article:|
Naushad T, Natarajan M. The lacey assessment of preterm infants: Predictive validity in early infancy. Arch Med Health Sci 2021;9:229-35
| Introduction|| |
Children born preterm are at significant risk of adverse neurodevelopmental outcomes, including cerebral palsy, developmental coordination disorder, gross motor delay, cognitive issues, language delay, and emotional/behavioral adjustment problems, as reported in several studies.,,,, Early intervention is beneficial to improve neurodevelopment for infants born preterm., However, the cost of early intervention remains high for preterm infants as compared to infants born at term. To optimize the benefits of early intervention and ensure the cost-effectiveness of such programs, early and accurate identification of preterm infants who are at higher risk for compromised neurodevelopment is needed.
Physiotherapists working in neonatal intensive care units (NICUs) use standardized clinical assessment tools to identify infants with a high risk of future neuromotor impairments. Although there are several assessment tools used to discriminate, predict, or evaluate the motor development of preterm infants during the First year of life, there are limited neuromotor and neurological assessment tools which are applicable for preterm infants while they are still at preterm age. The Lacey assessment of preterm infants (LAPI) is one such assessment tool designed specifically for the assessment of the neurological status of infants born preterm before they attain term age and to predict future neurological and motor outcomes for the infant. Developed by an Australian physiotherapist Joan Lacey, LAPI categorizes the neurological status of infants born preterm as “usual” or “monitor,” which implies normal neurological outcomes or high risk of cerebral palsy/motor delay, respectively. Compared to other assessment tools, LAPI has the advantage that it is mostly an observational tool involving a small amount of handling of the vulnerable preterm infant and can be quickly completed at the bedside. However, its psychometric properties are not well established. There is a shortage of studies investigating the predictive validity of the LAPI though it was originally developed as a diagnostic indicator for future cerebral palsy. LAPI was initially reported to have 86% sensitivity, 83% specificity, and 96% negative predictive value for subsequent cerebral palsy at 3 years of age. Two studies that investigated the predictive validity of LAPI showed high specificity at 2 years of age-the initial study conducted in 2014 showed 89% specificity and a more recent study showed specificity as 84%. The sensitivity values reported in these studies (75% and 47%, respectively) were much lower than was reported in the original validation study. Another study that investigated predictive validity at 1-year corrected age reported specificity as 96% and sensitivity as 66%.
The relatively low sensitivity values for predicting long-term neuromotor outcomes raises the question of whether LAPI classification alone can be used as a yardstick for referral to early intervention services. Since early intervention starts even before an infant born preterm is discharged from the NICU, there is a need to use accurate assessment tools which help to predict short-term and long-term neuromotor outcomes. Currently, there are no reported studies on the short-term predictive validity of LAPI. Hence, authors felt the need to investigate the predictive validity of the LAPI in early infancy. This information is important as it justifies the use of LAPI classification as a referral criterion for early intervention services before discharge from NICU.
Thus, in this study, our objective was to determine whether LAPI results could predict the infant's performance at 3–4 months corrected age on two well-established tests of neuromotor assessment, namely the Prechtl's general movement assessment (GMA) and the Test of infant motor performance (TIMP). We hypothesized that a usual classification in LAPI will be associated with normal fidgety movements and TIMP scores within 1 standard deviation (SD) from the mean for the corrected age, and monitor classification will be associated with absent or abnormal fidgety movements and TIMP scores -1SD from the mean.
GMA is a noninvasive and cost-effective assessment that focuses on the observation of spontaneous movements to assess the integrity of the central nervous system.
A prospective longitudinal cross-sectional study has reported that fidgety movements in GMA are reported to have a sensitivity of 98% and specificity of above 94% in predicting cerebral palsy. Another systematic review has indicated the sensitivity and specificity values as ≥92% and ≥82%, respectively. GMA is also reported to have high inter-observer reliability (kappa 0.75–0.91) and intrarrater reliability (kappa = 0.92). The TIMP is a test of functional movements in infants from 32 weeks' postconceptional age until 4 months corrected age. The psychometric properties of TIMP are well established in numerous studies. A study in 2018 showed that TIMP has high content validity, interrater reliability (α 0.65–0.99) intrarater reliability (α from 0.97 to 0.99), test-retest reliability (intraclass correlation coefficient = 1) and predictive validity for motor delay (r = 0.55–0.89). TIMP at 3 months of age is reported to have a high validity for predicting motor performance on the Alberta Infant Motor Scale at 12 months. TIMP Z scores between 10 and 15 weeks are related to cognitive, language, and motor outcomes on the Bayley-III at 2 years of age in infants born preterm.
