Update of the Amiel-Tison Neurologic
Assessment for the Term Neonate or at 40
Weeks Corrected Age
Claudine Amiel-Tison, MD
Amiel-Tison neurologic assessment at term has re-
cently been updated for clinical application. Experi-
ence in this field, in addition to a better understanding
of pathophysiologic characteristics of the immature
brain, has taught us that an increased precision in
assessing central nervous system function in the neo-
nate is compatible with a simplification of the clinical
instrument. The complete procedure takes approxi-
mately 5 minutes. A simple 0, 1, and 2 scoring system
is proposed. Because this coding system is not quanti-
tative, any computation of quotient or total score is
inappropriate. Rather, a final synthesis based on clus-
ters of signs and symptoms is advisable. A distinct final
synthesis is proposed for term newborn infants in the
first week of life and for preterm neonates at approx-
imately 40 weeks of age corrected. Clinical profiles
emerging from repeated assessments in the term new-
born and early clinical findings indicating a brain
damage of prenatal origin are described. Interrater
reliability has been proved to be more than satisfac-
tory. Such an assessment is useful for any newborn
infant in maternity wards or for any preterm infant
approximately 40 weeks of age, with or without abnor-
mal imaging findings. © 2002 by Elsevier Science Inc.
All rights reserved.
Amiel-Tison C. Update of the Amiel-Tison Neurological
assessment for the term neonate or at 40 weeks corrected
age. Pediatr Neurol 2002;27:196-212.
Introduction
Examining neonatal intensive care unit discharge sum-
maries the clinicians’ devaluation is observed all over the
world. Abnormal ultrasound findings provide the key to
From the Department of Pediatrics; Port-Royal; Paris V School of
Medicine; Paris, France.
196 PEDIATRIC NEUROLOGY Vol. 27 No. 3
the follow-up clinic, not clinical findings. This failure is a
shame, particularly at a time when clinical neurology in
the neonate has such a promising future, as expressed by
Volpe, “Perhaps of greatest importance is the realization
that careful clinico-anatomic correlations are only begin-
ning to be made in neonatal neurology, especially since the
advent of high-resolution brain imaging techniques. Fur-
ther significant insight into the impact of cerebral injury
on the neonatal neurological examination is expected to be
gained from such correlations” [1].
Because brain damage in the neonate is mainly located
in cerebral hemispheres, the best predictive value should
be found in responses depending on the upper control
system and not in responses depending mainly on brain-
stem activity. The cerebral maturation around term is such
that the upper hemispheric structures can be clinically
explored, within the first days of life in a term newborn or
at approximately 40 weeks corrected age in a premature
newborn.
The Amiel-Tison neurologic assessment at term is an
attempt to answer this challenge by (1) substantially
increasing clinical accuracy in assessing central nervous
system function in the neonate by using a simple scoring
system; (2) focusing on the most meaningful items,
eliminating those that appear redundant; (3) promoting a
clinical synthesis at term, for term and preterm infants, not
defined as the sum of individual scores but as a gradation
system based on clusters of signs and symptoms.
Trends in Clinical Methodology Since the Early
1960s
The French Methodology: Conceptual Background
Initial Description and Later Simplification. Largely
influenced by his background in adult neurology, André-
Communications should be addressed to:
Dr. Amiel-Tison; Port-Royal-Baudelocque; 123 Bd de Port-Royal;
75679 Paris Cedex 14, France.
Received January 2, 2002; accepted April 30, 2002.
© 2002 by Elsevier Science Inc. All rights reserved.
PII S0887-8994(02)00436-8 ● 0887-8994/02/$—see front matter
Table 1. Incidence of central nervous system dysfunction of severe and moderate grades in term infants during an 18-year period (1973-
1990) in the Port-Royal-Baudelocque Maternity Hospital
Maternity Years Term Live
Hospital Studied Births (n)
Port-Royal [32] 1973-75 1785
Port-Royal [33] 1976-78 5825
Baudelocque† 1979-80 2880
Baudelocque [16] 1981-82 2364
1983-84 3170
Baudelocque [14] 1985-86 3883
1987-88 4232
1989-90 3913
* Gradation based on signs and symptoms observed within the first week of life (after exclusion of central nervous system malformations, genetic
factors, infection).
