Neonate’s observation
TABLE OF CONTENTS
General State at the Time of Observation
·1
Sleep States
·2
Awake States
Vital Signs
·3
Temperature
·4
Heart Rate
·5
Respiration
Color
Muscle Tone
Spontaneous Movements
Body Posture
Basic Reflex Patterns
·6
Rooting and Sucking Reflexes
·7
The Moro Reflex
·8
The Asymmetrical Tonic Neck Reflex
·9
The Neck-Righting Reflex
·10Posture in Ventral
Suspension and the Landau Reflex
·11The Parachute Reflex and
Optical Placing of the Hands
·12Palmar and Plantar Grasp
·13Traction Response
·14Supporting Reaction
Later Stages in
Neurological Maturation
·15Hand Function
·16Sitting
·17Locomotion
The Senses, Sense Organs,
and Speech
·18Normal Visual Development
·19Detection of Visual
Abnormality
·20Normal Hearing Development
·21Detection of Hearing
Abnormality
·22Normal Speech Development
·23Specific Learning
Disability
·24Inspection of the Mouth and
Nose
·25Normal Development of Taste
and Smell
Sleep Patterns
Infantile Seizures (Spasms)
Inspection of the Fontanels
Body Measurements
General State At The Time Of Observation
Infants react differently
in different circumstances. For instance, the infant who is bombarded with
stimuli when naked and possibly slightly chilled or insecure during a bath may
appear to be quite hypertonic.
The same infant may appear
much more normal, flexed, and relaxed when warm and secure in the arms of the
mother or nurse. Similarly, being hungry or well-fed will affect the sucking
and rooting reflexes.
Crying inhibits some
reactions. Serial observations are therefore extremely important, as they
obviously make possible a finer degree of assessment.
A useful device for
recording the state of the infant at the time a particular manifestation is
observed, or the varying states in which the observation is repeated, is a code
developed by
The pattern of sleep states
and the movement from one state to another appear to be important
characteristics of infants in the neonatal period, and reactions to stimuli
must be interpreted within the context of the presenting state of consciousness
since reactions may vary markedly as the infant passes from one state to
another.
Evaluation of reactions to stimuli which are
interpreted within the context of the infant's state of consciousness may well
be the best predictor of the infant's receptivity and ability to respond.
Sleep States
State 1: Deep sleep with regular breathing, eyes closed, no
spontaneous activity except startles or jerky movements at quite regular
intervals; external stimuli produce startles with some delay; suppression of
startles is rapid, and state changes are less likely than from other states; no
eye movements.
State 2: Light sleep with eyes closed; rapid eye movements
can be observed under closed lids; low activity level, with random movements
and startles or startle equivalents; movements are likely to be smoother and
more monitored than in State 1; responds to internal and external
stimuli with startle equivalents, often with a resulting change of state;
respirations are irregular, sucking movements occur off and on.
Awake States
State 3: Drowsy or semidozing; eyes
may be open or closed, eyelids fluttering; activity level variable, with
interspersed, mild startles from time to time; reactive to sensory stimuli, but
response often delayed; state change after stimulation frequently noted;
movements are usually smooth.
State 4: Alert, with bright look; seems to
focus attention on source of stimulation, such as an
object to be sucked, or a visual or
auditory stimulus; impinging stimuli may break through, but
with some delay in response; motor
activity is at a minimum.
State 5: Eyes open; considerable motor
activity, with thrusting movements of the extremities,
and even a few spontaneous startles;
reactive to external stimulation with increase in startles or
motor activity, but discrete reactions
difficult to distinguish because of general high activity
level.
State 6: Crying; characterized by intense
crying, which is difficult to break through with
stimulation [Brazelton, 1973, p. 5-8].
Some hospitals use Brazelton's code or similar
criteria for uniform coding of the infant's state. An
assessment and description of the state of the
infant by the public health nurse at the time an
untoward symptom is noted can greatly help the physician
in evaluating the nurse's report.
Usually the first temperature is taken rectally to
detect the possible presence of an imperforate anus.
Auxillary temperatures are recommended after that
to provide an early indication that the baby is
being subjected to cold stress. The neonate may be
able to maintain a core temperature even when
subject to cold stress, so that a normal rectal
temperature could be misleading. Normal limits for
auxillary temperature are 36.5o to 37.0oC (97.6o to
98.6oF). (If the infant is in an incubator, the
incubator temperatures must also be recorded, since
hypothermia can be masked by a high
environmental temperature.) Any deviation from the
normal range merits report to medical attention
(Philip, 1977).
Heart Rate
Heart rate is usually monitored by listening to the
apex with a stethoscope. The usual rate is 120-160
beats per minute, but some normal infants have
rates of 100 or110 beats per minute. With current
monitoring techniques it may be possible to look at
the beat-to-beat variability (this is the rate
calculated on the basis of the time interval
between successive R waves).
