The Hammersmith Infant Neurological Examination (HINE): Early Detection of Cerebral Palsy and Developmental Delays

Introduction

Every parent anxiously watches their infant's development, celebrating each milestone—the first smile, the first time they hold their head up, their first steps. But for infants at risk of neurological impairments, these milestones may be delayed or absent, signaling potential cerebral palsy (CP) or other developmental disorders. Early identification of these conditions is critical, as intervention during the first year or two of life—when the brain's neuroplasticity is at its peak—can dramatically improve outcomes.

Enter the Hammersmith Infant Neurological Examination (HINE), a standardized assessment tool that has revolutionized early detection of cerebral palsy and neurological impairments in infants. Developed by Dr. Lilly Dubowitz and Professor Victor Dubowitz, and later refined by Dr. Eugenio Mercuri, the HINE provides clinicians with a practical, quick, and accurate method to assess neurological function in infants between 3 and 24 months of age.

What Is the Hammersmith Infant Neurological Examination?

The Hammersmith Infant Neurological Examination (HINE) is a standardized, scorable neurological assessment designed to evaluate various aspects of infant neurological function. It stands out among developmental assessments for its remarkable combination of simplicity, speed, and predictive accuracy.

Key Characteristics

Age Range: Designed for premature babies (adjusted for corrected age) and infants aged 3 to 24 months

Duration: 10-15 minutes to complete

Equipment: Minimal—no expensive or specialized equipment required

Setting: Can be performed in any clinical setting, on a bed, mat, or even partially on a caregiver's lap

Training: Requires learning and practice but is accessible to various healthcare professionals with proper training

Applicability: Suitable for both high-risk and low-risk infant populations

Historical Development

The HINE has a distinguished lineage in infant neurology:

1981: Dr. Lilly Dubowitz and Professor Victor Dubowitz initially developed the examination structure, establishing the foundation for standardized infant neurological assessment.

1998: Dr. Eugenio Mercuri updated and improved the evaluation methodology, refining the scoring system and enhancing its clinical utility.

Ongoing Evolution: The HINE continues to be refined based on extensive research, with updated guidance notes published regularly (most recent updates in 2023).

The examination has been extensively validated through numerous studies across different populations, establishing it as one of the world's standards for infant neurological assessment and a key tool recommended in international guidelines for early cerebral palsy diagnosis.

Structure of the HINE

The HINE consists of 26 neurological items divided into five scored sections, plus two additional non-scored sections that provide crucial clinical information.

Scored Sections

1. Cranial Nerve Function (Maximum: 15 points)

This section assesses the function of cranial nerves, focusing on:

Visual Response:

• Visual fixation and tracking
• Response to visual stimuli
• Eye movements and coordination

Auditory Response:

• Reaction to sounds
• Auditory attention
• Localization of sound

Sucking and Swallowing:

• Coordination of oral-motor function
• Feeding abilities
• Protective reflexes

Other Cranial Nerve Functions:

• Facial symmetry and movement
• Tongue movement
• Gag reflex

Each item is scored on a 0-3 scale, with 3 typically representing optimal function. The cranial nerve section provides insights into brainstem function and sensory processing abilities.

2. Posture (Maximum: 18 points)

Posture assessment examines the infant's ability to maintain various body positions and provides information about muscle tone and postural control:

Head Posture:

• Head control in different positions
• Alignment and positioning

Trunk Posture:

• Alignment and stability of the trunk
• Ability to maintain upright sitting position

Leg Posture:

• Position and alignment of legs in lying, sitting, and standing
• Scored in multiple positions with average taken

Arm Posture:

• Positioning of upper extremities
• Symmetry and alignment

Foot Posture:

• Alignment and positioning of feet
• Plantar flexion or dorsiflexion patterns

Hand Posture:

• Hand position and finger patterns
• Presence of fisting or other atypical patterns

Posture items provide critical information about underlying muscle tone and the development of postural control, which are fundamental for motor development.

3. Movements (Maximum: 6 points)

This section evaluates the quality and quantity of spontaneous movements:

Movement Quantity:

• Amount of spontaneous movement
• Activity level
• Repertoire of movements

Movement Quality:

• Smoothness and fluidity
• Variability and complexity
• Presence of atypical movement patterns
• Symmetry of movements

The movements section is particularly powerful for prediction, consistently showing the highest correlation with later cognitive outcomes and the best sensitivity and specificity for detecting cerebral palsy. Quality of movement—including smoothness, variability, and complexity—provides crucial information about neurological integrity.