†
Unpublished data.
‡
The difference between the values in the first two rows is statistically significant; P ⬍ 0.001.
Thomas in Paris [2] was fascinated by brainstem activity,
which is so conspicuous in the term newborn infant
because of the immaturity of the upper control system at
this stage of maturation. He defined passive and active
tone and considered tone changes to be valuable clinical
signs. As a young neonatalogist, I had the opportunity in
the early 1960s to observe his disciple, Saint-Anne Dar-
gassies, assessing neonates in Port-Royal-Baudelocque
Hospital in Paris. At the time, she was accumulating data
on the pattern of neurologic maturation from 28 to 40
weeks gestation [3]. Since then my goal has been to
integrate neurologic assessment into daily practice, which
meant devising a simplified methodology.
One significant step has been to reach a better under-
standing regarding what we are assessing clinically. Much
help concerning the construct validity of such an assess-
ment came from Sarnat [4] when he reviewed anatomic
and physiologic correlates of early neurologic develop-
ment. As a consequence of these clinicophysiologic cor-
relates, the modifications proposed in the clinical assess-
ment may be summarized as follows: more emphasis on
signs that depend on upper structures integrity, such as
passive and active tone in the axis, alertness tested by
visual fixation and pursuit, and cranial signs linked to the
volume increase of cerebral hemispheres at the expense of
signs depending on brainstem function, such as primary
reflexes and passive tone in limb flexor muscles. Then,
easy guidelines have been provided to understand matu-
rational steps in motor control from fetal life to infancy
and to interpret signs and symptoms. Most pediatricians
were at last able to develop the self-confidence to practice
a meaningful neurologic assessment [5,6] instead of con-
sidering this approach as exceedingly sophisticated, time-
consuming, and unreliable.
Gradation Based on Clusters of Signs Observed in the
Term Neonate. A gradation system based on a combina-
tion of individual signs and symptoms has been used in
our institution since 1969, describing three degrees of
central nervous system dysfunction [7]. An estimate of the
Neurologic Signs and Symptoms*
Severe Moderate
n Per 1000 n Per 1000
2 1.1 17 9.5‡
5 0.9 8 1.4‡
2 0.7 —
0 0 1 0.4
2 0.6 2 0.6
1 0.3 3 0.8
1 0.2 4 0.9
3 0.7 5 1.3
severity is proposed at the end of the first week, with the
following three grades:
1. Mild: abnormalities of tone and excitability but no
central nervous system depression and no seizure.
2. Moderate: abnormalities of tone with signs of central
nervous system depression (poor interaction, hypoac-
tivity, hyporeflexia) and up to two isolated seizures.
3. Severe: repeated seizures (lasting more than 30 min-
utes) associated with overt central nervous system
depression from lethargy to coma.
The only methodologic change to this gradation system
use was introduced in early 1980s. The use of the bull’s
eye to test the fix-and-track function [8] has helped to
establish a more accurate limit between moderate grade
(cluster of signs indicating central nervous system depres-
sion) and mild grade (cluster indicating no central nervous
system depression) [9].
This three-level gradation system has been routinely
used since that time in two referral maternity hospitals in
Paris to monitor safe obstetric management in term preg-
nancies [10-15]. Certain trends have been observed over a
period of 18 years. The incidence of newborns presenting
moderate or severe cerebral dysfunction is presented in
Table 1. The rate of severe grade was remarkably low and
stable with one per thousand or less. In moderate grade the
incidence has significantly decreased from 9.5/1000 in
1973-1975 to 1.4/1000 in 1976-1978 (P ⬍ 0.001), reach-
ing an almost similar incidence as that for severe grade.
This decrease could be explained by several changes in
these delivery rooms in the mid-1970s, which consists of
the constant in-house presence of a senior obstetrician,
systematic use of fetal heart rate monitoring, and the
presence of a pediatrician in the delivery room. This
gradation system has later been used in cases of cesarean
section to determine the morbidity rate [12,16].