As with the fetus, newborns usually have a good
deal of variability of heart rate. Loss of variability is
more likely to be seen in sick neonates.
Bradycardia, usually defined as a heart rate below
100 beats per minute, may be normal in some
babies, particularly during the latter part of the
neonatal period. However, bradycardia is a frequent
accompaniment of prolonged apnea and seems to
accompany hypoxia. Another likely explanation is
congenital heart block, with or without associated
cardiac abnormalities. Severe hypocalcemia is
another possible cause.
Tachycardia (increased heart rate) may be due to crying,
fever, or early cardiac failure. Very fast
rates (over 200 to 300 beats per minute) are
usually due to some form of atrial problem (Philip,
1977).
Policies should be clearly defined to guide nurses
and medical staff about intermediate measures to
be followed in the presence of abnormal heart or
respiratory symptoms.
Respiration
Respiration rate and pattern (regular or irregular)
are assessed by observation of the chest wall and
movements of the abdomen (diaphragmatic movement).
The normal rate is frequently stated to be 30
to 50 breaths per minute, but others use a range of
40 to 60 breaths per minute. Most term
newborns breathe regularly while in deep sleep but
may have considerable irregularity when awake.
Premature infants frequently have brief periods of
apnea interspersed with bursts of good ventilation
(periodic breathing). This is generally considered
to be the result of an immature respiratory center.
Other respiratory problems-such as dyspnea (hard or
difficult breathing) evidenced by grunting, or
retractions or flaring of the alae nasi-are looked
for during routine observation.
Apnea: Clinically significant apnea is generally
accepted as cessation of respirations for longer than
15 to 20 seconds, particularly when accompanied by
bradycardia. It requires careful medical evaluation and management.
Apnea seems primarily due to immaturity of the
respiratory center and also that a frequent cause of apnea in small prematures
is the passage of a bowel movement (or preceding a hard stool).
Dyspnea: Dyspnea may be associated with cyanosis and can be
due to a variety of causes, including
primary pulmonary diseases, central nervous system
disorders, and cardiovascular problems.
Abdominal distension (which limits diaphragmatic
excursion) and certain metabolic problems may
cause apnea as well as dyspnea.
Tachypnea: A respiratory rate exceeding 60 beats per minute
is known as tachypnea. Although
often transient and benign, it may be an early sign
of serious illness, such as congenital heart disease.
Stridor: A harsh, high-pitched respiratory sound called
stridor may be heard upon occasion during
the inspiratory or expiratory phase of breathing. A
high-pitched noise is more likely to be the result
of obstruction at the laryngeal level, while a
low-pitched noise is more likely due to tracheal
problems. In any event, stridor is caused by
intrinsic or extrinsic blockage of the upper airway.
Intermittent or inspiratory stridor should be
reported to the medical staff, as well as other respiratory
symptoms, although they tend to be more benign.
Continuous stridor warrants immediate medical
attention and written guidelines should be
available for personnel to follow until a physician is in
attendance.
Color changes in general tend to indicate
physiologic state, maturity, and reaction to temperature
changes in the environment. Usually the Caucasian
neonate will be pink in color or perhaps ruddy.
Cyanosis of the hands and feet is normal for
several hours after birth, but generalized blueness or
grayishness are signs of inadequate oxygenation. A
somewhat pale child may have anemia. Extreme
pallor may indicate a serious condition.
While pallor is also a warning sign in babies of
Asian background, pallorand jaundice may not be as
readily visible among those with darker complexions.
Observation of the conjunctiva for pallor and
the sclera for jaundice may provide more accurate
information in such Orientals.
Shades of skin color in black babies range from
very fair to very dark. Hands and feet of black
babies normally present a dusky appearance for a
few hours after birth. In assessing infants with
darker complexions, it may be helpful to observe
the overall appearance and then the color of both
the mucous membranes and the nail beds of the
fingers and toes.
Harlequinism is a striking, transient change in the
skin color of the newborn. Typically, one side is
normal or a little pale while the other side turns
a bright red, with a sharp line of demarkation in the
midline. This appears and disappears abruptly,
lasting only a few moments. It may recur. The cause
of the condition is not known, and it has no
serious aftereffects.
Petechiae (purple spots) may
be seen over the face or on the lower limbs after a breech delivery-
they usually result from pressure of one form or another
during delivery. Generalized petechiae are always worthy of report to
medical attention as they may indicate a coagulation abnormality.
Physiologic jaundice (a yellow color) occurs in
most newborns on the second or third day of life. It usually requires no
specific treatment, but medical monitoring is highly desirable since, following
baseline investigations, treatment such as phototherapy may be indicated.