Use of the GMA and the TIMP at 3 months corrected age gives a comprehensive neuromotor function of the preterm infant. The validity of LAPI to identify infants at high risk of neuromotor dysfunction at 3 months can be established if the infants who are in the monitor category in LAPI are found to have a low total score in the TIMP or have absent/abnormal fidgety movements in the Prechtl's GMA.
| Materials and Methods|| |
This study was designed as a prospective observational cohort study. This study was conducted in Latifa Women and Children Hospital, Dubai, United Arab Emirates (UAE). The NICU at Latifa hospital is the main tertiary referral center for neonates in Dubai and northern emirates of the UAE providing Level III care in its NICU. Data were collected from infants admitted to the NICU of Latifa hospital from January 2018 to March 2019 who met all the inclusion criteria and whose parents gave written consent to participate in the study. Ethical approval for the study was obtained from Dubai Scientific Research and Ethics Committee of the Dubai Health Authority. Infants were enrolled in the study after parents read and signed the informed consent form on behalf of the infant. The principal investigator had undergone mandatory training and obtained certification for LAPI and the Prechtl's GMA.
Infants born before 35 weeks' gestation with birth weight <2.5 kg and who underwent at least two serial LAPI assessments after they reached the postmenstrual age of 33 weeks were included in the study. Infants who were diagnosed with any metabolic, chromosomal, or congenital neuromuscular or musculoskeletal conditions were excluded from the study. The bias in results which could be caused by exclusively recruiting infants of extremely low gestational ages or extremely low birth weight was addressed in this study by recruiting preterm infants of varying gestational ages and birth weights. To avoid bias in LAPI classification, the principal investigator was blinded to neuroimaging results until LAPI assessment series was completed.
Longitudinal LAPI assessments were completed after infants reached 33 weeks' postmenstrual age, following all the guidelines, as specified in the LAPI manual. The developmental score was calculated, and the infants were classified as a neurological category “usual” or “monitor.” Infants were called for follow-up assessment between corrected ages 3 and 4 months. The TIMP and the Prechtl's GMA was completed on the follow-up visit. The sum of the scores on observed and elicited items was tabulated to get the total score in the TIMP. Based on the total score, infants were classified as having average, low average, below average, and far below average scores. The average score indicated score within ± 1 SD of the mean for the age group, the low average was the score between − 0.5 and − 1 SD below the mean, the below-average range indicated score between − 1 and − 2 SD below the mean and far below average indicated scores >−2 SD below the mean for the corrected age group. For this study, average and low average scores in TIMP were considered normal, whereas below average and far below average scores were considered atypical concerning a previous study.
For Prechtl's GMA, babies were suitably undressed and positioned supine on an examination cot in a distraction-free environment. When babies were in a quiet alert state, video clips of up to 5-min duration were recorded; later, these were played back at normal speed, and movement categorization was done based on the presence or absence of fidgety movements. Continuous or intermittent fidgety movements were classified as normal fidgety. If fidgety movements were sporadic/absent, it was recorded as absent fidgety, and any abnormal fidgety movement was separately noted. Although it is known that the trajectory of general movements helps to predict infants' neurodevelopment, for this study, general movements at preterm and writhing period were not considered. This was because the focus of this study was to find the short-term predictive validity of LAPI with fidgety movements as the outcome measure. It is also known that GMA done at fidgety age has higher sensitivity to predict future neuromotor outcomes as compared to assessment at earlier ages.,
Missing data were not replaced and were excluded from this study. Data were entered into a Microsoft Excel spreadsheet, and data analysis was done using the Statistical Package for Social Sciences software SPSS version 21.0 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp). The final LAPI classification and the developmental score were considered for statistical analysis. The association of LAPI with TIMP and GMA was calculated using the Fisher's exact test. Correlation between LAPI developmental scores and total scores in TIMP was estimated using Spearman's rank correlation. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated using a 2 × 2 contingency table to predict normal fidgety movements or absent/abnormal fidgety movements in the GMA and <-1 or >-1SD in TIMP.
| Results|| |
LAPI was conducted for 141 infants of which outcome measures were completed for 125 infants; hence, only these infants were included in the study. This is presented in [Figure 1]
Clinical and demographic characteristics
The clinical and demographic characteristics of the 125 infants who completed the study are given in [Table 1].
|Table 1: Clinical and demographic characteristics of the study population (n=125)|
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Performance on the tests
Initial LAPI assessment was done at a mean age of 35.42 (SD 1.91) weeks, and the final LAPI assessment was done at a mean age of 36.09 (SD 2.08). GMA and the TIMP were done at a mean age of 3.02 (SD 0.45) months.