Scoring System for Individual Items. To attain more
precision with a wider repertoire of possible responses for
Amiel-Tison: Neurologic Assessment at Term 197
each item, a description of the severity of signs and
symptoms has been achieved and then transferred on a
three-point scale. After the first attempt described above
other systems were devised, such as a research instrument
for birth asphyxia [17] and for the assessment of older
infants [18,19]. The assessment presented here for term
and preterm infants around due dates is an attempt to
progress in a 0, 1, 2 scoring system that is simple enough
to be used in daily practice. Despite the alphanumeric
character of the scale (0, 1, 2), any computation of quotient
or total score is inappropriate. One benefit of this scoring
system is to be in accordance with the assessment pro-
posed for follow-up in the first 6 years of life [19].
Other Clinical Methods
In the 1960s, André-Thomas was not the only pioneer in
newborn neurology. Peiper in Leipzig, Germany, [20] and
Prechtl in Groningen, The Netherlands [21] both devel-
oped other types of assessments derived from their own
scientific background—pediatrics for Peiper and ethology
for Prechtl. During the same time period, psychiatrists
were studying the behavior of neonates. Wolff, in North
America, carefully studied visual pursuit and attention
[22], and, subsequently, the organization of sucking [23].
Since then and with the impetus given by the work of
Brazelton [24,25], behavioral observations became part of
the neurologic assessment. As analyzed by Scott [26], the
distinction between neonatal neurologic and behavioral
assessments appears unclear, and the content of the assess-
ment instruments overlaps to a great extent. In more recent
years, technical apparatus for artificial ventilation and
monitoring of vital functions has made access to the
neonate in the acute stage even more difficult. These
circumstances explain the more recent emphasis given by
Prechtl and followers to the observations of spontaneous
movements [27-29].
Diversity in Approaches: Consensus on Predictive
Validity
Levene et al. [30] analyzed the predictive validity of the
neonatal assessment for adverse outcome based on five
different studies using the following grading systems: (1)
no infant with mild grade developed significant neurode-
velopmental handicap; (2) 15-27 % of infants with mod-
erate grade had a poor outcome; (3) in four of the five
studies, 75% of infants with severe grade manifested a
poor outcome. These results are in agreement with our
own data that have been pooled from several personal
follow-up studies and using the gradation system de-
scribed above [7,31-33]. A poor outcome was observed in
20-30% of infants with moderate grade and in 50-70% of
infants with severe grade. One can concur with Levene
[34] that, despite slight variations in defining the grades of
encephalopathy, there is a remarkable consensus when
predicting adverse outcome. A good negative predictive
198 PEDIATRIC NEUROLOGY Vol. 27 No. 3
value is even more consensually acknowledged in the
literature (i.e., a normal neurologic assessment around
term is reassuring).
Comparison of Data
Comparison of obstetric management between institu-
tions or nations requires an agreement on the gradation
system, as discussed by Levene [34]. Sarnat and Sarnat
[35] were the first to devise a method that described the
progression of symptoms in asphyxiated term infants.
Subsequently a number of methods based on the same
scheme has been described, including the method de-
scribed by Levene et al. [36].
Differences are mainly caused by the requirement for
perfect alertness in mild grade or by accepting mild central
nervous system depression for the first 48 hours as
compatible with mild grade. Researchers agree that to
define the limit between optimal central nervous system
function and mild degree of central nervous system dys-
function is the only real difficulty. Moreover, in the early
stages of extra-uterine adaptation, it is difficult to separate
the transient effects of cardiorespiratory and metabolic
problems from the specific expression of brain damage.
Repeated assessments provide the only good way of
resolving the difficulty posed by the fluctuation of the
clinical signs soon after birth. The definition of moderate
and severe degree is similar in various systems, therefore
allowing meaningful comparisons concerning obstetric
care (see the discussion of comparison of their predictive
value above).
Criteria for the Selection of the Appropriate Method
Based on these facts, what are the criteria for choosing
one method or another? Different schemes of reference
have been proposed in various parts of the world and have
spread. Currently there is no consensus on the theoretical
model for neonatal assessment. Purpose and feasibility
remain the two essential criteria. The context of applica-
tion is also important to consider.
