Dubowitz Neurological Examination: Indications and Criteria
Primary Indication
The Dubowitz neurological examination is indicated for comprehensive neurological assessment of newborn infants, particularly to identify neurological abnormalities and differentiate central nervous system involvement from peripheral neuromuscular disorders. 1
Specific Clinical Indications
High-Risk Populations Requiring Assessment
- Preterm infants examined at term-equivalent age (25-34 weeks gestational age at birth) to establish neurological status and predict motor outcomes 2, 3
- Term newborns during the first days of life as part of routine neurological screening 4, 1
- Infants with suspected motor delays or neuromotor abnormalities as part of the comprehensive evaluation, particularly when assessing tone abnormalities 5
- Neonates with major cranial ultrasound abnormalities to correlate imaging findings with clinical neurological status 2
- Infants at risk for cerebral palsy, as the examination helps assess neurological maturity and tone patterns 5
When to Perform the Assessment
- Term infants: During the first days of life as part of routine evaluation 4, 1
- Preterm infants: At term-equivalent age (37-42 weeks corrected gestational age) 2, 3
- Follow-up assessments: When monitoring infants with identified neurological concerns or abnormal initial findings 1
Examination Criteria and Components
Core Assessment Areas
The Dubowitz examination evaluates 34 specific neurological items across multiple domains 4, 2:
- Tone assessment: Flexor and extensor tone in limbs and neck, with specific attention to distribution patterns 4, 1
- Posture evaluation: Assessment of resting posture and positional responses 1
- Primitive reflexes: Including Moro reflex and other age-appropriate reflexes 4
- General movements: Evaluation of spontaneous movement quality and patterns 4
- Head control: Assessment in various positions including sitting posture 2, 3
- Visual following: Ability to track and fixate on visual stimuli 2, 3
- Excitability: Assessment of behavioral state and responsiveness 3
Optimality Scoring System
The examination uses an optimality score based on the distribution of findings in low-risk populations, with scores defined using 10th and 5th centiles for each item. 4
Interpretation Criteria for Term Infants:
- Normal variation: 1-2 deviant scores can occur in one-third of normal infants and have little diagnostic value 4
- Concerning findings: 4 or more deviant scores found in less than 10% of normal infants, warranting further evaluation 4
- Abnormal tone distribution patterns: Not found in normal populations but commonly observed in infants with brain lesions 4
Interpretation Criteria for Preterm Infants at Term-Equivalent Age:
- Mild concern: >7 items outside the 90th centile (40% of infants developing diplegia had this finding) 2
- Severe concern: >12 items outside the 90th centile (all such infants developed tetraplegia) 2
- High risk: 80% of infants developing tetraplegia had >7 items outside the 90th centile 2
Age-Specific Adjustments
The scoring system must account for gestational age variations between 37-42 weeks, as tone items and Moro reflex vary significantly with gestational age. 4
Expected Differences in Preterm Infants
When examining preterm infants at term-equivalent age, expect the following normal variations compared to term-born infants 2, 3:
- Less flexor tone in limbs
- Poorer head control in sitting posture
- Better visual following abilities
- Increased hyperexcitability
- Less extensor tone in neck when sitting
Clinical Application Considerations
Red Flags Requiring Prompt Referral
When performing the Dubowitz examination as part of motor delay evaluation, the following findings mandate urgent specialist referral 5:
- Increased tone suggesting upper motor neuron problems (cerebral palsy) - requires brain MRI 5
- Fasciculations indicating lower motor neuron disorders 5
- Abnormal tone distribution patterns not seen in normal populations 4
- Loss of previously acquired motor milestones suggesting neurodegenerative processes 5
Practical Implementation
The examination can be performed quickly at bedside using a standardized recording sheet with simple instructions and diagrams. 1, 6 This makes it feasible for routine use by pediatricians in clinical practice 6.
Correlation with Imaging
The examination findings should be correlated with neuroimaging results (cranial ultrasound or MRI) when available, as this combination provides more accurate prognostic information than either assessment alone 2, 1.