Pathologic jaundice may be present at birth or
during the first day. If jaundice does not fade by the
fourth day or recurs at any time thereafter, it
warrants immediate medical surveillance. Causative
factors include Rh or ABO incompatibility. Jaundice
may also be secondary to enclosed
hemorrhage, oxytocin infusion, inherited defects of
red blood cells, congenital biliary atresia, or other
causes. Babies with high levels of bilirubin may
have a strong orange-yellow color and/or a greenish
hue.
Babies born through meconium-stained amniotic fluid
may appear greenish on arrival at the newborn
nursery, but most of this color washes off.
However, a more lasting greenish color particularly
involving the umbilical cord, the head, and the
nails of the fingers and toes, is more apt to be found in
very post-term (postmature) infants.
Some mottling and changes from pink to ruddy to
pale, or other moderate color changes, may be
well within the normal color range. Serial
observations and recording of color changes by the nurse
may aid in the detection of an otherwise obscure
but important underlying difficulty. (The same might
also be said for recording changes in the color,
amounts, frequency, etc., of urine and stools.) Some
hospitals are now paying more attention to the type
of illumination provided in the nursery, to
facilitate recognition of deviations in color.
Certain types of electric light tend to obscure a
developing yellow cast or other subtle change. It
is helpful to check the child's color by daylight at
the nursery window in the course of daily care.
The nurse should also be alert to the
possible presence of abrasions or contusions, areas of edema
or redness, etc. Some of these marks may occur in infants who have been
subjected to a particularly difficult delivery or use of forceps.
Petechiae or other evidence of hemorrhage could be due to some
inherent blood dyscrasia. However, the possibilities of environmental causes,
such as lack of appropriate supervision or even child abuse, must not be
overlooked, particularly in the appraisal of
older infants and children.
MUSCLE TONE
The assessment of tone requires considerable
experience and judgment. It is not expected that the
average nurse will necessarily be able to discern
subtle variations, but most nurses soon become
aware of generalized hypertonicity (the extremely
"stiff" infant) or hypotonicity (the very "floppy"
infant).
Andre-Thomas et al. (1960) call attention to a
factor they term "consistency" - that component of
muscle tone which can be assessed by palpating a
muscle and noting the amount of transverse
"wobble" obtained when the limb is
shaken. Since the nurse must handle the newborn with some
delicacy, it is doubtful that the consistency
factor will be a major part of appraisal in the hospital
nursery. However, public health nurses caring for
the older baby should remain alert to the amount of
"wobble" as they play with or bathe a
youngster, particularly if there are other reasons to suspect that
this is an unusually flabby child.
Occasionally, a baby who is apparently normal in
every other way will be found to be very "floppy,"
that is-so lacking in tone that the head and trunk
must be carefully supported when ever the infant is
moved. The limbs appear to have little or no
resistance to passive motion. Sometimes, the phrase
"like a little rag doll" is used to
describe a child of this type. While it is possible that such a child may
mature normally, lack of tone may be an indication
of Down's syndrome or other dysfunction, and therefore warrants careful
follow-up. Silver and Gabriel (1964) have suggested that certain mental
illnesses, such as childhood schizophrenia, may first signal their presence
through generally poor
muscle tone as well as persistence of primitive
postural responses.
Infants may be found who have such marked extensor
tone that they "rear backwards" and stiffen
out as the mother or nurse attempts to hold or feed
them. In some infants, it may be noted during
bathing or diapering that one or more of the limbs
seem to "catch" at the midpoint of flexion and
extension, suggesting the possible presence of a
hyperactive stretch reflex. Or, on internal or external
rotation, one or more limbs may offer resistance,
and the child may indicate discomfort. These
manifestations may be signs of hypertonicity,
spasticity, or other deviations. All should have medical
attention.
Particularly fine illustrations of abnormal tone
and posture which may signal the presence of cerebral
palsy and related disorders have been provided by
Illingworth (1966).
The relevance of such observations and referral to
medical attention have implications for the primary
caregiver, usually the mother, as well as for the
child. Hopefully, medical attention will lead to early
diagnosis and the initiation of appropriate
management to remediate or alleviate the child's problems
early in life. However, even if the difficulties
prove to be transient and benign in the long run, the
normal process of bonding and attachment may be
interrupted if the child is too stiff or too floppy to
initiate self-comforting behaviors or invite
cuddling. The infant who rears backward when the parents
seek to feed or embrace the baby may be seen as
"rejecting" their nurturance. Insecurity or
frustration about their parenting skills may be
markedly exacerbated unless the parents are helped to
understand why the baby fails to respond in
expected ways. The nurse should help to meet the
parents' and the infant's needs under these
circumstances.
The next three sections are based primarily on the
neurological appraisal of infants as outlined by
Paine (1960), Prechtl and Beintema (1964), and
Touwen (1976).