In research, the choice depends mainly on the goal of
the study. When looking for identification of brain dam-
age, for instance, one of the “mainly neurologic” methods
would be appropriate. When looking for early adaptive
skills, one of the “mainly behavioral” methods is more
appropriate. Because of the characteristics of each avail-
able test (purpose, format, standardization, type of scoring,
time to administer), one test will be preferable to others.
In routine assessment, feasibility is essential, partly
because of the time necessary to perform the assessment.
Certainly, rapidity is not a goal in itself, but it must be
considered for practical and economic reasons. A basic
screening test based on optimal versus nonoptimal re-
sponses, administered in approximately 4 minutes has
been demonstrated to be satisfactory in maternity wards
[6].
 Personal preferences also have an influence. Some
clinicians like to observe spontaneous activity without
interfering, which is the ethologic approach developed by
Prechtl. Others like to manipulate the newborn infant to
establish a contact with his/her hands, to feel the tone at
rest, and to evoke activity in a given situation, which is
more akin to the French approach.
Revised Version of the Amiel-Tison Neurologic
Assessment at Term
Scoring and Recording
General Remarks. The record form presented here as
an Appendix is aimed to replace the form previously used
[10,12]. Because no new items have been added to
preceding descriptions, the technical definitions may be
found in various didactic texts [5,15,19,37].
Corrected age is used for children born before 37 weeks
gestation. To obtain corrected age, postnatal weeks are
added to weeks of gestation. For example, when a child
born at 36 weeks gestation is assessed 4 weeks after birth,
his/her corrected age is 40 weeks (i.e., around due dates).
No specific order is required. The assessment usually
proceeds from observation to manipulation. More activity
is demanded from the infant as the examination
progresses. When a poor response to a procedure is
obtained, the procedure should be repeated and the best
response taken as the right one.
A neurologic examination should ideally take place
when the infant is quiet but alert, spontaneously awake
after a 2-hour sleep after feeding. For one reason or
another, however, it is usually impossible to choose such
a favorable time and a clinician is faced with stimulating
a sleeping baby or quieting a disturbed one, hoping to
obtain a few minutes of quiet alertness.
Finally, it is important to stress one common pitfall in
interpreting findings, as a result of deformations (in utero
by restriction of space at the end of pregnancy or postna-
tally acquired in the neonatal intensive care unit). As an
example, when preventive positioning has been neglected
in sick and preterm infants, postural arching will often be
present and wrongly interpreted as a severe neurologic
sign [38]. Moreover, this acquired posture will not allow
the passage forward of the head in the raise-to-sit maneu-
ver. After a few weeks of physical therapy, if posture and
active responses are back to normal, this condition re-
quires a peripheral explanation. If it does not, brain
damage is very likely present. Therefore, correction of
fetal deformations and prevention of postnatally acquired
muscle shortening and deformations are important issues
to obtain accurate results when assessing central nervous
system function.
Scoring system. The scoring system for each item is as
follows:
0 ⫽ a typical result, within the normal range.
1 ⫽ a moderately abnormal result.
2 ⫽ a very abnormal result.
One usually is confident in assigning a score of 0 or a
score of 2. However, there is sometimes uncertainty when
assigning a score of 1, the latter indicating an abnormal
result of moderate degree.
For certain items, scoring is considered inappropriate,
and the examiner will circle an “X” to indicate examina-
tion results. No conclusions should be made regarding the
normal or abnormal nature of results.
Data Recording. Page I of the form includes four
columns that allow for recordings of repeated assessments.
In fact, four assessments are generally enough to cover the
neonatal period, except in a few severe conditions. Data on
fetal growth and perinatal events are summarized on page
II of the form. The result for each item is recorded on
pages III-VI. The assessment covers cranial characteris-
tics, alertness, behavior and spontaneous activity, passive
tone in limbs and axis, active tone, and primary reflexes.
Imaging, electrophysiologic data, and any additional in-
formation are summarized on page VII.
