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NICU Network Neurobehavioral Scale Manual

Smith, Lynne M. M.D.

Journal of Developmental & Behavioral Pediatrics: February 2005 - Volume 26 - Issue 1 - p 68

David Geffen School of Medicine at UCLA, Los Angeles Biomedical Research Institute at Harbor UCLA Medical Center, Torrance, California

NICU Network Neurobehavioral Scale Manual, by Barry M. Lester and Edward Z Tronick, Baltimore, MD, Paul H Brookes Publishing Company, 2004. 231 pp., soft cover, $50. Tool Kit, $299. Complete NNNS (Manual, Scoring Sheets, and Tool Kit) $325. Training can be arranged through Paul Brooks as well.

Accurate neurobehavioral assessments for newborns and young infants are critically important for research as well as clinical practice. From two of the pre-eminent leaders in the field of neurobehavioral assessment comes the NICU Network Neurobehavioral Scale (NNNS), a comprehensive, standardized neurobehavioral exam for the healthy and at-risk premature neonate and the at-risk term neonate. As T. Berry Brazelton discussed in the foreword to the NNNS manual, there is a rich history of infant assessments including the Neonatal Behavioral Assessment Scale (NBAS), an assessment the pioneering Brazelton developed. The NNNS is based on the NBAS, as well as other neurobehavioral assessments. However, it is sensitive enough to detect neurobehavioral effects in infants at risk because of prenatal substance exposure as well as a variety of other biological (premature delivery, intrauterine growth restriction), medical (birth injury) and social (poor nutrition, poverty) factors.

The NNNS exam provides an assessment of neurologic, behavioral, and stress/abstinence neurobehavioral function of neonates and infants from 30 to 48 weeks' gestation. In contrast to unstructured assessments such as the NBAS, administration of the NNNS is semi-structured which is less dependent on the examiner-infant interaction. This format decreases training demands and introduces less variability between examiners. Two chapters present normative neurobehavioral performance data in prenatally drug-exposed infants as well as healthy infants. These standardized data tables allow for determination of how an infant compares with an at-risk as well as a normative sample. The semi-structured format of the exam as well as its sensitivity to the effects of at-risk infants exposed to prenatal cocaine, opiates and tobacco make the NNNS an ideal neurobehavioral assessment tool for research of at-risk neonates, especially investigations involving multiple study sites.

The spiral bound NNNS Manual is logically organized and well written. Following an introductory chapter and chapters detailing the use, administration and scoring of the exam, a chapter is devoted to the clinical applications of the NNNS. Through case examples, the authors provide methods of summarizing results and creating clinical recommendations for infants in the NICU as well as the outpatient setting. Feedback from the reimbursable, cost effective NNNS may lead to modifications hastening the safe discharge of the infant. Response to medical treatment and suggested interventions can be documented with serial NNNS exams because repeated exams do not affect the reliability and validity of the scoring. Feedback to the parents may lead to appropriate levels and types of stimulation in the home environment as well as increase parents' feelings of competence.

Despite the detailed, 145 item assessment, administration is complete within 20-30 minutes minimizing newborn stress and fatigue. Items are introduced in sequenced "packages" that reduce unnecessary handling and the NNNS allows for flexibility in order to observe the infant's full behavioral capacity. Training is tailored to the level of examiner skills and can be modified for primarily clinical or primarily research purposes. Training is available in North America, Europe, South America, Southeast Asia and New Zealand.

In summary, the NNNS examination is an invaluable tool for clinicians and researchers working with healthy and at-risk preterm infants as well as at-risk term infants. In addition to the obvious research applications, the examination provides valuable information to the clinician as well as to the caregivers of the children. In his discussion of advances in newborn assessment tools, Dr. Brazelton states: "I am proud of the work that Lester and Tronick are doing to continue this effort in identifying threatened infants and their potential for recovery." Having used this tool in a clinical investigation of children exposed to methamphetamine exposure in utero, the reviewer joins Dr. Brazelton in his enthusiasm for this remarkable contribution to Pediatrics and to the field of substance abuse in particular.


David Geffen School of Medicine at UCLA

Los Angeles Biomedical Research Institute at

Harbor UCLA Medical Center

Torrance, California

© 2005 Lippincott Williams & Wilkins, Inc.