In recent years, the importance of early intervention and developmental programs has gained momentum and increased attention in order to promote general child health and well-being [1]. However, in order for early intervention to be optimally effective, early detection is paramount. As clinicians become progressively more involved in early examination, evaluation, and early intervention programs, the accuracy of these early examinations becomes essential in order to contribute to cogent decisions for intervention [2]. Accurate assessment and diagnosis is also essential in order to predict clinical course, manifestations, complications, prognosis, and to provide parental counselling.

Muscle tone assessment is an essential component during the neurological examination of infants and children. It is often crucial to the establishment of an accurate diagnosis and appropriate management of a child. A challenge for clinicians however, remains in the accurate identification and quantification of muscle tone due to the subjective nature of the clinical evaluation process [3]. This continues to confuse clinicians, and the scientific community has yet to gain consensus on the operational definition, the diagnostic criteria used to determine hypotonia, and the clinical assessment techniques for evaluation [4,5].

Hypotonia can be a confusing clinical presentation, often leading to inaccurate evaluation and unnecessary investigations due to the subjectivity of the assessment [6,7], which is frequently indicated in the literature [3-5,8-11]. If this confusion and uncertainty continues, it may have serious diagnostic implications (eg, psychological repercussions for both the child and family in terms of false labelling, invasive neurological investigations etc). Moreover, clinicians will continue to face the difficulty of accurately and consistently identifying children with hypotonia and diagnosis of the underlying cause. This may lead to a series of negative consequences with respect to proper management of these children and may also pose difficulty in conducting further research on the efficacy of intervention strategies or in the comparison of studies and an inability to apply or generalize results of studies to individuals.

There is evidence in the literature to indicate that the use of care pathways, algorithms, and practice guidelines, in clinical research will help in standardizing care and provide the necessary requirements for effective diagnostic and counselling interventions [12]. These guidelines and tools may also assist in providing a standard flowchart of the evidence-based diagnostic and treatment to be provided for a spectrum of diseases and disorders [12].

Although no gold standard currently exists, some researchers have begun to address the issue of criteria that may be used to assist in assessment of low muscle tone [4,5]. Thus, in order address the current challenges in clinical assessment of hypotonia, and in the move towards more evidence-based assessments, we will develop and validate a clinical algorithm for the assessment of hypotonia in children. The purpose of this tool would be to assist clinicians (paediatricians, occupational therapists, physiotherapists) in the decision making process in a stance towards more objective and accurate clinical diagnosis and making the appropriate referrals for early intervention. Such a study will also speak to the need for more evidence-based assessment and interventions as well as address the global health needs with respect to early detection and intervention. This will inevitably and indirectly advance the attainment of goal four, which is to reduce child mortality, of the United Nations Millennium Development goals [13].

Initial results from the systematic review revealed a paucity of scientific literature that documented the objective assessment of hypotonia in children. The review identified the need for more studies with greater methodological rigor in order to determine best practice with respect to the methods used in the assessment of low muscle tone in the paediatric population.

This proposed study will be guided by the overarching principles of evidence-based practice and will contribute to instrument development, more specifically with respect to a clinical algorithm. The study will also assist in addressing the current gaps in the literature, which may be considered the epistemological contribution. The study will additionally inform and provide a multidisciplinary team (paediatricians, occupational therapists, physiotherapists) with a clinical tool that is based on evidence and validated. It will also provide knowledge into the best practices for the assessment of low muscle tone to address current diagnostic challenges, and finally will contribute empirical evidence towards shaping educational curricula in the absence of a gold standard.