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Hammersmith Infant Neurological Examination

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Purpose

The Hammersmith Infant Neurological Examination (HINE) includes 26 scored items that assess neurological skills, including cranial nerve function, posture, tone, reflexes and reactions, and motor milestones. The test is used for the early detection of neuromotor impairment in both low- and high-risk infants between 2 months and 24 months of age and may also indicate a risk of developing cerebral palsy.

 

Link to Instrument

Link to Instrument

Acronym HINE

Area of Assessment

Activities & Participation
Movement
Bodily Functions
General Health & Development

Assessment Type

Observer

Administration Mode

Paper & Pencil

Cost

Not Free

Actual Cost

$87.20

Cost Description

Training course can be purchased on publisher’s website at indicated annual cost. Test administration manual can be accessed on publisher’s website.

CDE Status

Not a CDE—last searched 8/17/2025.

Diagnosis/Conditions

  • Cerebral Palsy

Populations

Pediatric and Congenital Conditions

Key Descriptions

  • The Hammersmith Infant Neurological Examination has 26 test items that are broken into five categories: Cranial nerve function, Posture, Movements, Tone, and Reflexes and reactions.
  • The minimum score is zero and the maximum score is 78.
  • Each test item ranges between a score of 0 and 3, with a higher score indicating better performance on the test.
  • The test form is a PDF with 5 pages that includes drawings and descriptions to help with scoring each item.

Number of Items

37 total items: 26 scored items, 8 unscored motor milestones, and 3 unscored items evaluating the state of behavior

Equipment Required

  • Floor mat or bed
  • Reflex hammer (can substitute with finger for taps)
  • Visual target (i.e. black or white circle or faces that can be found on test website)
  • HINE Recording & Scoring Proforma (found on test website)
  • Pencil/pen

Time to Administer

10 to 15 minutes

Required Training

Training Course

Required Training Description

The online training course allows trainees to learn the assessment through videos, interactive questions, and quizzes. It gives the opportunity to practice skills by assessing infants through pre-recorded videos. Trainees learn about the scoring system and how to apply it to various infant populations, as well as which cut-off scores predict different outcomes in populations of infants being tested. (https://www.mackeith.co.uk/product/hammersmith-infant-neurological-examination-online-training-course/)

Age Ranges

Infant (age in months)

2 - 24

years

Instrument Reviewers

Reviewed in August 2025 by Master of Occupational Therapy students Anjani Kodali, Annie Sulzhik, Liz Bishop, & Natalie VanDevanter under the supervision of faculty mentor: Brittany St. John, PhD, MPH, OTR/L, Division of Occupational Therapy, Department of Rehabilitation Medicine, University of Washington, Seattle

Body Structure

Head
Neck
Upper Extremity
Back
Lower Extremity

ICF Domain

Body Structure
Body Function

Measurement Domain

Motor
Sensory
Emotion

Professional Association Recommendation

None found—last searched 8/17/2025.

Considerations

The scoring form and guide are available in 21 additional languages on the publisher's website. Languages available include: Arabic, Armenian, Azerbaijani, Dutch, Finish, French, German, Greek, Hebrew, Hungarian, Italian, Japanese, Kazakh, Kyrgyz, Polish, Portuguese (Brazil and Portugal Versions), Russian, Spanish, Kiswahili, Turkish, and Ukrainian.

For additional information on how to administer the test there are videos and courses on the publisher’s website that can be watched with a membership.