The distribution of categorical scores of LAPI, GMA, and TIMP are presented in [Table 2].
|Table 2: Distribution of categorical scores on assessment tools used in the study n=125|
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Association of Lacey assessment of preterm infants with General movement assessment and the Test of infant motor performance
Analysis using Fisher's exact test showed that the P < 0.001 between LAPI and GMA and between the LAPI and the TIMP. This is shown in [Table 3].
|Table 3: Association of Lacey assessment of preterm infants classification with general movement assessment at fidgety age and test of infant motor performance categories (n=125)|
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Diagnostic accuracy of Lacey assessment of preterm infants
The diagnostic accuracy of the LAPI to predict fidgety movements in GMA and motor development as measured using the TIMP is shown in [Table 4].
|Table 4: Accuracy measures of Lacey assessment of preterm infants in comparison with general movement assessment and test of infant motor performance (n=125)|
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From the predictive accuracy measures as shown in [Table 4], the sensitivity of the test indicates that 87.5% of babies who lacked fidgety movements in GMA assessment were correctly identified as abnormal in LAPI and the specificity of the test indicates that 96.58% of babies with normal age-appropriate fidgety movements were identified as normal in LAPI. In terms of motor outcomes, only 40.91% of infants with atypical motor development measured using the TIMP were identified as abnormal in LAPI, although 98.06% of infants with typical motor development in TIMP were identified as normal in the LAPI.
Correlation of Lacey assessment of preterm infants and the Test of infant motor performance developmental scores
Spearman's rank correlation was used to find the correlation between LAPI developmental score and TIMP scores. Though statistically significant, LAPI developmental score showed a weak correlation with the TIMP scores at 3 months (P = 0.021 and correlation coefficient [r] =0.207). This is shown in [Figure 2].
|Figure 2: Correlation between Lacey assessment of preterm infant developmental score and test of infant motor performance scores|
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| Discussion|| |
The purpose of this study was to find the predictive validity of the LAPI for neuromotor function at 3–4 months corrected age in infants born preterm. Earlier studies on LAPI have focused only on whether the test can predict the occurrence of cerebral palsy at 2 years of age. Evidence shows that infants born preterm may suffer from a range of motor dysfunction issues other than cerebral palsy, which places them at higher risk of learning and behavioral disorders in later life. Hence, in our study, we focused on instruments that measure neurological integrity and motor development, namely Prechtl's GMA and the TIMP. To the best of our knowledge, this is the first study that investigated the predictive validity of LAPI for neurological and motor outcomes in early infancy.
Earlier studies have indicated that GMA had no concurrent validity with traditional neurological assessments. This study shows that the LAPI classification has high sensitivity (87%) for predicting absent fidgety movements in GMA. Although this finding cannot be taken as proof of concurrent validity between the two instruments, the results of this study indicate that LAPI and GMA could be measuring similar aspects of neurological function. This finding has significant clinical implications. There is extensive literature to show that GMA, which manifests as absent fidgety movements, is highly sensitive to predict future cerebral palsy/motor delay.,, It is also known that early intervention could improve fidgety movements in infants born preterm. Thus, it can be reasoned that LAPI classification can be used as a criterion for referral to early intervention before an infant's discharge from the NICU. Clear fidgety movements may not manifest until after 9 weeks of corrected age. Hence, crucial preventive time may be lost if clinicians wait for absent fidgety movements to emerge before referral for early intervention services. LAPI has the significant advantage that it can be used in the NICU much before the emergence of fidgety movements. Several studies have also reported that the integrated use of a neurological examination and GMA improves the early prediction of neurodevelopmental outcomes., This suggests that LAPI might be considered in combination with Prechtl's GMA as a discharge assessment tool in the NICU. This aspect can be investigated in future, and concurrent validity between the two assessment tools can be established.
Predictive accuracy of LAPI classification with TIMP was not reported before in any other study. Although it is interesting to note that 9 of the 11 babies (81.8%) who were in the monitor category of LAPI were found to have below average or far below average scores in the TIMP, the results obtained in the accuracy analysis showed that the predictive capacity of LAPI classification to identify infants who got scores below 1 SD from the mean in TIMP, was merely 40.9%. This could be because the two tests may be focusing on different aspects of neuromotor function. The focus of LAPI is on identifying neurological integrity by the observation of spontaneous movement patterns, whereas the TIMP is a motor test focusing on functional movements and emphasizes elicited responses in response to specific handling. Results of this study also indicate that the correlation between LAPI developmental score and TIMP score was weak. In LAPI, the developmental score is not the sole basis for deciding the neurological categories of “usual” and “monitor.” Rather, these two categories are decided based on the presence of one or more of the nine atypical features. The developmental score is used only as an objective measure to communicate the motor, oromotor, and tone scores. A drawback of the LAPI is that a 'cut off' developmental score is not established since such a quantitative scoring cannot be used as the sole criteria for identifying neurological dysfunction.
