Hammersmith Infant Neurological Examination (HINE)
Introduction and Clinical Application
- The HINE is a standardized clinical tool for assessing neurological development in infants aged approximately 2 to 24 months.
- Used extensively for early identification of neurodevelopmental disorders, particularly cerebral palsy (CP).
- Consists of 26 scored items across five domains: cranial nerves, posture, movements, tone, and reflexes/reactions.
- Each item scored from 0 (severely abnormal) to 3 (normal), with a maximum total score of 78.
- Lower scores and significant asymmetry indicate higher risk of developmental disorders, especially CP.
Examination Preparation
Proper preparation is important to ensure a successful HINE assessment. The exam should be done when the infant is **calm, alert, and not hungry or tired**. A feeding or nap beforehand can help the baby stay content. The environment should be warm, quiet, and free of distractions. It is best to lay the infant on a **firm, flat surface** (e.g. an exam table or mat) for most of the assessment. Have a caregiver present to provide comfort and to assist with positioning if needed. Before you begin, gather any necessary materials:
- High-contrast visual target: e.g. a black-and-white toy or card, to test visual tracking
- Noisy toy or rattle: to test response to sound
- Reflex hammer: to elicit deep tendon reflexes (modified technique for infants).
- Measuring tape: for head circumference (if part of your routine exam) and to measure angles (optional, usually estimation is sufficient).
- Scoring sheet (proforma): the HINE score sheet provides specific criteria and diagrams for each item, which helps ensure standardized scoring.
Ensure the infant’s **safety and comfort** at all times: use soft padding on the surface and have the caregiver close by or touching the baby if that soothes the infant. Plan the sequence of exam items strategically – often it works best to start with less intrusive observations (like watching spontaneous movements) before moving on to hands-on maneuvers that might upset the baby. If the infant becomes fussy or agitated, pause and console them or allow a short break. Flexibility and a gentle approach will yield the best cooperation and most accurate exam.
Examination Procedure and Key Components
Cranial Nerve Function
- Observe facial symmetry at rest, during crying, or stimulation (e.g., symmetrical smile or cry).
- Check eye movements using high-contrast objects to evaluate visual fixation and tracking in all directions.
- Assess visual responses: infant should turn eyes or head to follow an object through a complete arc.
- Evaluate auditory response using soft rattles or voice; look for quieting, turning, or startling reactions.
- Test sucking and swallowing during feeding or using a pacifier; ensure coordinated, strong suck and swallow.
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