Pediatric and Congenital Conditions

back to Populations

Standard Error of Measurement (SEM)

Pediatric and Congenital Conditions: (dos Santos Furtado et al., 2024; n = 43; mean age = 7.84 (5.5) months; age range = 3-22 months; infants were referred as high risk for developmental disability; Brazilian Portuguese translation of the HINE) 

  • SEM (calculated) for entire group (n = 43): 3.19

     

Pediatric and Congenital Conditions: (Adıgüzel et al., 2022; n = 35; mean age = 10.25 (1.43) months; age range = 8-12 months; male = 22; Turkish translation of the HINE)

  • SEM (calculated) for entire group (n = 35): 1.73

 

Minimal Detectable Change (MDC)

Pediatric and Congenital Conditions: (dos Santos Furtado et al., 2024)

  • MDC (calculated) for entire group (n = 43): 8.84

     

Pediatric and Congenital Conditions: (Adıgüzel et al., 2022)

  • MDC (calculated) for entire group (n = 35): 4.78

 

Cut-Off Scores

Pediatric and Congenital Conditions: (Jackman et al., 2025; n = 95; mean age = 13.6 (0.8) weeks; infants were assessed at three months of age using Prechtl’s Assessment of General Movements (GMA), HINE, Bayley Scales of Infant and Toddler Development-III (Bayley-III), and Motor Optimality Score (MOS-R). All infants were then assessed at one year of age (mean age = 15 (3) months))

  • < 50 total score on the HINE indicates greater likelihood of developmental delays at one year age in one or more domains of the Bailey III (sensitivity = 0.167, specificity = 0.971, PPV = 0.909, NPV = 0.405, AUC = 0.569)
  • < 60 total score on the HINE indicates greater likelihood of developmental delays at one year age in two or more domains of the Bailey III (sensitivity = 0.844, specificity = 0.460, PPV = 0.443, NPV = 0.853, AUC = 0.652)

 

Pediatric and Congenital Conditions: (Pietruszewski et al., 2021; n = 101; mean corrected age at assessment = 7.5 (2.5) months; age range = 3-12 months; includes infants born pre-term, developing typically (n = 50) and developing atypically (n = 51))

  • ≥ 4 for the HINE asymmetry score indicates infants with the greatest likelihood of having abnormal scores on the Hand Assessment for Infants (HAI), defined as having an HAI point difference of 3 or more between hands (sensitivity = 100%; specificity = 88%)

 

Pediatric and Congenital Conditions (Cerebral Palsy): (Romeo et al., 2013; n = 1541; male = 816 (53%); median gestational age = 36 weeks; range 25-43 weeks)

  • Infants with global HINE scores ≤ 56 at 3 months, ≤ 59 at 6 months, ≤ 62 at 9 months, and ≤ 65 at 12 months showed a higher likelihood of developing cerebral palsy (≥ 90% sensitivity and ≥ 85% specificity). HINE scores < 40 were only found in association with severe CP.

 

Normative Data

Pediatric and Congenital Conditions: (Ljungblad et al., 2022; n = 168; 3- to 7-month term infants w/weight appropriate for gestational age) 

Predicted HINE Total Score

Chronological Age:

12 weeks

16 Weeks

20 Weeks

24 Weeks

28 Weeks

10th Percentile

52.1

55.6

59.0

61.8

63.8

50th Percentile

57.1

60.6

64.1

66.7

68.8

 

 

Test/Retest Reliability

Pediatric and Congenital Conditions: (Adıgüzel et al., 2022; test-retest interval = 2 weeks)

  • Excellent test-retest reliability: (ICC = 1.00)

 

Pediatric and Congenital Conditions (Cerebral Palsy): (Hidalgo-Robles et al., 2024; n = 25; mean age = 8.8 (3.0) months; age range = 3-15 months; test-retest interval = ≥15 days; cross-cultural translation and adaption of HINE into Spanish)

  • Excellent test-retest reliability: (ICC = 0.96)

 

Interrater/Intrarater Reliability

Pediatric and Congenital Conditions: (Adıgüzel et al., 2022; two physiotherapist raters, no data on mean practice experience)

  • Excellent interrater reliability: (ICC = 0.969)

 

Pediatric and Congenital Conditions (Cerebral Palsy): (Hidalgo-Robles et al., 2024; 3 physiotherapists with experience and training in pediatrics following a 4-hour training on the HINE)

  • Excellent intra-/interrater reliability for HINE total score: (ICC = 0.98)       

     

Pediatric and Congenital Conditions: (dos Santos Furtado et al., 2024)

