Table 1

Classification of neonatal encephalopathy (NICHD neurological examination)

Categories (total 6)Signs of NE in each category (circle the most appropriate level)
 NormalMild NEModerate NESevere NE
1. Level of consciousness
Alert, responsive to external stimuli (state dependent, eg, postfeeds)Hyperalert, has a stare, jitteriness, high-pitched cry, exaggerated responds to minimal stimuli, inconsolableLethargicStupor/coma
2. Spontaneous activity
Changes position when awakeNormal or decreasedDecreased activityNo activity
3. Posture
Predominantly flexed when quietMild flexion of distal joints (fingers, wrist usually)Moderate flexion of distal joint, complete extensionDecerebrate
4. Tone
Strong flexor tone in all extremities+strong flexor hip toneNormal or slightly increased peripheral toneHypotonia (focal or general) or hypertoniaFlaccid
5. Primitive reflexes (circle only the highest level in each sign; the maximum score is only one in any one category)
  SuckStrong, easily illicitWeak, poorWeak but has a biteAbsent
  MoroCompletePartial response, low threshold to illicitIncompleteAbsent
6. Autonomic system (circle only the highest level in each sign; the maximum score is only one in any one category)
 PupilsIn dark: 2.5–4.5 mm
In light: 1.5–2.5 mm
MydriasisConstrictedDeviation/dilated/non-reactive to light
 Heart rate100–160 bpmTachycardia (HR >160)Bradycardia (HR <100)Variable HR
 RespirationRegular respirationsHyperventilation (RR >60/min)Periodic breathingApnoea or requires ventilator
Total score
  • Infant who has seizure will be moderate or severe NE depending on the neurological exam. Seizure with normal or mild NE or moderate NE on neurological exam will be ‘moderate NE’. Seizure with severe NE will be ‘severe NE’. The level of encephalopathy will be assigned based on which level of signs (moderate or severe) predominates among the six categories. If moderate and severe signs are equally distributed, the designation is then based on the highest level in category no 1: the level of consciousness.

  • HR, heart rate; NE, neonatal encephalopathy; NICHD, National Institute of Child Health and Human Development; RR, regular respiration.