SPONTANEOUS MOVEMENTS
The normal movements of newborns are jerky and
usually alternate in the legs but are symmetrical in
the arms. They may be jittery or tremulous. The
limbs are usually flexed. Premature infants, on the
other hand, show greater tendency to extension of
the limbs, and their spontaneous movements may
be writhing and athetotic.
Possible abnormalities include deviations from
these characteristics, asymmetry, or abnormal
movements such as myoclonus or convulsions.
BODY POSTURE
The posture of the limbs and trunk at rest is also
important in appraisal. The presence of a "pithed
frog" position, marked opisthotonos, or
constantly outflung arms will usually be readily apparent. The
asymmetry of brachial palsy may also be quite
obvious. Hemiparesis, on the other hand, is rarely
apparent in the newborn.
In infants born with congenital cerebral lesions,
such as porencephaly, the earliest sign is usually
minimal movement of one arm and a greater tendency
to keep that hand clenched than the other. In
the legs, a greater tendency toward external
rotation of the hip may suggest a possible hip
dislocation, a pyramidal tract abnormality, or
future spastic hemiparesis. Abnormal postures that are
apparent for only brief periods may be due to
seizures, which are discussed in a later section.
Pithed frog position
BASIC REFLEX PATTERNS
This section includes suggestions intended to help
sharpen surface observations for possible
anomaly, plus a few highlights on the potential effects
of the abnormal findings on the child or primary
caregivers.
Rooting and Sucking Reflexes
A hungry infant will turn the head to the right or
left when the cheek is brushed by a hand or
facecloth. If a nipple is touched to the face
-whether to the right or left, above or below the
mouth-the lips and tongue will tend to follow in
that direction.
These rooting and sucking reflexes should be
present in all full-term babies. As might be expected,
they are more easily elicited before than after a
feeding. The reflexes may be absent in small
prematures. Absence among full-term infants
suggests depression of the central nervous system from
maternal anesthesia, hypoxia, or congenital defect.
Rooting reflex
These responses usually last until the infant is 3
or 4 months old. However, the rooting response may
persist during sleep until as late as 7 or 8
months. At later ages, visual stimulation plays a part-babies
may root for a bottle but may not respond to the
touch of a finger.
Persistence of the response beyond the 7th month,
or its reappearance later in life, warrant thorough
medical evaluation.
While rooting and sucking reflexes are being
appraised, attention should also be given to the possible
presence of such anomalies as a particularly small
chin, a face that appears unusually fat in relation to
a rather small skull, peculiar dentition (such as
double-fused teeth), a cleft lip or palate, or asymmetry
of the nasolabial folds. Excess salivation, mucus,
and frothing always warrant attention. Feeding
problems are discussed later.
The Moro reflex, sometimes termed a
"startle" reflex, is a series of movements by an infant in
response to a stimulus. The pattern of movement
varies among infants, and gradually alters during the
first few months of life with increasing maturity.
It is not possible, therefore, to give a single
description for all ages and all infants. Mitchell
described the reflex in the infant a few days old:
The initial part of the response is
extension and abduction of the upper ex- tremities with
extension of the spine and retraction of
the head. The forearms are supinated and the digits
tend to extend and fan out, with the
exception of the distal phalanges of the index finger and
thumb, which may be C-shaped ... the upper
extremities describe an arc-like movement,
bringing the hands towards one another in
front of the body, and finally return to the position
of flexion and abduction [Mitchell, 1960,
p. 9].
Sometimes there is a slight tremor or even a
rhythmic shaking of the limbs. The movement of the
lower extremities is usally less pronounced. Both
legs tend to extend and abduct with the upper
extremities, although there may be a slight
movement of flexion first. If the lower extremities are
extended when the stimulus is applied, the flexion
movements may be more readily noted.
A sudden jolting movement, such as that produced by
striking the mattress or table on both sides of
the infant, will usually cause the startle
response. Occasionally a loud noise may precipitate the reflex.
Extension of the head relative to the trunk or a
sudden strong stimulus appear to be the most reliable
means of eliciting the reflex.
Moro reflex
The Moro reflex is strongest during approximately
the first 8 weeks of life. Thereafter, it becomes
less pronounced. McGraw (1937) found that most
infants change at about 90 days from the
newborn phase to a transitional phase in which
movements become less gross, and at about 130
days to the final "body-jerk" phase.
Persistence of the Moro reflex after the 6th month should be
considered suspicious and deserves careful medical
evaluation.
The Moro response is missing or incomplete
in the younger premature but should be readily obtained
in any full-term normal baby. Its absence in a
newborn may be due to a central nervous system
disorder. Occasionally, an infant will display the
Moro reflex on the first day, but this is followed by
greatly diminished intensity of the response during
the ensuing weeks, possibly because of birth injury
or general muscular weakness. Occasionally cerebral
edema or other factors may cause the reflex to
be absent on the first day and gradually develop
during the following 4 days. In some cases of
cerebral hemorrhage, the reflex may be present the
first day, disappear, and return slowly after the
6th day. These variations point to the value of
public health nurses following up infants who have
been discharged early from the hospital after
delivery.
