Dept. for Speech, Music and Hearing

Quarterly Progress andStatus Report

Cry score. A method forevaluating the degree of

abnormality in the pain cryresponse of the newborn and

young infantVuorenkoski, V. and Lind, J. and

Wasz-Hockert, O. and Partanen, T.

journal: STL-QPSRvolume: 12number: 1year: 1971pages: 068-075

http://www.speech.kth.se/qpsr

STL-QPSR 1/197 1

V. MEDICAL APPLICATIONS

A. CRY SCORE. A METHOD FOR EVALUATING THE DEGREE O F ABNORMALITY IN THE PAIN CRY RESPONSE O F THE NEWBORN AND YOUNG INFANT

V. Vuorenkoski, J. ~ i n d f 0. Wasz-HockerbS3and T.J . Partanen-%**

Introduction

The c r y of the newborn infant has fo r a long t ime been regarded a s an

important clinical manifestation for the pediatrician. Numerous d iseases

have been combined with cer tain c r y character is t ics and have even been said

to indicate a specific state of the infant: intracranial hemorrhage, brain

tumor, meningitis, kernicterus, cretinism, anoxia, hypoglycemia, Cornelia

de Lange syndrome, Tay-Sach' s disease, Down' s syndrome, maladie du c r i

du chat, etc. In general, r e m a r k s on the c ry of abnormal infants have been

based on subjective, auditory observations lacking methodological analyses

and physical-, o r even pertinent phenomenal definitions. The refore, many

obvious deviations f rom normality have been clinically unusable and without

generally accepted diagnostic value.

During the l a s t decade, however, attempts have been made to measure in an

objective way normal and abnormal propert ies of the cry( 1 ,3 ,5 ,6 ,8 ,9 , 10-12, 16) . Recently, attention has been focused on the description of specific c r y char-

acter is t ic s which enable discrimination between some specific pathological

conditions and normality (2 ,4 ,7 , 13, 15, 17) . Although m o r e descriptive anal-

y ses of the c r y for different diagnoses a r e obviously needed, there i s the

p r imary need of a simple method fo r pract ical determination of normality o r

degree of abnormality in the c r y of an individual newborn infant. The purpose

of this study i s to make a f i r s t effor t in solving this problem by constructing

a rating system based on sound spectrographic analyses which includes a l l the

relevant c r y character is t ics studied hitherto and resu l t s in a single c r y score

which directly indicates normality o r degree of abnormality.

The choise of the c ry type in regard to the stimulus and state of the baby

is of p r i m a r y importance in c r y analysis. It i s spontaneous crying which a t -

t r ac t s the attention of the pediatrician. Often, however, that c r y is difficult

to catch and record on tape, a s long a s recording and analysis of the c r y is

* The Wenner -Gren Medical Resea rch Laboratory, Norrtull ' s Hospital, Stockholm, Sweden

.x .. 2 + Department of Pediatr ics , University of Oulu, Oulu, Finland

3 % Institute of Occupational Health, Helsinki, Finland

STL-QPSR 1/1971 69.

not routine and continuous( 14). There i s also the difficulty of obtaining a

clear-cut situation for the baby which could be categorized and compared with

normal material. It i s a difficult task to make accurate and practical defini-

tions, when selecting a standardized and representative sample for instrument-

a l analyses f rom spontaneous crying of abnormal infants; there a r e also sick

babies which seldom emit spontaneous cries , e. g. those with Down' s syn-

d r ~ r n e ' ~ ) . F o r these reasons, a standardized pain cry analysis has been

used fo r spectrographic comparison of the normal and abnormal cry( 4 ,5 , 15, 16) .

Materials and methods

The c r y material used in this study consists of 240 pain c ry recordings

from 240 newborn and young infants ranging in age from 0 days to 8 months.

One half of the cr ies were from normal infants, the other half from patholog-

ical ones. Some detailed spectrographic analyses from a group of 120 normal

infants (5' 16), from a group of 30 cases with Down' s syndrome(4) and from a

group of 45 cases with hyperbilirubinemia( 15) have been published elsewhere.

