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Jitter‐index of the fundamentalfrequency of infant cry as apossible diagnostic tool to predictfuture development problemsE. Ludwig Grauel a , Sabine Hock a & HartmutRothg#auanger ba Pediatric Clinic, Department of Neonatology ,Univ.‐Hospital [Charite], Humboldt‐Univ., Berlin, GDRb Institute of Anthropology , Univ.‐Hospital [Charite],Humboldt‐Univ., Berlin, GDR.Published online: 07 Jul 2006.

To cite this article: E. Ludwig Grauel , Sabine Hock & Hartmut Rothg#auanger (1990)Jitter‐index of the fundamental frequency of infant cry as a possible diagnostic tool topredict future development problems, Early Child Development and Care, 65:1, 23-29, DOI:10.1080/0300443900650104

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Early Child Development and Care, 65, p. 23-29 © 1990 Gordon and Breach Science Publishers S.A.Reprints available directly from the publisher Printed in the United KingdomPhotocopying permitted by license only

Jitter-index of the fundamental frequency ofinfant cry as a possible diagnostic tool topredict future development problems

Part 2: Clinical considerations

E. LUDWIG GRAUEL, SABINE HOCK

Pediatric Clinic, Department of Neonatology, Univ.-Hospital(Charite), Humboldt-Univ., Berlin, GDR.

HARTMUT ROTHGÄNGER

Institute of Anthropology, Univ.-Hospital (Charite),Humboldt-Univ., Berlin, GDR.

In 36 newborn babies, 22 of them from a high risk population, cry analyses wereperformed at the age of up to 4 weeks. The jitter-index, a parameter derived fromthe microfluctuation of the fundamental frequency, showed a good correlation tothe developmental outcome of the children at the age of 2 years. A low jitter-index of pain cry (jP) predicts an unfavourable outcome. The results, however, areso far preliminary, since the number of patients is too small and the group tooheterogeneous to draw final conclusions. The authors, however, are hopeful thatcry analysis will become a supplement to the battery of noninvasive methods,which permit a prognosis for newborns at risk concerning possible futuredevelopmental problems.

1. INTRODUCTION

The peculiar cry of severely brain damaged infants has been known to physicians forcenturies. Sonagraphic studies on infants with cerebral diseases and 21-Trisomy(Wolff, 1969; Wasz-Hockert et al., 1968) as well as in infants with the Cri-du-chatsyndrome (Luchsinger et al., 1967, Schroeder et al., 1967; Wasz-Hockert et al., 1968)suggested the use of the infant cry as a diagnostic indicator (Lester & Boukydis, 1985;Murry & Murry, 1980).

To make a developmental prognosis for an individual newborn is even to-day, avery difficult and dubious problem. The Apgar score as well as different biochemicalparameters seem to be poor predictors of individual outcome (Ruth & Raivo, 1988;Menzel et al., 1974; Menzel et al., 1984; Bottcher et al., 1975); EEG and ultrasoundcontribute only in relatively severe cases to the developmental prognosis (Staudt et al.,1982; McMeramin et al., 1984).

Correspondence: Prof. Dr. sc. med. E.L. Grauel, Abt. Neonatologie, Univ.-Kinderklinik, Schumannstrasse20/21, Berlin, GDR-1040

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24 E. L GRAUEL ETAL

It was out intention to use cry analysis in newborns to diagnose disturbances of theCNS, which cannot be detected properly by conventional methods. If it provesvaluable, cry analysis might be a supplementary noninvasive bedside method, easilyapplied with a minimum of disturbance for the infant. Some preliminary results of ourinvestigations will be presented.

2. METHOD AND STUDY DESIGN

Altogether 36 babies were included in the study; the 14 infants already mentioned inPart 1 of this publication and in addition, 22 infants from a high risk population.Their birth weights ranged from 930 to 3,900 g, their gestational age ranged between27 and 40 weeks and the 5-minute Apgar score between 4 and 10.

Since the majority of premature babies were unable to produce reliable cry signalsduring the first week of life, the investigations were carried out at about 4 weeks afterbirth. The condition of stimulation and recording of the cries were the same asdescribed in Part 1.

All babies were followed up by an experienced neuropediatrician and classified inthree groups after two years: normal, moderately impaired and severely impaired.Moderate impairment was defined as developmental delay of up to 3 months, severeimpairment was defined as developmental delay of more than 3 months, and/ordistinct neurological disturbance.

From a previous preliminary study on 5 healthy newborns and 5 newborns withmoderate adaptional disturbances, we had gained the impression that the jitter-indexof pain cry (jP) yielded the best discriminatory parameter for the characterization of"normal" and "disturbed". As normal, we defined indices above 7.0, as intermediate,

j P between 5.5 and 7.0 and as abnormal, j P less than 5.5. The 36 infants underinvestigation were classified accordingly.

In a second step, the cry groups were then classified according to the outcome.

3. RESULTS

Fifteen infants belonged to the group with normal j P , 12 infants belonged to theintermediate group and another 9 babies had an abnormal j P .b It can be seen (Table 1) that in contrast to the distinct discriminatory values of j P

the other two parameters (f0 and t) show no clear differences between the 3 groups.This holds true not only for pain cry but also for hunger and frustration cry.

It seems noteworthy that, if j is reduced in pain cries it is also reduced in hungerand frustration cries.

