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HINE: Hammersmith Infant Neurological Examination

In brief

  • The Hammersmith Infant Neurological Examination (HINE) is a structured, scored neurological exam validated for infants from 3 to 18 months of age, and used up to about 2 years in many studies. It is used to identify babies at higher risk of cerebral palsy.
  • It scores 26 items across five sections (cranial nerve function, posture, movements, tone, and reflexes and reactions), each scored 0 to 3, for a maximum total of 78.
  • In the 2017 clinical guideline in JAMA Pediatrics, the HINE showed around 90 percent sensitivity for later cerebral palsy, and the guideline recommends combining it with MRI.
  • It does not diagnose cerebral palsy on its own. It flags babies at higher risk so they can be referred for intervention during the period when the brain is most adaptable.
  • It appears on our premature babies page, which recommends asking whether a HINE has already been done.

If your baby was born premature or is being followed for developmental risk, you may hear two assessments mentioned together: the General Movements Assessment and the Hammersmith Infant Neurological Examination. The first has its own explainer on this site. This one explains the HINE: what it is, what it scores, what it does and does not tell you, and how to ask for one by name.

What is the Hammersmith Infant Neurological Examination?

The Hammersmith Infant Neurological Examination (HINE) is a standardized neurological examination for infants and young children. It is validated from 3 to 18 months of age for global scoring and prediction of gross motor outcomes, and it has also been used up to about 2 years in many studies, although some reflex and lifting items become less applicable at that age. It was developed at Hammersmith Hospital in London as part of the Hammersmith Neurological Examinations, a family of tools that also includes an assessment for newborns. The older-infant version was described with its scoring system in a 1999 paper in the Journal of Pediatrics by Haataja and colleagues.

Unlike an assessment that asks a baby to perform a task, the HINE records what the examiner can observe and elicit: how the baby tracks with the eyes, how the body is positioned at rest, the quality and quantity of spontaneous movement, tone, and the reflexes and reactions present. It is quick, needs little equipment, and is used by clinicians trained in its administration and scoring.

How the HINE is scored

The scored portion of the HINE is made up of 26 items. Each item is scored on a scale of 0 to 3, with 3 representing the most optimal response, giving a maximum total (optimality) score of 78. The 26 items are grouped into five sections:

The five sections

Cranial nerve function (including visual tracking and facial movements), posture, movements (quantity and quality of spontaneous movement), tone, and reflexes and reactions. The exam also records the infant's behavioral state, noted but not counted in the 78-point total.

Reading the total

A higher score reflects a more typical examination; a lower score reflects more findings of concern. The score is read in the context of the child's age and tracked over repeated visits. A single score is not a diagnosis.

The official guidance gives reference points. In term-born infants, a global score above 72 at 12 months and above 73 at 18 months is considered optimal. Thresholds are lower in younger infants, at around 65, with a typical range of 62 to 69, at 3 months. These are guides read alongside the clinical picture, not pass or fail marks.

The same sources also give thresholds for concern. The 2017 guideline and the official guidance both treat a score below 73 after about 5 months of age as placing a child at risk of cerebral palsy, and a score below 40 as almost always indicating cerebral palsy.

How accurate is it?

The 2017 clinical practice guideline by Novak and colleagues, published in JAMA Pediatrics, reviewed the predictive value of early infant assessments for cerebral palsy and reported that the HINE showed around 90 percent sensitivity for later cerebral palsy. In the same review, the General Movements Assessment during the fidgety period showed around 98 percent sensitivity and term-age MRI around 86 to 89 percent.

The guideline recommends combining a standardized motor assessment with neuroimaging and the child's history. It reports that, before 5 months' corrected age, the General Movements Assessment plus MRI is more than 95 percent accurate, and that after 5 months, the HINE plus MRI is more than 90 percent accurate.

One practical advantage of the HINE

The General Movements Assessment is only scored during a narrow window, from about 6 to 9 weeks until about 20 weeks post-term, after which fidgety movements disappear naturally. The HINE covers a much wider age range: it is validated from 3 to 18 months of age, and it has been used up to about 2 years in many studies, although some reflex and lifting items become less applicable at that age. If your baby has already passed the fidgety window, the HINE is still available to you. That makes it a realistic option for older infants who were not assessed early.