In addition, spectrographic analyses of the pain cr ies from a mixed group of

45 newborn and young infants with different pathological conditions were in-

cluded in the present ser ies (recorded in the Department of Pediatrics, Uni-

versi ty of Oulu, and the Department of Pediatrics, Karolinska ~jukhuset). 1 This group represents various types of serious conditions and diseases:

(1) 21 cases with diseases affecting the central nervous system (intracranial

hemorrhage, meningitis, meningomyelocele, hydrocephalus), (2) 19 cases

where the respiratory system was directly involved (neonatal asphyxia, lung

atelectasis, respiratory d is t ress syndrome), and (3) 5 cases with chromo-

somal aberrations (13- 15, 17 - 18 trisomies, maladie du c r i du chat). The

methods of collection and analysis of the c ry material have been presented in

detail elsewhere (5, 16)

Thirteen different c r y characteristics sr phenomena occurring in the pain

cry response were measured for the c ry score (see Table V-A-1). Seven of

them a r e continuous variables : latency, second latency, length, minimum

pitch, maximum pitch, pitch of shift and change of pitch. One deals with the

different melody forms of the cry pattern. Four a r e acoustic phenomena

re la ted to the occurrence of different types of c ry phonation: bi-phonation, I

" f ~ r c a t i o n " ( ~ ~ ) , and vibrato. One i s related to the type of

cry respiration: expiratory v. inspiratory cry.

Table V - A - I . Rating system for the cry score. '

ATTRIBUTE CLASSIFICATION RATING

Latency, s ec .

0.7 - 0.9 ~0.7.

Second latency, s e c .

no second signal,

Length, aec.

1.0 - 1.2,

0.7 - 0.9. 0.5 - 0.6,

<o. 5,

Minimum pitch. Hz

'Maximum pitch, Hz 550 - 760 470 - 540, 770 - 930 420 - 460, 940 - 1200 380 - 410, 1210 -2200

0 8 0 9200

Pitch of shift, Hz

Change of pitch/f00 m s e c . Hz

Melody form

Bi-phonation

: Furcation

Stuttering

Vibrato

Respiration

falling, rising-falling

flat, rising,

falling-rising

- + .

expiratory cry inspiratory cry

STL-QPSR 1/197 1

As seen in Table V-A- 1, the values in different attributes were t rans-

formed into ratings between 0 and 4, and in two at t r ibutes between 0 and 3.

The c r y score which was formed a s the sum of the t ransformed ratings of

the different attributes was designated abnormal when i t exceeded 3.

The construction of the rating system has been made in accordance with

al l the variations of abnormality in order not only to divide the c r i e s roughly

between normal and abnormal, but also to give the c r y score the widest pos-

sible indication of different degrees of abnormality. This has been done,

however, without the purpose of making the differential diagnosis.

Re sults

The classification of the 240 pain c r i e s into abnormal ( score > 3) and

normal ( score < 3 ) i s shown in Table V-A-2, where a l l the pathological diag-

noses a r e combined into one group. The sensitivity of the score (percentage

of t rue positives of a l l diseased) was calculated f rom this table to be 95 70, and the specificity (percentage of t rue negatives of a l l non-diseased) 94 '$0.

DIAGNOSIS

S C O R E

Normal Abnormal Total

Pathological 6 114 120

Normal 113 7 120

Total 119 12 1 2 40

Table V-A-2. Cross-classification of diagnosis and c ry score

The distribution of the score in the normal and the various pathological

groups appears in Fig. V-A- 1. The median sco res a r e given in Table V-A-3

with percentages of c r i e s with abnormal scores . The la t ter a r e sensitivity

figures for the abnormal groups, ranging f rom 93 to 98 %. It can be seen

f rom Fig. V-A- 1 that the normal group had the most narrow range of var ia -

tion of c ry score, while the highest dispersion was shown in the hyperbili-

rubinemia and the mixed pathological groups.

It was of interest to determine what attributes contributed mos t to the

total score in the different diagnostic groups a s constrasted to the normal

group. For this purpose, contributions of each attribute to the total score

NORMAL MATERIAL (N=120)

Q2

0.1

MIXED ABNORMAL GROUP (N=45)

a2

0.1

I 0 10 20 30

- DOWN 'S SYNDROME (N =40)

CRY SCORE

I 0 10 20 30

'-

0 2 -

0.1

Fig. V-A- I. Relative frequency h i s tograms for values of the c r y s c o r e in different diagnostic groups.