After the follow-up at age two years the 36 infants could be classified as 20 withoutdevelopmental problems, 9 with moderate developmental delay and/or minorneurological deviations and 6 severely handicapped ones.

The correlation of the grouping according to j P during the newborn period and thatof the clinical outcome after 2 years revealed statistical significance approaching the1%-level (Table 2).

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EARLY CNS DIAGNOSIS BY CRY ANALYSIS 25

Table 1 Jitter-index (j), fundamental frequency (f0) and duration of cry (t) in different groups ofnewborn according to jitter-index in pain cry

Type of cry

1. Hungerjfo(Hz)t(ms)

2. Painjfo(Hz)t(ms)

3. Frustrationjfo(Hz)t(ms)

X

5,224441170

8,675053470

9,965431550

normalJP>7,0n = 15

SD

0,6646380

1,1464

1050

2,66100400

intermediateJi

X

4,794561470

6,205063660

7,095281650

P 5,5-7,0n = 12

SD

0,6646390

0,3245

1000

0,7053200

abnormaljP<5,5n = 9

X

4,604091550

4,724653510

5,884621550

SD

0,7557200

0,6055

1700

1,7480350

Table 2 X2-correlation of jitter-index groups (jp) and outcome at 2 years of age (n = 36)

follow-up (2 years of life)jitter-index 1 2 3

(normal) (moderate (severe controlimpairment) impairment) n X2

1 (normal)z 12 3 0 15

X2 1,61 0,33 2,5 4,44

2 (intermediate)z 4 6 2 12

X2 1,07 2,13 0 3,20

3 (abnormal)z 4 1 4 9

X2 0,20 0,9 4,17 5,27

2,88 3,36 6,67 12,91

X2 table, f =4 <x 5%= 9,49oc 1% = 13,28

4. DISCUSSION

Minimal changes in the fundamental frequency of infant cries and other vocalinformations, "jitters", seem to belong to a kind of signal comparable to themicrofluctuation, which is found in different other biological signals, such as thecardiotachogram. The loss of such microfluctuations usually indicates the loss ofstability in a system. Therefore, we suppose that a reduction of the vocal jitter in

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26 E. L. GRAUEL ETAL.

infant cry may indicate certain abnormalities of the central nervous activities, whichregulate and control the function of the cry producing organs.

In healthy infants there is some parallelity in the course of j , fo and t of cries after acry stimulation (see Part 1). There seems to be no parallel modification of fo and t if jdecreases in cases of infants at risk of cerebral dysfunction (Table 1). This indicatesthat the jitter is either controlled in a different way than fo and t, or at least is moresensitive to disturbances of the system.b The good correlation between abnormality in j P and outcome at age 2 years seemsto prove our hypothesis concerning the possibility of drawing prognostic conclusionsfrom the jitter-index of pain cry (Table 2). There are, however, some reservations tobe made:

1. The number of patients is small, the prevalence of infants with later developmen-tal problems is high. This might lead to apparently more significant results.2. The result is greatly influenced by the fact that all infants with severeimpairments after follow-up could be correctly diagnosed by intermediate orabnormal j (Table 3). Such infants, however, are usually easily recognized early ininfancy by simple clinical observation. Only seven often with moderate impairments,(a group which we believe is of special interest, because the diagnosis in these infantsis frequently missed or made too late for efficient therapy), are correctly diagnosed byan intermediate or abnormal j . And finally, only 12 out of 20 infants who later onproved to be normally developed, had a normal j . Thus, if we would calculate — thesmall number, however, forbids this — the diagnostic sensitivity would be relativelyhigh, but the specificity would be very low.3. The clinical data alone (Table 4 and 5) lead to expect some developmentalproblems: the frequency of low birth weight and immaturity as well as the necessity ofrespiratory assistance, were higher in the groups of infants, who proved to beimpaired later on.4. Last but not least (Table 4, last line) the postconceptional age at which the cryanalysis was performed differed considerably between the groups with normal andimpaired development. It is possible that the differences are due to maturationalfactors. So far we lack sufficient data on ontogenesis of pain cry jitter, particularly atdefined gestational ages.

Table 3 Distributiongroups)

normal jintermediate jabnormal j

of jitter-indices (j)

normal(n = 20)

602020

in the newborns followed up to 2 years (%

moderateimpairment

(n = 10)

306010

of the follow-up-

severeimpairment

(n = 6)

03366

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EARLY CNS DIAGNOSIS BY CRY ANALYSIS 27

Table 4 Birth weight and maturity of the infants followed up at age 2 years (median, range)

birth weight

%<2000g

gestationalage%<32w.

gestationalage at cryrecord

normal(n = 20)

3390(1035-3900)

15

39(31-41)

5

40(35-40)

moderateimpairment

(n = 10)

1880(930-3500)

60

32(27-40)

40

36(33-43)

severeimpairment

(n = 6)

1630(1260-1850)

100

31(29-33)

66

34(33-35)

Table 5 Clinical data of newborns followed up to 2 years (% of the follow-up-groups)

c-section rate

umbilical pH^7,2

Apgar 5' s=7

respiratory assistance

normal(n = 20)

30

44

25

5

moderateimpairment

(n = 10)

33

75

22

22

severeimpairment

(n = 6)

33

25

50

66

Thus, there is no doubt that the results presented here are only preliminary. We are,however, convinced that it is worthwhile to continue the investigations and tocomplete the data and — if the jitter-index should prove not sufficiently predictive —to look for other features hidden in the cry signals.

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