Asymmetry of response may occasionally be noted in
normal full-term infants, but asymmetry usually
suggests fracture of the clavicle or humerus,
injury to the brachial plexus, or neonatal hemiplegia.
Paine (1964) points out that a defective Moro,
opisthotonos, and the setting-sun sign of the eyes
(only the upper half of the iris showing above the
lower lid) are the principal and probably
indispensable clinical signs of kernicterus in the
first week of life. Whenever such symptoms are
noted, the need for medical attention is immediate
and urgent.
Paine did not find persistence of the Moro reflex
beyond the 6th month in any of the infants in his
series who had homologous retardation of psychic
and motordevelopment. But abnormal persistence
was seen occasionally in the presence of spastic
tetraparesis, and in one infant who subsequently
developed athetosis. Touwen (1976) points out that
it may be hard to differentiate the Moro reflex
from a fright response occurring later in life.
Nevertheless, the older child with a persistent Moro is at
risk of having this resemblance overlooked. As an
example, in teaching the child self-feeding, the
sudden extension of the arms and opening of the
hands, causing the spoon to fly off in one direction
and perhaps the food in the other, may be
interpreted by the caregiver or "behavior shaper" as due
to volitional, maladaptive behavior. Or it may be
ascribed to the possibility that the child is too
retarded to understand what is expected of him. In
fact, this behavior may be due to elicitation of the
Moro by lack of ability to maintain the head erect
so that it drops back unexpectedly, a sudden flash
of sunlight on the spoon, or a loud noise or
unexpected jostle of the chair or table.
In the course of routine nursing functions, no
matter how gently the infant is handled, the reflex will be
elicited several times in any 24-hour period in a
hospital nursery, during the appraisal and
demonstration bath carried out in the home by the
public health nurse, or during the infant's visits to a
well-child conference.
If the infant's limbs are free to move, the
hospital nurse should be alert for the Moro response when
she rolls the bassinet to display the infant at the
nursery window or when she replaces the infant in
the bassinet after changing the crib sheet.
The public health nurse should look for the
Moro reflex as she puts the infant down just before or
after demonstrating how to bathe the infant.
Extreme care should be exercised at all times in
handling distressed or premature infants, and they
should receive more constant and consistent medical
surveillance. However, while feeding, when
checking vital signs, and in other circumstances
when the infant is subjected to slight movements, the
nurse can observe if and when the Moro appears and
the characteristics of the response.
Articles by Gesell (1938) and Gesell and Ames
(1960) contain descriptions of the asymmetrical
tonic neck reflex. These authors assert that it is
present in practically all infants during the first 12
weeks of life, often spontaneously manifested by
the quiescent baby in the supine position as well as
during general postural activity. The asymmetrical
tonic neck reflex appears "when the infant, lying on
the back, turns the head to one side or if the head
is passively rotated to one side." The infant tends
to assume a "fencing" position-with his
face toward the extended arm, while the other arm flexes at
the elbow. The lower limbs respond in a similar
manner.
Asymmetrical tonic neck
reflex
Paine (1960), Prechtl and Beintema (1964), and
Andre-Thomas et al. (1960) have pointed out,
however, that there is no constant asymmetrical
tonic neck pattern among newborns. The response
tends to be most noticeable between 2 and 4 months
of age, being replaced by symmetrical head
and arm positions (when the baby is in supine
position) by the time the infant is 5 or 6 months old.
Paine (1964), Prechtl and Beintema (1964), and
Vassella and Karlsson (1962) agree that, while the
tonic neck pattern may be partially imposed on a normal
infant by passive rotation of the head, this is
not a consistent response.
A study of 66 normal infants during their first
year of life found that a few infants under 3 months of
age could sustain the asymmetrical tonic neck
pattern for more than 30 seconds, but none
demonstrated an imposable, sustained response
(Paine et al., 1964).
The studies indicate that while the asymmetrical
tonic neck posture may be apparent from time to
time during the first few months of life,
persistence of the response after the 7th month constitutes an
index of suspicion. Responses that are completely
obligatory or unusually strong on one side or the
other deserve medical attention at any age.
A persistent asymmetrical tonic neck reflex is
potentially a very handicapping disability. The child is
prevented from seeing both hands simultaneously
unless measures are instituted to position the head
and hands in midline. The effort to bring food or
any object to the mouth is also inhibited. The
influence of the pattern on the legs obviously
poses severe restriction on the ability to achieve
standing and walking.