Comparison of the sensitivity values in this study with other predictive validity studies of LAPI is difficult since the demographics of the study population, age of outcome measurement, and reference tools were not the same. Except for the original validation study, long-term follow-up studies that focused on neurological outcomes have generally reported lower sensitivity values (66%–75%)., Based on this study, it appears that LAPI has better sensitivity to predict short-term rather than long-term neurological outcomes. This could be because some abnormal transient neurological signs could be resolved spontaneously with age. It is also interesting to note that sensitivity value for motor outcomes at 3 months as measured in this study (40%) was closer to the sensitivity obtained in a very recent study by Lukens et al. (47%) which measured motor performance at 2 years. This again reiterates the effectiveness of LAPI as a neurological assessment tool than a motor assessment tool.
Results of this study also point to the high accuracy of LAPI classification to identify infants who are likely to have normal neurological or motor development at three to four months corrected age. The high specificity and negative predictive values as obtained in this short-term follow-up study are in general agreement with similar values obtained previously for long-time predictive studies. All previous studies on LAPI have reported high specificity values ranging from 83% to 96%.,,, Hence, normal findings in LAPI may be used to reassure anxious parents in the NICU and give informed feedback about the infant's current state of neuromotor function. Current research evidence points to the need to refer babies for early intervention without delay, as opposed to referral after a specific diagnosis of cerebral palsy is confirmed, by which time deformities would have set in. Early risk stratification is also reported to be beneficial for parents., Studies have shown that interventions that are continued beyond the period of neonatal care can have an impact on the motor development of preterm infants. However, to avoid straining early intervention services with unnecessary referrals, neonatal physiotherapists need to use the most appropriate assessment tools in the NICU to identify babies at high risk for future neurodevelopmental issues. The result of this study points out that LAPI can be an effective tool in the NICU with good predictive validity for neurological function at 3 months. If the infant's LAPI classification is “usual” it could be used as an indicator to wait till the infants reach 3 months corrected age, at which time the infant can be reassessed to decide whether direct therapeutic intervention is required at that stage.
LAPI is a useful clinical assessment tool for neonatal physiotherapists working in the NICU. It involves minimal handling of the preterm infant as it emphasizes on observation of postures and spontaneous movements. LAPI has detailed assessment guidelines to minimize the stress of preterm babies during handling. Infants born preterm are at risk for behavioral and physiological stress during neurological assessments. Hence, minimizing stress to vulnerable premature infants is of vital importance during the assessment process. As an observational assessment tool, LAPI can be quickly completed at the bedside and requires no specific equipment. Thus, it is a very cost-effective clinical tool which can be used in low-resource settings. The use of developmental scores in the LAPI ensures that the results can be objectively communicated to other health care professionals in the NICU and facilitates to objectively record the course of an infant's development in the NICU. Certification is necessary before therapists can use the LAPI in neonatal units without supervision.
Limitations and implications for future studies
This was a single-center study, and data were collected from infants of Asian origin. All follow-up assessments were conducted by the principal investigator who was not blinded to the results of the initial assessment. Infants with abnormal neurological or motor development at 3–4 months were fewer in the study sample which could have influenced the sensitivity values in this study. These factors could be considered a source of bias and thus restrict the generalizability of the findings of this study to all infants born preterm. To address these concerns, we recruited preterm infants in a wide range of gestational ages, birth weights, and prematurity-associated complications. The population was a usual representation of premature infants typically found in a Level III NICU.
Long-term longitudinal follow-up of infants and large multi-center studies are needed for a clear understanding of the predictive validity of LAPI. Future research may focus on finding and comparing the psychometric properties of LAPI with established neonatal assessment tools applicable in the NICU namely Hammersmith neonatal neurological examination and Prechtl's GMA.
| Conclusion|| |
This study sought to determine the early predictive validity of the LAPI. Our findings suggest that LAPI classification was significantly predictive of absent fidgety movements at 3 months of adjusted age. LAPI also showed a high potential to predict normal neurological and motor function. These findings suggest that LAPI has potential as a discharge assessment tool in the NICU. LAPI classification can be used by neonatal therapists to reassure parents of premature babies or provide a referral for early intervention.
The authors would like to acknowledge the valuable contribution of Mrs. Nawvi Gopalakrishnan, Paediatric physiotherapist in Kings College Hospital Dubai, for her assistance in data interpretation related to the Prechtl's General Movement Assessment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]