- - r- - - 1

0 10 20 30

TOTAL PATHOLOG lC AL (N=120)

-

-

-

HYPERBILIRUBINEMIA (N=45)

-

C -

T

-

-

-

7

-

- -

n

-

r P

-

7

- T

-j--ry--m ,-, "

STL-QPSR 1/1971

Median P e r centage with

score abnormal score

Normal group 1.0

Down' s syndrome 7.5

Hyperbilirubinemia 12.0

Mixed abnormal group 12.0

Total pathological 11.0

Table V-A-3. Median score and percentage of cr ies with abnormal score in the normal and the three pathological groups.

were calculated a s score units per cry; this was done for al l the diagnostic

groups under consideration (Table V-A-4). As can be seen in Table V-A-4,

the maximum pitch and bi-phonation a s scaled in the rating system were the

attributes that discriminated best between the pathological and normal groups.

A significant contribution of maximum pitch to the total score i s especially

characteristic for hyperbilirubinemia (2.8) and for the mixed abnormal

group (2.8); both also have rather high ratings in minimum pitch (1.9 and

1.4). Of the other continuous variables, only length contributes significantly

to the total score in all the abnormal groups. There a r e several attributes

which influence the total score in specific abnormal groups: stuttering and

melody form in Down' s syndrome, furcation in hyperbilirubinemia, second

latency, vibrato, and inspiratory cry in the mixed abnormal group.

Figs. V-A-2 - V-A- 10 show sound spectrograms of pain cr ies from cases

with various diagnoses and cry scores (a copy of the tape including these c r i es

i s available by request from the authors). The highest scores a r e seen in

Fig. V-A-5 (intracranial hemorrhage, score 28) and Fig. V-A-7 (neonatal

asphyxia and brain damage, score 23) while the lowest scores a r e found in

Fig. V-A-2 (normal infant, score 0) and Fig. V-A-9 (RDs, score 7). ,

In addition to the use of c ry score in diagnostics and screeiiing, the cry

score also has potential value in surveillance of clinical cases. Examples

of repeated measurements of cry score during the newborn period from three

pathological cases a r e presented in Figs. V-A- 11 - V-A- 13, correlated with

clinical data.

STL-QPSR 1/197 1

Discussion

The c r y score presented in this paper , based on spectrographic analysis

of pain c r y f rom 120 normal and 120 pathological infants, suggests ra ther

good possibilities for application in screening for disease in newborn and

young infants. The correspondence between diagnosis and c r y score was very

good; this, however, depends part ly on the fact that such diagnostic groups

were selected for analysis in which, according to the experience of the au-

thors , c lear deviations f rom normality in the c r y were expected.

The rating system of the score (Table V-A- 1) seems ra ther complicated,

but it was seen during this work that i t did not slow down the analysis of the

spectrograms if a special rating formula was used (available by request f rom

the authors). Thus, this scoring system actually gives a pract ical possibility

for an evaluation of the individual pain c r y recording.

The se r i a l data on the c ry score f rom three pathological cases (Figs.

V-A-11 - V-A- 13j makes i t c lear that there i s a possibility to follow the clin-

ical development in cer tain rapidly changing conditions. On the other hand,

it i s a lso evident that a single c ry analysis i s often insufficient and m a y resu l t

in an erroneous conception of abnormality in the c r y which is related to c e r -

tain pathological conditions.

The method of construction of the cumulative rating system also allows for

additional charac ter i s t ics which may be found l a t e r ( s imi lar in nature e . g. fo r

bi-phonation, furcation, and stuttering), without changing the set-up of the

score. The highest average sco res in different diagnostic groups were found I

in hyperbilirubinemia and mixed ahnoi-lnal groups (median 12.0). The groups

of infants with Down' s syndrome and of normal infants had significantly lower I median value s (7.5 and 1.0). The maximum single score obtained in this

mater ia l was - 28 (for the c ry of a case with intracranial hemorrhage, Fig.