Since the newborn needs gentle cleansing of the
face, neck, and area around the ears several times in
a 24-hour period, the nurse has many opportunities
to watch for the asymmetrical tonic neck
response as she rotates the head of the infant in
supine to cleanse first one side of the face and then
the other. An observant nurse can discern whether
the asymmetrical tonic neck reflex is present,
whether the response is stronger on one side than
the other, and whether it is compulsory or
persistent.
If the body response seems dependent on the head
position in serial observations of an infant over 6
months of age, the nurse should ascertain whether
the reflex has persisted. Waving a bright toy first
to the right and then to the left of the child is
an effective way to elicit active rotation of the head.
With young infants it is a bit easier to use a
passive head rotation maneuver.
Observation for the asymmetrical tonic neck reflex
pattern provides opportunity for carefully
examining the child's neck to note the possible
presence of torticollis or webbing. A particularly short
neck in relation to the rest of the body is also
worth noting.
Finally, it is of interest to note that the early
and normal tendency of the infant to extend the "face
arm" places the hand in an excellent position
to be viewed without effort. Even during the first few
days and weeks of life, many normal infants may be
observed maintaining attentive eye contact for
minutes at a time with the hand they are facing
while in this position. "Learning" that the hand is there,
at the end of the arm, is a first step toward later
learning what can be done with a hand.
As the asymmetrical tonic neck response is
"lost," it is replaced with a neck-righting reflex, in which
passive or active rotation of the head to one side
is followed by rotation of the shoulders, trunk, and
pelvis in the same direction. In the true
neck-righting response, there is a momentary delay between
the head rotation and the following of the
shoulders, as opposed to the automatic, sudden, and
complete body rotation in immediate response to a
passive turn of the head that may occur in some
abnormal states.
Neck-righting reflex
The nurse may observe the two-step righting
response in the normal child of 1 or 2 years, as he
voluntarily gets up to a sitting position from the
supine. First, he turns the head, then the shoulders,
trunk, and pelvis, before undertaking the more
complicated series of maneuvers by which he rolls
over and achieves sitting (and/or rises from the
floor in the quadrupedal manner). Paine et al. (1964)
found that the neck-righting reflex was obtainable
in all normal infants by 10 months of age and was
gradually covered up by voluntary activity, making
the age of its disappearance difficult to gauge.
However, they point out that a neck-righting reflex
in which the response is much stronger with the
head to one side than to the other is not seen in
normal infants; nor should the response at any age be
so completely invariable that the baby can be
rolled over and over. Stereotyped reflexes of this type
are considered pathologic and are often found in
infants with cerebral palsy.
It also is relevant to note that infants with low
muscle tone (hypotonicity) or with considerable excess
of tone (hypertonicity) and infants with an
obligatory asymmetrical tonic neck reflex would be
impeded from demonstrating a normal neck-righting
reflex.
Posture in Ventral Suspension and the Landau Reflex
All normal neonates display some evidence of tone
when suspended in the prone position. The nurse
may observe this when the baby is turned to prone
during the nursery admission cleansing
procedure. Public health nurses may assess tone as
they weigh and measure the baby at well-child
clinics or while bathing the child at home. As the
newborn infant is turned to prone, with the trunk or
abdomen supported, the legs should be flexed. While
the head may sag below the horizontal and the
spine be slightly convex, the infant should not be
completely limp and collapse into an inverted U.
As the baby becomes a little older, the head and
spine are maintained in a more nearly horizontal
plane. There is a gradual increase in the tendency
to elevate the head as if to look up, while the spine
remains straight. Still later, there is elevation
of the head well above the horizontal and arching of the
spine in a concave position. Paine et al. (1964)
found that the head was above the horizontal in 55
percent of their series at 4 months and in 95
percent at 6 months. The spine was at least slightly
concave in approximately half of the 8-month-olds,
but concavity was noted universally at 10
months. Many physicians designate this posture, with
the back slightly arched, as a "positive Landau"
(Touwen, 1976). Dissolution of the reflex is
difficult to ascertain since it is gradually covered up by
struggling or other voluntary activity.
The Landau reflex is tested in a different way by
others. While holding the infant in ventral suspension
with the head, spine, and legs extended, the nurse
then passively flexes the head forward. The reflex
is considered present if the whole body then
flexes. The reflex may be seen as early as 3 to 4 months
but should be present after 7 months of age. In
general, the nurse will find that holding the infant in
ventral suspension provides more useful information
than elicitation of the Landau by means of
passive flexion of the head. In any event, the
nurse's report to the physicians should describe exactly
what was done and the infant's response. Whatever
the infant's age, his limp collapse into an inverted
U when held in ventral suspension should be called
to immediate medical attention.