What the HINE does not tell you

The HINE is a screening and prediction tool, not a diagnostic test. A score of concern tells you a child is at higher risk and should be referred for a full developmental assessment and early intervention. It does not establish the type or severity of cerebral palsy that may develop, and it does not reliably predict cognitive or behavioral outcomes on its own. Its scores were validated for predicting cerebral palsy, sitting, and walking in preterm and term infants at risk of cerebral palsy. The official guidance advises caution in using them for prediction in infants with genetic syndromes, metabolic or neuromuscular disorders, or congenital heart disease, where they have not been validated in large groups.

The 90 percent figure comes from research settings with trained examiners following a standardized procedure. It is not perfect: it misses roughly 1 in 10 children who later develop cerebral palsy, and results in routine practice can vary. The score is always interpreted alongside the clinical picture, not in isolation, and a normal result is not a guarantee that no differences will emerge later.

The 90 percent figure comes from the 2017 guideline review, not from the original 1999 paper that first set out the scoring system. The two sources do different work, and the distinction matters.

What this means for your child

If your baby was born premature, spent time in a NICU, or has a known risk factor for developmental differences, the HINE is a specific assessment you can ask about. Unlike the General Movements Assessment, it does not depend on a narrow age window, so it can be done later in the first two years.

It is recommended in the 2017 international guideline for early detection of cerebral palsy, and asking for it by name is entirely reasonable. A normal result gives you a documented baseline you will want regardless of what else you pursue. A result of concern is a head start, not a verdict, pointing to early intervention while the brain is most adaptable.

What to ask

Ask your pediatrician, NICU follow-up clinic, or early intervention provider directly: "Has my baby had a Hammersmith Infant Neurological Examination, and what was the score?" If not, ask whether one would be useful and who can perform it. If so, ask what the score was and what follow-up it recommends.

In Idaho, the Idaho Infant Toddler Program serves children from birth to 3 years with a developmental delay or a condition, such as prematurity, that may lead to one, at no cost to families, and families can apply on their own.

The official guidance is published by Mac Keith Press and lists Professor Frances Cowan and Professor Eugenio Mercuri as contacts for questions about the examination.

Where it appears on this site

This assessment is mentioned on our premature babies and NICU graduates page, which lists it alongside the General Movements Assessment and term-age MRI as part of the early detection pathway for cerebral palsy, and recommends asking whether a HINE has already been done. For the companion tool, see our explainer on Prechtl's General Movements Assessment.

Sources

  • Haataja L, Mercuri E, Regev R, Cowan F, Rutherford M, Dubowitz V, Dubowitz L. Optimality score for the neurologic examination of the infant at 12 and 18 months of age. Journal of Pediatrics, 1999;135(2 Pt 1):153-61. PubMed
  • Novak I, Morgan C, Adde L, et al. Early, accurate diagnosis and early intervention in cerebral palsy: advances in diagnosis and treatment. JAMA Pediatrics, 2017;171(9):897-907. PubMed
  • Mac Keith Press. Hammersmith Infant Neurological Examination (HINE) guidance notes. Official guidance
  • Idaho Department of Health and Welfare. About the Infant Toddler Program. idaho.gov

Nothing here is medical advice, and no single assessment should change your child's care on its own. Discuss anything you read here with your child's pediatrician or therapist.

About this site

Idaho DMI is an independent, non-commercial resource. It is not run by a clinic, it has no financial relationship with any provider listed here, and it accepts no advertising or referral fees. There is nothing to buy and no one selling you anything. The only form on this site asks families and therapists to tell us about DMI-certified providers we haven't found yet. It exists because Dynamic Movement Intervention is not well known in Idaho, and families whose children haven't progressed with conventional therapy deserve to know it's an option worth asking about.

Information here is drawn from DMI's official training organization and published clinical literature, and is linked to its sources so you can check it yourself. Nothing on this site is medical advice. Always talk with your child's pediatrician or therapist before starting a new therapy.

Last updated: September 2026

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