V-A-5). Also, according to our experience (outside this mater ia l ) with the

occurrence of abnormalit ies in the pain cry, we in fact consider 0-30 to be

the pract ical l imi ts of the score although the theoretical maximum i s 50.

The rating system for the c r y score and weighing of the separate a t t r ib-

utes have been made on an approximative basis instead of solving for a c las -

s i f ier function that i s based on formal optimization of some aspect of the

diagnostic value of the function. We consider the resu l t s staisfactory enough

to be reported. An alternative computer solution based on a l a rge r body of

independent pathological s e r i e s will be presented la ter .

TlME IN SEC

Fig. V-A-2 . Spectrogram of the pain cry of a normal infant, score 0 (latencies are not shown in the spectrograms).

TlME IN SEC

Fig . V -A-3, Down' s syndrome 12 (different ratings: maximum pitch 1, melody form 3, bi-phonation 4, stuttering 4).

TlME IN SEC

Fig. V-A-6. Meningomyelocele, score 13 (ratings: minimum pitch 2, maximum pitch 3, change of pitch 4, inspiratory c r y 4).

TIME IN SEC

TlME IN SEC Fig, V-A-7. Neonatal asphyxia and brain damage, score 23 (ratings:

latency 2, second latency 3 , length 1, maximum pitch 4, bi-phonation 4, change of pitch 3 , melody form 3, vibrato 3).

TIME IN SEC Fig. V-A-8. Lung atelectasis, score 14 (ratings: latency 3, length 1,

maximum pitch 4, melody form 3, vibrato 3).

TIME IN SEC Fig. V-A-9. RDS, Hyaline membranes, score 7 (ratings: min-

-- imum pitch 2, maximum pitch 2, vibrato 3).

CL 4000 -1 3000 *'

- - -A-

2000. I- .- P . - l00O0 - - - P,

' - -- - - -- 0 .--- I

0.5 1 .O 1.5 2 .O 2.5 3 .O 3.5 4 .O 4.5 5.0 5 .S & .O

TlME IN SEC - 5000. - C=L n - - - --_ _ - -

--/- - . c 4000* - - - -: -+L

-,.. -- /" - . '-wk . - <.- -

-& --- -:- :r . . 1 3000a- 4vd- - -- - - .--- _r - --- ,-*.-- A % . u 2 0 0 0 . ~ . - -.--~.--- w-: -< I- 9-- - . - f - - 6 - IOOO* -- a r -. - *--*

6 .o 6.5 ?o 7.5 8:o 8:s 9.0 9.5 160 165

TlME IN SEC

Fig. V-A-10. Maladie du cr i du chat, score 13 (ratings: latency I, length 4, minimum pitch 2, maximum pitch 3 , melody form 3).

u - . . . . . - - . . . - . . . . . . . . . . . . . - . - . . - - NORMAL RANGE OF THE CRY 1 I I I 1

15 20

URINARY INFECTION

SCORE 4 A6E,

25 30 35 40 DVSPNEA t t

EXITUS (CEREBRAL

, DAYS

Fig. V-A-11. Development of cry score in a c a s e with Down's syndrome. ending fatally in cerebral oedema at the age of 40 days.

I NORMAL RANGE. OF THE CRY SCORE

Fig. V-A-12. Development of cry acore in a c a s e with ABO immuniza- tion, correlated with serum bilirubin value (ma per 100 ml) .

r-

2 NORMAL RANGE OF THE CRY SCORE

RDS HVALINE

2 3 i 5 MEMBRANES RESP FREQ.

6 t RESP FREO

PULMONARY 60 / mln Y-RAV

100,' min OXVCEN l5: 1

F ~ K . V - A - 1 3 . Development of cry score In a c a s e with RDS. correlated to clinical findings.

STL-QPSR 1/1971

Summary

In order to get practical determinations of normality o r degree of ab-

normality in the pain c r y of a n individual newborn and young infant, a new

rating system, c r y s c o r e , has been constructed. Sound spectrographic

analyses were made of the pain cr ie s obtained f rom 240 infants ranging in

age f r o m 0 days to 8 months. The values in 13 different c r y character is t ics

were transformed into ratings between 0 and 4. Cry score, the sum total of

the different ratings, was designated abnormal when i t exceeded 3. The

correspondence between diagnosis and c r y score was very good: both the

sensitivity and the specificity of the score exceeded 90 O/o for groups of 120

normal infants and 120 infants in various types of ser ious pathological con-

ditions and disease s (affecting the central nervous system o r r e s p i r a t o r ~

system, hyperbilirubinemia, chromosomal aberrations). Repeated measure - ments of c r y score in three pathological cases during the newborn period I

showed a n interesting .po ssibility to follow the clinical development in certain

rapidly changing conditions.

