Hammersmith Infant Neurological

Examination (HINE)

Guidance notes for completing the form

Main references (others at the end)

Haataja L et al. Optimality score for the neurologic examination of the infant at 12
and 18 months of age. J Pediatr 1999;135:153-61
Neurological Assessment in the first 2 years of life. Ed Cioni G & Mercuri E. 2008
Clinics in Developmental Medicine 176; ISBN: 978-1-898683-54-4; Mac Keith Press
(now Wiley)

This neurological examination aims to be easy and quick to perform. It is divided into
5 scoring sections (cranial nerves, posture, movements, tone, reflexes). Then there is
two sections, which we do not assess, that document the milestones of motor development and age
to which the achievements were made and a record of the child's responsiveness and interaction.

The exam is validated for term and preterm infants from 6 to 18 months in terms of
optimal scores and prediction of gross motor outcomes. We have also used it in
2-year-old babies, although some of the reflex movements and those that involve
levantar objetos pueden ser difíciles de evaluar para el examinador y los niños pueden
Deliberately letting them fall or they like to manipulate them, which makes the evaluation difficult
of those items.

The exam should be easy to complete in 5 to 10 minutes. Ideally, it is done in a

bed, but it can be done in the parents' / caregivers' lap as long as it is
possible to lay the child down for some elements.

Exam registration
To register and grade the exam, indicate the answer to any item by enclosing it.
in a circle the corresponding image (stick drawing) on the form

If an answer does not clearly fall into one of the offered options, but does among
two options, mark the vertical line that divides them.

If the answer is asymmetrical, mark the observation twice, once for the
left and another for the right. You will see that in many boxes L and R are written.

If there are two drawings in any box, mark the one that is closest to what you see.

If the response or observation you find is not provided in the form, please write it down.
descriptively.
 There is no need to carry out the points in any particular order.

If you are not sure about the answer, do it again or wait a bit and come back.
try it if the child is restless.

If you are unsure of the answer, say so instead of marking an answer.

definitive.

Score
● Within the scored section of the exam, there are 26 items (cranial nerves 5,
postura 6, movimientos 2, tono 8, reflejos 5).

The maximum and optimal score for any item is 3 and it appears in column 1.
giving a total optimal score of 78

As you scroll through the page from left to right for any
element, the scores are reduced to 0.

If you do not believe that the answer is optimal for an item, but not sufficiently
poor enough to get a score of 0 or 1, give a score of 2.

If the answer to an item is asymmetrical, subtract 0.5 from the score.

At 12 months, scores > 72 are optimal and at 18 months, the

Scores above 73 are optimal. The scores above 66 (term) and 64.
(premature) are associated with independent walking and scores above
40 (term) and 52 (premature) are associated with independent walking.
score in the premature is independent of the gestational age at birth and of the
age in the assessment within the age range of our study.

Section - 1: Cranial nerves

Most of this section can be easily observed while talking with the
parents / caregivers before the formal exam.

Observe the eye movements and also make the child follow a target.
clear in a completely vertical, horizontal, and circular manner.

The ideal is to have someone out of the child's line of sight to help them.
evaluate the auditory response. (If this is difficult and the parents report that the child has
had a formal audition test and you have no concerns, you can
assume a score of 3).

● Observe the child's face to see a variety of movements. If there are no

specific problems but believe there is a lack of movement, grant a
score of 2

Similarly, if a child does not have defined difficulties in sucking, chewing or

swallow, but does not eat well, score with 2.
The following sections should be evaluated, ideally, with the child naked or up to a
shirt and diapers. However, if the child gets upset when you undress them, at least take off the
shoes and socks, pants and thick coats.

Section - 2: Elements of posture

● Head position when sitting: Younger children will need to be supported.
for them to sit down

● Trunk posture when sitting: to achieve a score of 3, the back must

to be straight most of the time.

● Observe the arm positions during the exam.

● Observe the hand positions during the exam.

Long sitting, that is, sitting on a flat surface with the legs
stretched forward (this cannot be done sitting in a chair). For the
children who still do not sit, lie them down and observe the position of the legs from
the hips.

● Observe the position of the foot in relation to the lower leg; many
children will have some external inclination of the foot, but this generally comes from
the hip and it is not really an alteration of the ankle.

Section - 3: Movements
It is likely that these elements have been previously observed during the visit, but it is
It is necessary to observe the child and decide if the quantity and quality of the movements are
are within normal limits. Some children will have slightly
spasmodic, that is, column 3, but they rarely fall into column 4. If you consider that
the child's movements are not optimal but do not fall into column 3, place it in the
column 2.

Section - 4: Tone Elements

Ideally, this section should be done with the child lying on a bed. However,
if the child is very reluctant to go to bed, you can do this by placing the child in both
on their lap like in that of their parents / caregivers. To do this, sit in a chair
in front of the caregiver so that their knees almost touch and then sit the child on the
caregiver's lap, then I slowly pulled the legs towards you so that
the child lay down on his two laps. It's not ideal, but he can take the exam of
that way.

● Scarf sign: Pull the arm gently but firmly. Keep the
child's head in the midline and observe if the elbow only reaches the edge
exterior of the cheek (column 3), to the middle of the ipsilateral cheek, to the
 chin or crosses the midline to the middle of the opposite cheek. (mark all
in column 1, either the drawing on the left, between the two, or the drawing of the
right, as appropriate.
Most of the babies will be to the right of column one, but many
they are in column 3 because the elbow reaches to the outer edge or beyond
contralateral cheek.