The Parachute
Reflex and Optical Placing of the Hands
There is a tendency to refer to the parachute
reflex when the behaviors being elicited and the
reactions being described are actually those
associated with the optical placing reaction of the hands.
Touwen (1976) calls attention to and describes the
difference between the two.
In each instance, the infant is held in vertical
suspension and suddenly lowered toward a flat surface.
The normal positive response is a forward extension
of both arms and dorsiflexion of the infant's
hands during the movement. The difference between
the two is that, in the optical placing reaction,
the infant is permitted to see where he is going.
This response may be noted as early as 3 months of
age. In the true test for the parachute response,
the maneuver is the same but the child's visual
attention is first attracted to a bright toy
displayed in front of and a little above him and he is then
suddenly plunged downward. Under these
circumstances the parachute response may not be seen
until about 6 or even 9 months of age. Touwen
(1976) suggests that the earlier appearance of the
positive response, when the child can anticipate
visually that he is going down to a flat surface,
illustrates the reinforcing effect of visual on
vestibular input. Since the older infant tends to smile or
chuckle under anticipatory circumstances but may be
frightened when unexpectedly plunged, the
former is usually the method of choice by the nurse
in eliciting the presence of the reflex. If the child
is plunged sideward as well as downward to the flat
surface, the influence of the optical factors is
reduced. Under these circumstances, partial
response may be noted as early as 3 months. The
complete response begins a little later; it will be
noted in most infants by 9 months and in all normal
infants by 12 months (Paine et al., 1964). In any
event, the nurse should describe in her report
exactly the way in which the parachute was
elicited. An asymmetrical or absent response warrants
medical appraisal.
Parachute reflex
Public health nurses are alerted to watch fathers
at play with their children, as the game of "so high"
or "airplane" may provide the
opportunities to observe for the presence and character of the
parachute reflex, as well as for extensor tone in
ventral suspension. Nurses who have developed a
warm rapport with the child and family may
themselves play with the infant in this fashion, since most
infants respond with great glee.
Palmar grasp AND Planter grasp
Palmar and Plantar Grasp
Palmar and plantar grasp are strong automatic
reflexes in full-term newborns. They are elicited by
the observer placing a finger firmly in the child's
palm or at the base of the child's toes. The palmar
grasp response weakens as the hand becomes less
continuously fisted, merging, sometime after 2
months, into the voluntary ability to release an
object held in the hand. The plantar response
disappears at about 8 or 9 months, though it may
persist during sleep for a while thereafter. Possible
abnormality may be suspected in asymmetry of
response. While there is a tendency to fisting in the
neonate, this should not be evident at all times.
Serial observation of infants in the nursery should
reveal relaxation of both hands at some point,
usually during or right after feeding, or perhaps when
asleep. These appraisals provide additional
opportunities for detecting abnormalities of color such as
cyanosis of the extremities, edema, simian palm
crease (a straight line rather than an M-shape across
the palm), and possible malformations of the hands
and feet. Persistent edema of the feet is always
worth noting, particularly if occurring in a female
child, as it may signal the presence of a
chromosomal abnormality (X. 0. Turner's syndrome).
Simian palm crease
Physicians test the traction response by placing
the infant in supine, then drawing him up by the hands
to a sitting position. Normally, assistance by the
shoulder muscles can be felt and seen. The
newborn's head lags behind and drops forward
suddenly when the upright posture is reached. Even
in the newborn period, however, there should be
sufficient head control to bring it back upright, and
greater control is expected with age. The nurse in
testing the neonate may gently raise the infant from
supine in this way, in order to note the presence,
absence, or asymmetry of response; but she should
avoid reaching the midline point, which causes the
head to drop forward suddenly.
The supporting reaction is elicited by holding the
infant vertically and allowing his feet to make firm
contact with a table top or other firm surface. The
"standing" posture includes some flexion of the hip
and knee. Automatic stepping may also be observed
when the newborn is inclined forward while
being supported in this position. During the first
4 months of life, the crouching position gradually
diminishes; this is followed by increase in
support, so that normal infants will usually support a
substantial propor- tion of their weight by 10
months (Paine, 1964).
Supporting reaction and
stepping
In this supported standing position, it is to be
expected that a few infants will stand on their toes from
time to time or occasionally cross or
"scissor" their legs. However, consistent standing on the tips of
the toes or scissoring of the legs after 4 months
of age may be considered an index of suspicion
warranting medical attention. A club foot or a
deformity at the knee or hip may also become
apparent while the supporting reaction is being
appraised.
By the age of 6 months, the supporting reaction is
less easily demonstrable, and by 10 or 11 months,
it is difficult to distinguish from voluntary
standing.
LATER STAGES IN
NEUROLOGICAL MATURATION
Hand Function
As a rough guide, the baby can be expected to reach
and grasp with the whole hand at 4 or 5
months, grasp with thumb and two fingers at 7
months, and pick up small objects with thumb and
forefinger (pincer grasp) at 9 months. Paine et al.
