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. 2025 Oct 7;184(11):661.
doi: 10.1007/s00431-025-06483-0.

Application of the neonatal 'floppy module' to older infants: can it be used for differential diagnosis?

Costanza Cutrona  1   2   3   4 , Martina Sbarbati  1   2   3 , Martina Malaspina  1   2   3 , Chiara Velli  3 , Francesca Sini  3 , Roberta Onesimo  5   6 , Giorgia Coratti  1   2 , Domenico M Romeo  1   3 , Marika Pane  1   2 , Eugenio Mercuri  7   8   9
Affiliations

Application of the neonatal 'floppy module' to older infants: can it be used for differential diagnosis?

Costanza Cutrona et al. Eur J Pediatr. .

Abstract

In this study we applied the 'floppy module', originally developed for newborns with hypotonia, to older infants in order to establish the range of findings in both low-risk infants and in those with hypotonia due to different etiologies. Data were collected from 413 assessments obtained in 159 low-risk infants assessed at different ages between the age of 3 and 24 months. The distribution of findings in the low-risk infants was similar to the data previously obtained in low-risk newborns, with all assessments having optimal findings (column 3) on all items. The only item with a small number of findings outside column 3 was tendon reflexes. The module was also applied to a cohort of 57 infants with hypotonia older than 3 months in order to identify individual items that may be useful in differential diagnosis. Items assessing antigravity movements were the most sensitive to identify neuromuscular disorders. Dysmorphic features and other organ involvement were most suggestive of genetic disorder, while seizures were a reliable indicator of CNS involvement.

Conclusion: Our findings suggest that the neonatal floppy module can be reliably administered also in infants from the age of 3 months. The pilot application of the module in infants with hypotonia from the age of 3 months also suggested that the module could be used to help the clinician in the differential diagnosis of infants with hypotonia.

What is known: • Hypotonia is a relatively common finding in the neonatal period and can be due to multiple causes. • As hypotonia can be observed also after the neonatal period and clinicians often face the challenge of differential diagnosis, the question has arisen whether the 'floppy module' validated in newborns could also be used in infants.

What is new: • Most of the infants with hypotonia, between the age of 3 to 24 months, have a diagnosis of neuromuscular disorders. • Most of the infants with CNS involvement and with genetic diagnosis, who may have shown hypotonia in the neonatal period, by 6 to 12 months have normal or increased tone.

Keywords: Floppy infant module; Hypotonia; Neonatal neurological examination; Neuromuscular disorders.

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Conflict of interest statement

Declarations. Ethics approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the ethics committee of our center (Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, protocol number: 0036454/2). Consent to participate: Informed consent was obtained from parents or legal guardians of all participants included in the study. Consent for publication: Informed consent was obtained from parents or legal guardians of all participants included in the study. Competing interests: The authors declare no competing interests.

Comment in

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