Final Synthesis
For the term newborn within the first week of life, the
final synthesis is found on page VIII. When every item is
assigned a score of 0, it can be concluded that central
nervous system function is optimal. Most often one
assessment on day 1 or 2 is enough. A second assessment
may be necessary within the first 48 hours if the alertness
does not appear perfect at the time of the first assessment,
preventing any valid interpretation of the infant’s perfor-
mance.
When a score of 1 or 2 is assigned to some items in the
first days of life of a term newborn, the assessment will be
repeated on the following days. The type of clustered
abnormalities observed within the first week of life is the
basis of the gradation change into mild, moderate, and
severe, as mentioned above. Moreover the clinical profile
will be identified based on repeated examinations. Finally,
the presence or absence of morphologic signs that could
indicate a prenatal origin when observed since birth should
be recorded.
For the preterm infant around 40 weeks corrected, the
final synthesis is found on page IX. The preterm infant
should be assessed as close as possible to 40 weeks. The
infant may be assessed in the post-intensive care unit,
ready or not for discharge, or asked to come to the
follow-up clinic if already at home at this age. In this case,
any time between 37 and 42 weeks may be acceptable
because of practical contingencies. The central nervous
system function may be judged optimal when every
individual item is coded 0. When a score of 1 is assigned
on some or most of the items, an impairment of minor to
moderate degree is considered. When some or most of the
Amiel-Tison: Neurologic Assessment at Term 199
Table 2. Distribution of 100 term neonates according to
optimality or nonoptimality of central nervous system function at
birth (assessed separately by the pediatrician and by the midwife
[39])
Pediatrician Midwife
Neurologic Final Final
assessment n Outcome n Outcome
Optimal findings 97 97
First assessment 86 71
Second assessment 11 26
Nonoptimal findings 3 3
items are coded with 2, severe impairment should be
considered. Some difficulties in interpretation because of
extraneurologic problems are not rare in very low– birth-
weight infants and should be mentioned in the synthesis.
In the same line, in utero growth retardation and maternal
diabetes may modify the initial pattern of maturation at
birth and should be taken into account in the interpretation
of the infant’s performance.
For any neonate with neurologic findings the most
probable etiology will be recorded on page X, as well as
the guidelines for the neurodevelopmental surveillance.
Interrater Reliability
Between March and December 1998, a convenient
sample of 100 low-risk term newborn infants was tested at
Port-Royal Maternity Hospital, Paris, France [39]. A
double-blind design was used to test the interrater reliabil-
ity. One rater was the pediatrician in charge, and the other
was a midwife in her last year of training. She previously
was taught the theoretical basis for this examination (3
hours) and was then trained by technical demonstration
and personal practice under supervision (10 hours within a
2-week period). The mean duration for this assessment
was approximately 4 minutes, ranging from 2 to 8 min-
utes. At the time of this study, the three-level scoring
system was not yet available. Therefore, the dichotomous
approach, optimal or nonoptimal, was used [6]. Reliability
was calculated on this final score using Kappa coefficient
as recommended for categorical data.
The results are presented Table 2. Although the same
three infants were found to have moderate signs at the first
examination by both raters, a total of 26 infants needed to
be reassessed to confirm their normality in the first week
of life. Eleven of these infants were the same for both
raters, whereas the other 15 needed to be reassessed only
by the midwife mainly because of her difficulty in obtain-
ing a good fix-and-track at the first assessment, demon-
strating the importance of training.
Interrater reliability was good with a Kappa of 0.57 for
the first examination and of 1 for the second examination.
Meanwhile, the instability of results over time for up to
25% of the cohort, even though the method could not
allow the calculation of test-retest reliability coefficient
because of repetition of assessment only on infants with
200 PEDIATRIC NEUROLOGY Vol. 27 No. 3
nonoptimal outcome, corroborated other studies. A recent
review of psychometric properties of nine standardized
neurologic assessments [40] indicated that stability of the
scores over the first weeks of life is generally poor. One
can agree with this review that the infant himself changes
rapidly so that variable results do not mean that the clinical
instrument is not reliable; it simply confirms the tradi-
tional warning to young pediatricians: “Never trust a
newborn!” The need for repeated assessments is well
recognized.
