Who Should Be Examined with HINE
The Hammersmith Infant Neurological Examination (HINE) should be performed on all infants with newborn-detectable risk factors for cerebral palsy, including those born preterm, those with neonatal encephalopathy, those with birth defects, and all infants admitted to the NICU. 1
Primary Indications for HINE Assessment
High-Risk Populations Requiring HINE (Strong Recommendation)
The HINE is specifically indicated for infants with the following risk factors 1:
- Preterm birth (especially <32 weeks gestational age)
- Neonatal encephalopathy (including hypoxic-ischemic encephalopathy)
- Birth defects
- NICU admission for any reason
- Abnormal neuroimaging findings (brain injury, hemorrhage, periventricular leukomalacia)
Age-Specific Applications
For infants younger than 5 months (corrected age):
- HINE serves as an alternative when General Movements assessment or MRI are unavailable or unaffordable 1
- HINE score <57 at 3 months is 96% predictive of cerebral palsy 1
- This represents a strong recommendation based on moderate-quality evidence for resource-limited settings
For infants 5-24 months (corrected age):
- HINE is recommended as part of standardized neurological assessment 1
- HINE scores <73 at 6,9, or 12 months indicate high risk of CP 1
- HINE scores <40 at 6,9, or 12 months almost always indicate CP 1
- 90% predictive accuracy for CP in this age range 1
Clinical Red Flags Triggering HINE Assessment
Any infant presenting with the following should receive HINE examination 1:
- Inability to sit independently by 9 months
- Hand function asymmetry at any age
- Inability to take weight through the plantar surface (heel and forefoot) of feet
Additional Clinical Applications
Beyond CP Detection
Recent evidence demonstrates HINE utility extends beyond cerebral palsy screening 2, 3:
- Predicting cognitive delays at 2 years of age in term-born infants
- Monitoring neurodevelopmental trajectories in high-risk populations 4
- Assessing motor severity and prognosis in infants already diagnosed with CP 1
Severity Prediction in Diagnosed CP
For infants with confirmed or suspected CP, HINE scores predict functional outcomes 1:
- Scores 50-73: Likely unilateral CP (95-99% will walk)
- Scores <50: Likely bilateral CP
- Scores 40-60: Likely GMFCS I-II (better function)
- Scores <40: Likely GMFCS III-V (more severe impairment)
Implementation Considerations
Resource-Limited Settings
HINE is particularly valuable when advanced diagnostics are unavailable 1:
- Serves as primary screening tool when MRI is not safe or affordable
- Functions as alternative to General Movements assessment when specialized training is unavailable
- Recent implementation studies in Ethiopia demonstrate feasibility in low-resource settings 5
Longitudinal Monitoring
HINE should be performed serially, not as a one-time assessment 4, 6:
- Recommended at 3,6,9, and 12 months corrected age
- Tracking score trajectories improves diagnostic accuracy
- Progressive changes inform prognosis and guide intervention planning 7
Critical Caveats
- Normal HINE scores do not exclude CP risk if other clinical concerns persist
- Always combine HINE with clinical history and, when available, neuroimaging 1
- In infants <2 years, severity predictions should be made cautiously as motor development is incomplete 1
- Parent concern alone is a valid trigger for formal HINE assessment and referral 1