4. Tone (Maximum: 24 points)

Tone assessment examines muscle resistance to passive movement in various muscle groups:

Scarf Sign (Upper Limb Tone):

• Resistance when bringing arm across chest
• Shoulder girdle flexibility

Hip Adductor Angles:

• Resistance to hip abduction
• Tightness of inner thigh muscles

Popliteal Angle (Hamstring Tone):

• Degree of knee extension when hip flexed
• Posterior lower limb flexibility

Dorsiflexion of Foot:

• Ankle flexibility
• Calf muscle tone

Arm Traction:

• Upper limb tone during pull
• Shoulder and elbow resistance

Leg Traction:

• Lower limb tone during pull
• Hip and knee resistance

Tone assessment helps identify hypertonia (increased tone seen in spastic CP), hypotonia (decreased tone), or dystonia (fluctuating tone). Different tone patterns suggest different types of neurological impairment.

5. Reflexes and Reactions (Maximum: 15 points)

This section evaluates primitive reflexes, protective reactions, and age-dependent responses:

Tendon Reflexes:

• Knee jerk
• Ankle jerk
• Biceps and triceps reflexes
• Symmetry and intensity

Protective Reactions:

• Lateral Tilting: Response when tilted to side while sitting
• Forward Parachute: Protective arm extension when moved forward
• Backward Protective: Response to backward displacement

Pull to Sit:

• Head control during pull from lying to sitting
• Trunk and neck muscle activation

These reflexes and reactions provide information about the maturation of the nervous system and the integration of primitive reflexes. Persistence of primitive reflexes beyond expected ages or absence of protective reactions can indicate neurological impairment.

Non-Scored Sections

Section 6: Motor Developmental Milestones

This section documents the age at which various motor milestones are achieved:

• Head Control: Ability to hold head steady in various positions
• Sitting: Independent sitting without support
• Voluntary Grasp: Reaching for and grasping objects
• Ability to Kick: Leg movement and strength
• Rolling: From supine to prone and vice versa
• Crawling: Commando crawling, four-point crawling
• Standing: Pulling to stand, standing with support
• Walking: Cruising, independent walking (5 steps)

While not included in the global score, this section provides valuable context about the child's functional motor development and progression through typical milestones.

Section 7: Behavior

This section observes and records behavioral characteristics:

Conscious State (1-6 scale):

• Level of alertness
• Sleep-wake patterns
• Attention and arousal

Emotional State (1-5 scale):

• Mood and affect
• Irritability or contentment
• Emotional regulation

Social Orientation (1-4 scale):

• Engagement with examiner and caregivers
• Social responsiveness
• Interactive behaviors

The behavior section (maximum 15 points) provides important clinical information about the infant's overall state and neurological function, though it doesn't contribute to the predictive global score.

Scoring System

Item-Level Scoring

Each of the 26 neurological items is scored on a 0-3 point scale:

• 3 points: Optimal response (column 1)
• 2 points: Slightly suboptimal but within acceptable range (column 2)
• 1 point: Clearly abnormal but not severely impaired (column 3)
• 0 points: Severely abnormal or absent response (column 4)

Important Note: A score of 3 is generally optimal, but typical infants may not score 3 on every item. For some tone and reflex items, scores less than 3 are normal in younger infants under 7 months of age as these responses change with maturation.

Global Score

The global HINE score is the sum of all 26 item scores:

• Maximum Score: 78 points
• Typical Range: Varies by age
• Scoring Approach: Items are summed across all five sections

Asymmetry Score

In addition to the global score, examiners record asymmetries between the right and left sides for applicable items. The asymmetry score is particularly valuable for detecting hemiplegic cerebral palsy:

• Range: 0-26 points (one point for each asymmetrical item)
• Clinical Significance: Asymmetry score >5 is particularly useful for identifying unilateral cerebral palsy

Subsection Scores

Scores can also be calculated for each of the five subsections, which is valuable for:

• Identifying specific areas of strength and weakness
• Understanding patterns of impairment
• Predicting types of cerebral palsy
• Monitoring development over time

Interpretation Guidelines

Age-Dependent Cut-Off Scores

HINE scores must be interpreted relative to the infant's corrected age (for premature infants) or chronological age. Research has established age-specific cut-off scores:

For Typically Developing Infants (10th Percentile):

3 months: 52-53 points6 months: 56-62 points9 months: 67 points12 months: 70 points

For Detecting Cerebral Palsy:

At 3 months:

• Score ≥67: Typical development likely
• Score 50-66: May indicate risk
• Score <50: High risk of bilateral CP

At 6-12 months:

• Score ≥73: Optimal (typical development likely)
• Score 63-72: May indicate risk; monitor closely
• Score 50-62: Suboptimal; likely unilateral CP
• Score <50: High risk of bilateral CP

Predicting Cerebral Palsy Type and Severity

The HINE not only predicts the likelihood of cerebral palsy but also provides information about type and severity:

Hemiplegic CP (Unilateral):

• Total HINE score: 50-73
• Asymmetry score: >5 (highly predictive)
• Walking prognosis: 95-99% will walk independently

Diplegic/Quadriplegic CP (Bilateral):

• Total HINE score: <50
• More symmetrical presentation
• Variable walking prognosis depending on severity

GMFCS Prediction (at 3-6 months):

• Score 40-60: Likely GMFCS I-II (mild to moderate impairment)
• Score <40: Likely GMFCS III-V (moderate to severe impairment)

Brief-HINE Cut-Off Scores

For the Brief-HINE screening version (11 items), different cut-offs apply:

3 months: <22 points (sensitivity 0.88, specificity 0.92)6 months: <25 points (sensitivity 0.93, specificity 0.87)9 months: <27 points (sensitivity 0.95, specificity 0.81)12 months: <27 points (sensitivity 1.0, specificity 0.86)

Predicting Cognitive Outcomes

Research demonstrates that HINE scores also predict cognitive performance at 2 years:

• Strong correlation between HINE scores and Bayley Mental Development Index
• Movements subsection shows highest correlation with cognitive outcomes
• Predictive for identifying both cerebral palsy and cognitive delays
• Particularly useful at 9-12 months for cognitive prediction

Clinical Applications

1. Early Detection of Cerebral Palsy

The HINE is internationally recognized as one of the most effective tools for early cerebral palsy detection:

Sensitivity and Specificity:

• High accuracy for detecting CP across all ages
• Particularly strong when combined with neuroimaging and General Movements Assessment
• Can detect CP as early as 3 months corrected age

Advantages:

• Earlier detection than waiting for missed milestones
• Identification before secondary complications develop
• Enables early intervention during peak neuroplasticity

2. Risk Stratification

The HINE helps identify which infants require close monitoring and intervention:

High-Risk Populations:

• Premature infants (especially <32 weeks gestation)
• Infants with hypoxic-ischemic encephalopathy
• Those with abnormal neuroimaging
• Infants with neonatal complications

Clinical Decision-Making:

• Determines need for referral to specialists
• Guides frequency of follow-up assessments
• Informs discussions with families about prognosis

3. Monitoring Development Over Time

Serial HINE assessments track developmental trajectories:

Typical Assessment Schedule:

• Initial assessment at 3 months
• Repeat at 6, 9, and 12 months
• Additional assessments as clinically indicated

Benefits of Serial Assessment:

• Documents progression or regression
• Identifies infants with emerging concerns
• Provides evidence of intervention effectiveness
• Adjusts risk stratification as infant matures

4. Predicting Functional Outcomes

HINE scores predict various functional outcomes beyond CP diagnosis:

Motor Outcomes:

• Independent sitting achievement
• Independent walking ability
• GMFCS level in children with CP

Cognitive Outcomes:

• Risk of cognitive delay at 2 years
• Mental Development Index scores
• Need for educational support

5. Guiding Family Counseling

HINE results inform sensitive, accurate discussions with families:

Information Provided:

• Likelihood of cerebral palsy diagnosis
• Probable severity of motor impairment
• Expected functional abilities
• Cognitive development prognosis

Communication Principles:

• Provide clear, accurate information
• Maintain hope while being honest
• Explain variability in outcomes
• Emphasize benefits of early intervention

6. Research Applications

The HINE serves as a valuable research tool:

• Endpoint measure in neonatal intervention trials
• Standardized assessment across research sites
• Validation of other assessment tools
• Population-based studies of neurological development

The Brief-HINE: A Screening Version

Recognizing that comprehensive neurological examination isn't always feasible for all infants, researchers developed the Brief-HINE as a screening tool.