Clinical Profiles and Etiologic Orientation
The following two statements are generally accepted in
neonatal neurology: (1) the nonspecific character of early
neurologic signs whether the cause is related to a hypoxic-
ischemic event or to any other adverse factors, and; (2) the
absence of free interval in cases of hypoxic-ischemic
encephalopathy (i.e., signs are present from birth). When a
free interval is actually present, experience indicates that
the etiology is to be found in a genetic disease or brain
malformation, not in hypoxic-ischemic encephalopathy
[41]. These two statements are used in any litigation to
accept or refute birth asphyxia as the possible cause of an
encephalopathy. Neurologic signs have to be present from
birth, but they are not specific of birth asphyxia.
Identification of the clinical profile becomes essential
for interpretation. When the profile is identified as dy-
namic (evolving), cranial signs of intracranial hyperten-
sion and autonomic nervous system disturbances are often
present. This evolving profile is typical of a recent insult,
most often occurring intrapartum. When central nervous
system depression remains stable within the first weeks,
with nearly no variation in the clinical picture, the profile
identified as static indicates that the insult occurred several
weeks or months earlier, the birth occurring after the phase
of stabilization that took place in utero.
In such cases, when present from birth, morphologic
signs, such as a high-arched palate, a nonreducible adduc-
tion of thumbs in a tightly clenched fist, and cranial
sutures ridges, indicate prenatal brain damage [41,42].
These signs are not specific for any etiology, although
early identification may be the only way to exclude
intrapartum birth asphyxia as the cause of brain damage. If
these signs are not identified soon after birth, but only
later, their presence will be of no value in dating the insult
as prenatal (just as adductus thumb and cranial ridges may
develop a few weeks after any severe brain damage at
birth).
All of these observations are obviously of the utmost
importance in cases of litigation. If an adequate neurologic
assessment was offered to every term neonate, debates on
the role of birth asphyxia among other causes of cerebral
palsy, such as the recent one published in the British
Medical Journal [43,44], would be less passionate and
more consistent.
Screening in the Low-Risk Group of Term Newborns
Many newborn infants resulting from a high-risk preg-
nancy or birth will fortunately demonstrate an optimal
central nervous system function from birth. To be able to
reassure, immediately and firmly, parents of a neonate
with a threatening gestational or obstetric history, an
optimal central nervous system function from the first
assessment is essential. This situation is frequent with the
increasing sophistication of obstetric investigations during
pregnancy and delivery. As an example, in the study
quoted above concerning 100 term newborns [39], 23 of
them were identified as “at risk” before birth, although 21
of them demonstrated an optimal central nervous system
function. Such optimal responses at birth are the best way
to relieve parents’ anxiety because of the extensive check-
lists of risk factors during pregnancy and delivery.
Integration of Other Investigations in Clinical
Thinking
The correct way to proceed is from clinical findings to
other investigations, investigations that are qualified as
“complementary.” The choice for the most useful investi-
gations varies with the signs and symptoms observed and
according to gestational age. A common tendency, espe-
cially in preterm newborns, is to rely mainly on imaging
findings. Certainly cerebral atrophy visible by ultrasound
by the end of the first month of life has a positive
predictive value for adverse outcome. However, the re-
verse is not true, as has been repeatedly demonstrated
[45-49]. Normal imaging results are not enough to predict
a good outcome. An optimal central nervous system
function at 40 weeks corrected age is necessary as well.
Conclusion
Why have we been so slow in the systematic application
of the experience acquired by the pediatricians and neu-
rologists in this field? It may be a result of the lack of
self-confidence of many pediatricians in their ability to
test central nervous system function at this age. Alterna-
tively, it may be a result of the lack of confidence of many
neurologists in the ability of the neonates themselves to
demonstrate the quality of their higher cerebral functions
or the complexity of the available neurologic assessments.
The simplification, the coding of each performance, and
the clustering of signs and the definition of different
profiles obtained by repeated assessments may clearly
justify the systematic use of neonatal neurologic assess-
ment, which should be central to any valid diagnostic
process.
I want to thank Julie Gosselin for the help she generously provided at
each step of the preparation of this manuscript and the assessment
checklist.
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