Acknowledgments

This study was supported in pa r t by Sigrid ~ u s & l i u s Foundation, Finland

and Sallskapet Barnavdrd, Sweden.

References

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(2) Gleiss, J. and Hohn, W. : "Das Verhalten beim Schreiben nach konstanter Schmerzreizung atemgesunder und atemgestiSrter Neugeborener", Deutsch. Z. Nerveheilk. - 194 (1968), pp. 311-317.

(3) Karelitz, S. and Fisichelli , V. R. : "Infants' vocalizations and their signi- ficance", Clin. Proc. Child. Hosp. - 11 (1969), pp. 345-36 1.

(4) Lind, J . , Vuorenkoski, V., Rosberg, G., Partanen, T. J . , and TYasz- Hoclcert, 0. : "Spectrographic analysis of vocal response to pain stimuli in infants with Down' s syndrome", Develop. Med. Child. Neurol. - 12 (1970), pp. 478-486.

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(6) Lind, J . , Wasz-Hoclcert, O., Vuorcnkoski, V., and Valanne, E.: "The vocalization of a newborn, brain-damaged child", Ann. Paediat. Fenn. - 11 (1965), pp. 32-37.

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cont. refs .

(7) Luchsinger, R . , Dubois, C. , Vassella, F., Joss , E . , Gloor, R . , and Tlriesman, U. : "Spektrananalyse des Miauens bei Cri-du-Chat- Syndrom", Folia Phoniat. - 19 (1967), pp. 33-27.

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(9 ) Partanen, T. J . , Wasz-Hockert, O., Vuorenkoski, V., Theorell, K., Valanne, E. H. , and Lind, J. : "Auditory identification of pain c ry signals of young infants in pathological conditions and i t s sound spectrographic basis", Ann. Paediat. Fenn. - 13 (1967), pp. 56-63.

( 10) Ringel, R. L. and Kluppel, D . D. : "Neonatal cry: a normative study", Folia Phoniat. - 16 ( 1 9 6 4 ) ~ pp. 1-9.

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( 13) Vuorenkoski, V. , Lind, J. , Partanen, T. J. , Lejeune, J. , Lafourcade, J . , and Wasz-Hockert, 0. : "Spectrographic analysis of c r i e s f rom children with maladie du c r i du chat", Ann. Paediat. Fenn. 12 (1966), pp. 174-180. -

(14) Vuorenkoski, V., Kaunisto, M. , Tjernlund, P., and Vesa, L. : "Cry detector. A clinical apparatus for surveillance of pitch and ac - tivity in the crying of a newborn infant", Proceedings of the XVI Northern Pediatr ic Congress, Turku, 1977, Acta paediat. Scand. ---- - -.--ppp-p Supvl. 206 (1970), pp. 103-104.

(15) Wasz-Hockert, O., Koivisto, M. , \Juorenlcoski, V., Partanen, T. J., and Lind, J. : "Spectrographic analysi s of pain c r y in hyper- bilirubinemia", Biol. Neonate 17 (197 l ) , pp. 260-27 1. -

(16) 7Tiasz-H~cker t , O., Lind, J . , Vuorenkoski, V., Partanen, T. , and Valanne, E. : The - Infant ---- Cry. - A S~pectrographic and Auditory A~ialysis , Clinics in Develop. ex. 29, Spastics International - Iiedical Publications, Heinemann, London 1968.

(17) Wasz-Hockert, O., Simila, S. , Rosberg, G . , Vuorenkoski, V;, and Linci, J. : "El sindroine de Smith-Lemli-Opitz en dos ninas , con esrec ia l atencion a lo s patrones de sus gr i tos de dolor", Rev. Alex. Pediat. 38 (1969), pp. 63-68. -