Shoulder elevation: Hold the arm by the wrist, lift it and pull it towards
up along the side of the head to rest on the bed. Sometimes it
finds with a certain resistance that can be easily overcome (column 1), but
premature children often show little resistance to this
maneuver (column 3). Repeat the shoulder lift maneuver on each side
to feel slight asymmetries.

● Supination and pronation: Extend the elbow and hold the wrist and rotate it to supinate and
turn completely 180 °.

Hip adduction: It is necessary for the child to be lying down in position

horizontally ideally with a loose diaper. Keep the legs straight for the
hips and knees, first together in the midline and then gently abduce
as much as I can, keeping the knees straight.

● Popliteal angle: Place the child in a horizontal position. Flex the hips to
that the front side of the thighs touches the abdomen, making sure to keep the
child's glutes in contact with the bed; if he lets him get up, the popliteal angle
measured will be greater. Then, extend the bottom part of the legs to the height of the
knees as much as possible and estimate the angle behind the knee. Sometimes it is more
easy to do one leg at a time, especially if the child is wriggling and you are
trying to keep it in contact with the bed. Evaluate both legs at the same time.
time allows for better observation of any asymmetry.

● Dorsiflexion of the ankle: It is important to do this with the leg straight at the height of the
knee and hip. Keep the knee down against the bed and at the same time
place the other hand flat on the sole of the foot and dorsiflex the ankle
maximum. Estimate the angle between the foot and the leg. Some children will resist
voluntarily to this maneuver, but in reality they are quite flexible, others
they will have an involuntary resistance and then will suddenly give in; if this is the
Sure, take note of it.

Manual traction: Hold the child by the wrists and lift them to sit.
observing the position of the head as it rises. If you feel that they have a
lower performance repeat it. This can be difficult to note if he cries and keeps the
head back.

Ventral suspension: Hold the child around the abdomen and place them in
ventral suspension. Some children may weigh too much to hold them.
comfortably around the abdomen in this position. They can also
to become disorganized or they do not like being held in the air for fear of falling. If this
Happens, write it down instead of grading the element.
Section - 5: Reflections and reactions
● Tendon reflexes: It is better to do them while the children are lying down.
but, they can be done in other positions. It can be difficult to use a hammer with
many children and, often, it is better to hit hard with the fingers when the
child relaxes.

Side parachutes: Any child who can sit up should have this response.
and in some older children, they will not respond in the drawn manner, as they are
too competent. Write it down if you think this is the case instead of
incorrectly classify them. If they obviously have side parachutes, mark them in
column 1. To perform the test, lay them down, place your hand on your hip
contralateral to the arm with which you will lift it. Then, pull from the wrist and observe.
if you place the free arm on the bed to support yourself. Repeat it in reverse to try.
the other side.

Axillary suspension: Hold the child in a vertical position just under the armpits,
with your back to you so that you can see your father or caregiver, and see if he extends his
legs in the same way and properly. Sometimes it is necessary for someone to do it for you.
tickling on the feet to encourage a response. They are mainly sought after.
subtle differences between the legs. If they are too heavy to lift them, you
dejan caer o se ponen rígidos deliberadamente, escríbalo y no califique.

Lateral tilt: hold the child just above the hips (not below)
from the armpits) with their back towards you so that they can see their parents/caregivers.
Then, lean to the sides, not too abruptly, so as not to scare him and
see/feel the muscle response of the trunk beneath your upper hand. Some
Older kids can be too heavy to lift and some let themselves go.
fall. To score in column 1 (see drawing) they must have a vigorous response
not only with the trunk but also with the elevation of legs and shoulders.

● Parachute reflection: Hold the child just above the waist and tilt them
quickly towards a bed or table. Look for a symmetrical arm response and
energetic forward.

Motor milestones and behavior

We do not score these elements, but they act as a record of motor development and the
status during the exam. The images and descriptions of the motor milestones are obvious.
I asked if the child played with their toes when they were younger. I asked if
the child rolls to both sides and to both sides. Make a comment if only it
They dragged the commands and moved to the back. Take into account the age of the march.
independent.
References:
● Neurological Assessment in the first 2 years of life. Ed Cioni G & Mercuri E. 2008
Clinics in Developmental Medicine 176; ISBN: 978-1-898683-54-4; Mac Keith Press
(now Wiley)

Haataja L et al. Optimality score for the neurologic examination of the infant at 12
and 18 months of age. J Pediatr 1999;135:153-61

Frisone MF et al. Prognostic value of the neurologic optimality score at 9 and 18

months in preterm infants born before 31 weeks’ gestation. J Pediatr 2002;140:57-60

● Haataja L et al. Neurologic examination in infants with hypoxic-ischemic

encephalopathy at age 9 to 14 months: Use of optimality scores and correlation with
magnetic resonance imaging findings. J Pediatr 2001;138:332-7

Haataja L et al. Application of a scorable neurologic examination in healthy term

infants aged 3 to 8 months (Letter) J Pediatr 2003;143: 546

Ricci D et al. Sequential neurological examinations in infants with neonatal

Encephalopathy and low Apgar scores: relationship with brain MRI. Neuropediatrics
2006;37:1-6

● Romeo DMM et al. Neuromotor development in infants with cerebral palsy

investigated by the Hammersmith infant neurological examination during the first year
of age. Eur J Paediatric Neurol 2008;12:24-31

● Romeo DMM et al. Early psychomotor development of low-risk preterm infants:

Influence of gestational age and gender. Eur J Paediatric Neurol 2016;20:518-523

Haataja L et al. A new approach for neurological evaluation of infants in

resource-poor settings. Annals of Tropical Paediatrics (2002) 22, 355–368.