  • Excellent interrater reliability for the total score (ICC = 0.95), and for the five subtests (ICC = 0.83-0.94)

 

Internal Consistency

Pediatric and Congenital Conditions: (dos Santos Furtado et al., 2024)

  • Excellent internal consistency (Cronbach’s alpha = 0.91) was found for the 26 items of the HINE-Br

 

Criterion Validity (Predictive/Concurrent)

Predictive validity:

Pediatric and Congenital Conditions: (Jackman et al., 2025)

  • Excellent predictive validity of HINE total scores <60 to predict delayed cognition on the Bailey III at 1 year of age (sensitivity 88.9%, specificity 38.3%, NPV = 0.971). Note: few participants (9%) in the cohort studied were found to have delays in cognition at 12 months.

 

Bibliography

Adıgüzel, H., Sarıkabadayı, Y. Ü., Apaydın, U., Katırcı Kırmacı, Z. İ., Gücüyener, K., Günel Karadeniz, P., & Elbasan, B. (2022). Turkish validity and reliability of the Hammersmith Infant Neurological Examination (HINE) with high-risk infant group: A preliminary study. Turkish Archives of Pediatrics, 57(2), 151-159. https://doi.org/10.5152/TurkArchPediatr. 2022.21231 

dos Santos Furtado, M. A., Leite, H. R., Klettenberg, M. R. P., Alves Rodriguez, V., Ferreria, L. S., Marques, M. R., de Oliveira Cavalcante, I., Santos, T. S., de Souza, T. G., Mendonça, A. S. G. B., Camargos, A. C. R., & Ayupe, K. M. A.  (2024). Translation and measurement properties of the Portuguese-Brazil version of the Hammersmith Infant Neurological Examination (HINE-Br). Revista Paulista de Pediatria, 42, 1-7. https://doi.org/10.1590/1984-0462/2024/42/2023105

Hidalgo-Robles, Á., Merino-Andrés, J., Rodríguez-Fernández, Á. L., Gutiérrez-Ortega, M., León-Estrada, I., & Ródenas-Martínez, M. (2024). Reliability, knowledge translation, and implementability of the Spanish version of the Hammersmith Infant Neurological Examination. Healthcare, 12(3), 380-393. https://doi.org/10.3390/healthcare12030380

Jackman, M., Morgan, C., Luke, C., Korostenski, L., Zawada, K., Juarez, M., Webb, A., Blatch-Williams, R., & Crowle, C. (2025). The predictive validity of HINE, Bayley, general movements and MOS-R in infancy. Early Human Development,203(106226). https://doi.org/10.1016/j.earlhumdev. 2025.106226

Ljungblad, U. W., Paulsen, H., Tangeraas, T., & Evensen, K. A. I. (2022). Reference material for Hammersmith Infant Neurologic Examination scores based on healthy, term infants age 3-7 months. The Journal of Pediatrics, 244(12), 79-85. https://doi.org/:10.1016/j.jpeds.2022.01.032

Mac Keith Press. (2025). Hammersmith Infant Neurological Examination online training course. https://www.mackeith.co.uk/product/hammersmith- infant-neurological-examination-online-training-course/ 

Mac Keith Press. (2025). Hammersmith Neonatal and Infant Neurological Examinations. https://www.mackeith.co.uk/hammersmith-neurological- examinations/

Pietruszewski, L., Nelin, M. A., Batterson, N., Less, J., Moore-Clingenpeel, M., Lewandowski, D., Levengood, K., & Maitre, N. L. (2021). Hammersmith Infant Neurological Examination clinical use to recommend therapist assessment of functional hand asymmetries. Pediatric Physical Therapy, 33(4), 200-206. https://doi.org/10.1097/PEP.0000000000000822

Romeo, D. M. M., Cioni, M., Palermo, F., Cilauro, S., & Romeo M. (2013). Neurological assessment in infants discharged from a neonatal intensive care unit. Journal of Paediatric Neurology, 17, 192-198.

 

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