Structure

The Brief-HINE includes 11 items selected for their predictive power:

1. Visual response
2. Trunk posture
3. Movement quantity
4. Movement quality
5. Scarf sign
6. Hip adductor angles
7. Popliteal angle
8. Pull to sit
9. Lateral tilting
10. Forward parachute reaction
11. Tendon reflexes

Scoring

• Maximum Score: 33 points (11 items × 3 points each)
• Time: Approximately 5-7 minutes
• Age-Specific Cut-Offs: See interpretation section above

When to Use Brief-HINE

Appropriate for:

• Routine screening in well-child visits
• Initial assessment in primary care settings
• Large-scale screening programs
• Settings with time constraints
• When full HINE expertise unavailable

When Full HINE is Needed:

• Any infant with Brief-HINE score below cut-off
• Presence of more than one warning sign
• High-risk infants requiring detailed assessment
• Research protocols requiring comprehensive data

Administration Guidelines

Preparation

Environmental Setup:

• Quiet, comfortable room with minimal distractions
• Adequate lighting for observation
• Appropriate temperature (infant should be comfortable)
• Bed, mat, or examination table for positioning

Materials Needed:

• HINE proforma for recording observations
• Small attractive objects (for visual attention)
• Noisemaker (for auditory response)
• Minimal additional equipment

Examiner Preparation:

• Review infant's history before exam
• Know corrected age for premature infants
• Understand age-appropriate expectations
• Have proforma ready for efficient recording

Optimal Timing

Infant State:

• Awake and alert (state 4-5 on behavioral scale)
• Fed but not immediately after feeding
• Not overtired or overstimulated
• Relatively content and calm

Scheduling:

• Allow flexibility in timing within visit
• Can pause if infant becomes upset
• May complete over two short sessions if needed

Examination Technique

General Principles:

• Items can be assessed in any order
• Start with least invasive observations
• Save potentially upsetting items for last
• Build rapport before formal testing

Handling:

• Gentle, confident handling
• Smooth, controlled movements
• Respect infant's comfort
• Allow recovery time between items

Observation:

• Watch carefully for spontaneous behaviors
• Note quality as well as presence of responses
• Record asymmetries as they appear
• Document items that cannot be scored

Recording and Scoring

During Examination:

• Mark responses by circling appropriate pictures on proforma
• Note asymmetries immediately
• Record any relevant observations
• Don't calculate scores during exam (focus on observation)

After Examination:

• Calculate item scores (based on column: 1=3 points, 2=2 points, etc.)
• Sum subsection scores
• Calculate global score
• Calculate asymmetry score
• Consider patterns across items

Training and Reliability

Learning the HINE

Training Resources:

• Written manuals and guidance documents
• Online training course through Mac Keith Press
• Teaching videos demonstrating each item
• Practice opportunities with feedback

Skills Development:

• Observation of experienced examiners
• Supervised practice examinations
• Scoring reliability checks
• Ongoing quality assurance

Establishing Reliability

Research shows the HINE achieves high reliability when examiners are properly trained:

Interobserver Reliability:

• Correlation coefficients: 0.93-0.97
• Differences typically one column or less
• Maintained with annual guided observation
• Standard: 97% concordance (≤2.5 points difference)

Test-Retest Reliability:

• Consistent scores across short time intervals
• Reflects actual developmental changes over longer periods

Ongoing Quality Assurance

Best Practices:

• Annual reliability checks with standard scorer
• Peer review of scoring with colleagues
• Participation in training updates
• Consultation on difficult-to-score items

Integration with Other Assessments

The HINE is most powerful when combined with complementary assessment tools:

General Movements Assessment (GMA)

Complementary Strengths:

• GMA: Excellent for very young infants (0-5 months)
• HINE: Most predictive from 3 months onward
• Combined: Superior sensitivity and specificity for CP prediction

Recommended Approach:

• GMA (fidgety movements) at 12-16 weeks
• HINE at 3 months and serially thereafter
• Combined assessment enhances early detection

Neuroimaging

MRI Findings:

• Structural brain abnormalities
• Location and extent of lesions
• Correlation with HINE patterns

Integration:

• Neuroimaging + HINE provides comprehensive picture
• HINE adds functional component to structural findings
• Predictive accuracy enhanced when combined

Developmental Assessments

Bayley Scales:

• HINE predicts Bayley cognitive and motor scores
• Bayley provides detailed developmental profile
• Complementary information for intervention planning

Motor Assessments:

• Test of Infant Motor Performance (TIMP)
• Alberta Infant Motor Scale (AIMS)
• Peabody Developmental Motor Scales (PDMS)

Medical History and Risk Factors

Considerations:

• Gestational age and birth weight
• Perinatal complications
• Genetic conditions
• Family history

Populations Assessed

The HINE has been validated in diverse populations:

Premature Infants

Applicability:

• Appropriate for infants born as early as 23-24 weeks gestation
• Always use corrected age for scoring
• Validated in extremely preterm populations (<28 weeks)
• Particularly valuable for very low birth weight infants

Findings:

• Scores increase predictably with age
• Can identify CP risk before term-equivalent age
• Predicts long-term outcomes at 11 years

Term Infants at Risk

Populations:

• Hypoxic-ischemic encephalopathy
• Neonatal encephalopathy
• Congenital infections
• Neonatal stroke
• Hyperbilirubinemia

Utility:

• Detects risk of CP and cognitive delays
• Guides need for therapeutic hypothermia follow-up
• Monitors recovery from acute injuries

Low-Risk Term Infants

Applications:

• Establishes normative data
• Provides reference values for clinical interpretation
• Screens for unexpected developmental concerns
• Supports research on typical development

Specific Conditions

Genetic Syndromes:

• Down syndrome
• Other chromosomal abnormalities
• Single-gene disorders affecting motor function

Neuromuscular Conditions:

• Spinal muscular atrophy
• Muscular dystrophies
• Congenital myopathies

Strengths of the HINE

1. Excellent Psychometric Properties

Reliability:

• High interobserver agreement (0.93-0.97)
• Consistent results across examiners with training
• Stable scores on repeat testing

Validity:

• Strong predictive validity for cerebral palsy
• Correlates with long-term motor and cognitive outcomes
• Validated across multiple populations and countries

Sensitivity and Specificity:

• High accuracy for detecting CP (sensitivity >0.90, specificity >0.85)
• Identifies both unilateral and bilateral CP
• Distinguishes severity levels

2. Practical for Clinical Use

Efficiency:

• Quick administration (10-15 minutes)
• No expensive equipment required
• Minimal space requirements

Accessibility:

• Can be learned by various healthcare professionals
• Applicable in diverse clinical settings
• Feasible in resource-limited environments

Flexibility:

• Can adapt to infant's state and cooperation
• Some items can be done on caregiver's lap
• Allows for incomplete assessments when necessary

3. Comprehensive Assessment

Breadth:

• Evaluates multiple aspects of neurological function
• Assesses both structural and functional domains
• Includes observation of spontaneous behavior

Depth:

• Detailed scoring system captures nuances
• Asymmetries provide additional information
• Subsection scores reveal patterns of impairment

4. Early Detection Capability

Timing:

• Can be used as early as 3 months corrected age
• Enables intervention during peak neuroplasticity
• Earlier than traditional wait-and-see approach

Accuracy:

• Reliable prediction of CP before 6 months
• Identifies infants needing intensive monitoring
• Reduces diagnostic uncertainty

5. Multiple Predictive Applications

Beyond CP:

• Predicts cognitive outcomes
• Forecasts functional motor abilities
• Identifies risk of various developmental delays

Severity Prediction:

• Estimates GMFCS level
• Predicts walking ability
• Informs prognosis discussions

Limitations and Considerations

1. Training Requirements

Learning Curve:

• Requires dedicated training time
• Practice needed for accurate scoring
• Ongoing reliability checks necessary

Expertise Dependency:

• Quality depends on examiner skill
• Subjective elements in some items
• Potential for scorer variability

2. Age-Dependent Interpretation

Complexity:

• Different cut-offs for different ages
• Requires age-appropriate expectations
• Normative changes over time

Reference Data:

• Limited published norms for some age ranges
• Most research focuses on 3-12 months
• Less data for older infants approaching 24 months

3. Infant State Dependency

Performance Variability:

• Requires optimal infant state
• Fatigue or hunger affects scores
• Illness can temporarily lower performance

Cooperation:

• Older infants may resist handling
• Some items difficult with uncooperative children
• Behavioral issues can confound results

4. Cultural and Contextual Factors

Normative Considerations:

• Most norms based on Western populations
• Cultural variations in motor development
• Caregiver practices may influence performance

Interpretation:

• Must consider context when applying cut-offs
• Adapt expectations for different populations
• Recognize limitations of cross-cultural application

5. Not Diagnostic in Isolation

Clinical Context Needed:

• Should not be sole basis for diagnosis
• Requires integration with history, imaging, other assessments
• Serial assessments more valuable than single scores

False Positives/Negatives:

• Some typical infants score below cut-offs
• Mild CP may not be detected early
• Scores improve with intervention (which is positive but complicates prediction)

Recent Advances and Future Directions

Research Innovations

Expanded Applications:

• Use in clinical trials of neuroprotective interventions
• Validation in understudied populations
• Cross-cultural adaptation and validation

Enhanced Prediction:

• Machine learning algorithms incorporating HINE data
• Combined prediction models with multiple tools
• Refined age-specific and population-specific norms

Technology Integration

Potential Developments:

• Video-based scoring for reliability training
• Telehealth adaptations for remote assessment
• Digital proformas with automatic scoring
• Integration with electronic health records

Clinical Implementation

Scaling Up:

• Integration into high-risk infant follow-up programs
• Training initiatives for community healthcare providers
• Quality improvement projects in NICU follow-up
• Public health screening applications

Practical Tips for Clinicians

For New Users

1. Invest in Proper Training: Use official training resources; don't rely solely on written descriptions
2. Practice with Typical Infants First: Build experience with normal variations before assessing high-risk infants
3. Use the Proforma: Don't try to memorize—let the form guide you
4. Focus on Observation First: Complete examination before worrying about scoring
5. Seek Feedback: Have experienced examiners observe your technique

For Experienced Users

1. Maintain Reliability: Participate in annual reliability checks
2. Stay Updated: Review guidance updates and new research
3. Integrate Findings: Combine HINE with other assessments for comprehensive picture
4. Consider Context: Always interpret scores within clinical context
5. Communicate Carefully: Use results to inform, not alarm, families

For All Users

1. Respect the Infant: Prioritize comfort and rapport
2. Document Thoroughly: Note observations beyond formal scoring
3. Use Serial Assessments: Single scores provide snapshot; trends tell the story
4. Collaborate: Discuss challenging cases with colleagues
5. Remember the Goal: Early identification enables early intervention

Conclusion

The Hammersmith Infant Neurological Examination represents a significant advance in early detection of cerebral palsy and neurological impairments in infants. Its unique combination of simplicity, speed, and accuracy makes it an invaluable tool for clinicians working with at-risk infant populations.

By providing a standardized, scorable method to assess neurological function as early as 3 months of age, the HINE enables:

• Earlier diagnosis of cerebral palsy, often before 6 months of age
• Risk stratification to identify which infants need intensive monitoring and intervention
• Prediction of outcomes including CP type, severity, and functional abilities
• Monitoring of development through serial assessments over time
• Informed family counseling with accurate prognostic information
• Research advancement through standardized outcome measurement

The HINE's strength lies not only in its predictive accuracy but also in its practical feasibility. Unlike assessment tools requiring extensive equipment or hours of administration time, the HINE can be completed in 10-15 minutes in any clinical setting. This accessibility makes it suitable for implementation in diverse healthcare environments, from tertiary NICUs to community-based follow-up clinics.

As our understanding of early brain development and neuroplasticity continues to expand, the importance of early detection grows. The HINE provides a critical bridge between identification of risk factors (such as prematurity or birth complications) and initiation of targeted early intervention. When cerebral palsy and other neurological impairments are identified during infancy—rather than waiting for clearly missed milestones at 18-24 months—children can receive intervention during the period of maximal brain plasticity, optimizing their developmental trajectories.

For healthcare professionals working with infants at risk of neurological impairments, mastering the HINE is an essential skill. Whether you're a neonatologist following NICU graduates, a developmental pediatrician assessing high-risk infants, a physical therapist providing early intervention, or a researcher studying neonatal outcomes, the HINE offers a powerful tool for your clinical and research toolkit.

The examination's continued evolution—including development of the Brief-HINE screening version, establishment of age-specific reference data, and integration with complementary assessments like General Movements Assessment and neuroimaging—ensures that it will remain at the forefront of early detection efforts for years to come.

Ultimately, the true measure of the HINE's value lies in the infants and families it serves. By enabling earlier, more accurate identification of neurological impairments, the HINE opens the door to timely intervention, family support, and optimized outcomes for vulnerable infants navigating the critical early years of life.

Note: The Hammersmith Infant Neurological Examination should be administered only by healthcare professionals who have received appropriate training. This article is for educational purposes and does not constitute professional training or medical advice. Clinicians interested in using the HINE should seek formal training through established resources such as the Mac Keith Press online training course.

Additional Resources

• Mac Keith Press: Official training materials and courses (https://www.mackeith.co.uk/hammersmith-neurological-examinations/)
• HINE Proforma: Official scoring forms available through Mac Keith Press
• Research Literature: Extensive publications validating HINE in PubMed
• Clinical Guidelines: International guidelines for early CP detection recommend HINE as key assessment tool