P1.209: Limitations of the Ages and Stages Questionnaire for Early Neurodevelopmental Screening in Survivors of Hypoxic Ischemic Encephalopathy

Background: Hypoxic Ischemic Encephalopathy (HIE) is a leading cause of neonatal neurodevelopmental disabilities, but children with HIE have a wide spectrum of outcomes ranging from typical development or mild neurodevelopmental delay (NDD) to severe neurodevelopmental impairment (NDI). Early identification of those most at risk for NDD/NDI can facilitate a targeted approach to allocation of diagnostic and therapeutic resources. The objective of this study was to determine the ability of the Ages and Stages Questionnaire, Third Edition (ASQ-3) to detect NDD/NDI in children with moderate to severe HIE at birth, as diagnosed by the Bayley Scales of Infant Development, Third Edition (Bayley-III).

Methods: This single-center cohort study collected data from infants diagnosed with moderate or severe HIE who were treated with therapeutic hypothermia (TH) and had neurodevelopmental follow-up from 2009-2020. Infant and maternal characteristics were obtained in addition to all ASQ-3 and Bayley-III scores. ASQ-3 screenings were deemed positive if the raw score correlated with the age-specific “monitoring” (gray) zone or was below the cutoff value (black zone). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR), negative LR, and accuracy of the ASQ-3 to detect NDD/NDI as diagnosed by Bayley-III were calculated for the complete cohort. In subgroup analysis, we assessed the test characteristics of ASQ-3 administered at specific ages to detect NDD/NDI. Pearson correlation coefficients (r) were calculated to determine the linear relationship between ASQ-3 and Bayley-III scores.

Results: A total of 81 patients with at least one ASQ-3 screening (range 2-60 months) and at least one Bayley-III test (range 9-47 months) were included. ASQ-3 screening occurred a median of 2 times (IQR 1, 3) at a median age of 18 months (IQR 3, 25 months). Complete cohort analysis revealed low sensitivity but higher specificity for cognitive and language components; however, the motor component demonstrated high sensitivity and high specificity (Table 1A). Subgroup analysis by age at administration of the ASQ-3 revealed modest improvements in sensitivity with increasing age and consistently high specificity for all domains, particularly the motor domain (Table 1B). Additionally, there were modest improvements in correlation (r) between ASQ-3 and Bayley-III scores with increasing age at ASQ-3 administration for all domains, though correlations were weak overall (Figure 1).

Conclusion: The ASQ-3 may have limited use for early detection of NDD/NDI in cognitive and communication domains for children with a history of HIE, even when considering results in the “monitoring” (gray) zone as a positive screening result. However, the ASQ-3 shows acceptable performance in screening for motor deficits, even at younger ages. Additional research is needed to determine more appropriate cutoff values for a positive screening result of the ASQ-3 in survivors of HIE, who are at increased risk for NDD/NDI.