(1964) found that the pincer grasp was obtainable
in 52 percent of their series at 8 months but was
not universally present until 12 months.
Any unusual use or disuse of the hand(s), or
peculiar hand positions, such as a tendency to ulnar
deviation, deserves medical appraisal, as do
athetosis, consistent avoiding reflexes, or a
developmental lag of 3 months in attaining pincer
grasp.
The ages at which the infant sits with some
support, sits alone, stands, and walks correlate to a
considerable degree with the ages at which changes
take place in postural reflexes. Sitting usually
takes place at about 6 or 7 months, with inability
to sit unsupported after the age of 9 months
constituting an index of suspicion.
One useful criterion for judging whether or not a
child is truly "sitting without support" is to note
whether or not he can sit with a fairly straight
back and turn the head or rotate the body without
losing balance. Another useful test is to play with
the child, at some time when he is happy and
comfortable, while he sits on a hard surface. When
the child is given a slight push to one side or the
other, it should be noted whether or not he
"instinctively" reaches out on either side for support, and
whether the head and trunk curve slightly to the
opposite side to counterbalance the impending fall. If
balance is maintained in this way, the infant can
be termed well able to "sit alone." As a rule the baby
will not develop the ability to guard against
falling backward by protective extension of the arms to
the rear until about 12 months of age.
Once the child develops reasonable security in
sitting, there will be a tendency to use the hands more
effectively. Therefore, in appraising the child's
ability to use the hands while sitting, it is always wise
to note first if the child needs lateral or
posterior support. It may be that the child can use the hands
to hold or transfer a block or toy, but is
prevented from doing so by a need to use arms and hands
for support. It is possible, for instance, for a
child with cerebral palsy to have sufficient hand function,
intelligence, and interest to learn to eat without
assistance but be unusually delayed in developing
sitting balance. Under such circumstances the child
may need to be positioned with secure arm,
back, and foot supports before the needed hand
skills can be demonstrated. If these factors are
overlooked, the situation can prove quite
frustrating and may be inappropriately interpreted.
About half of all normal infants begin to creep or
crawl between 6 and 12 months of age; by 12
months the infant should be able to pull erect, and
by 18 months begin walking independently.
Failure to walk independently after 1 8 months of
age constitutes an index of suspicion.
By the age of 3 years, the child should have
achieved motor independence, including walking up
stairs. Delays in single items of development may
be due to a variety of specific causes, which may
be of a motor, sensory, or emotional kind (Denhoff
and Robinault, 1960; Silver and Gabriel, 1964).
An overall lag in several developmental aspects may
be due to cerebral palsy, mental retardation, or
related cerebral dysfunctions. A peculiar method of
creeping or crawling may also warrant special
evaluation, e.g., some children with cerebral palsy
develop a bunny hop, wherein both knees are
drawn up simultaneously under the trunk, followed
by an awkward push forward.
A type of cerebral dysfunction has been described
by different investigators as brain-damage
disorder, minimal neurological handicap, or the
hyperkinetic behavior syndrome (Laufer and
Denhoff, 1957). It is of interest to note that
children who later manifest hyperkinetic behavior
disorder (characterized by involuntary and constant
overactivity) may be significantly advanced in
achievement of the milestones of motor development.
Such children may climb out of the crib before
1 year of age and walk early. Parental histories
also indicate that some of these children cannot be
kept in the playpen, get into everything, run
rather than walk, find it intolerable to sit quietly (even at
meal times), are hyperirritable, cry readily, and
wake several times during the night. Such symptoms
warrant referral for thorough professional
appraisal, for the sake of both the child and the family.
However, some children who manifest hyperkinetic
behavior patterns in later childhood display no
evidence of this disorder during infancy.
The child who is greatly accelerated in phases of
growth and development might be evidencing a
generally superior endowment. However, an
individual of superior endowment may have a normal
developmental course or even be delayed in some
aspects. The nurse must remain objective at all
times and be guided by the general rule that a
deviation of 3 months in the achievement of
developmental milestones constitutes a valid reason
for referral to medical attention.
THE SENSES, SENSE
ORGANS, AND SPEECH
Normal Visual Development
The infant's ability to fix his or her eyes upon
the face of the mother in the face-to-face (or "en face")
position within minutes after natural delivery can
provide initial evidence of an infant's state of vision
at birth. This is also one of the most effective
means of helping a mother begin to develop the normal
attachment and bonding process with her infant.
Increased attention is now being given to bonding
and to encouraging the father to be present when
the baby is delivered. A slight delay in instilling
prophylactic medication (to prevent infection) in the
infant's eyes, plus positioning the mother and
child in the en face position as soon as the child is
breathing properly, enhances the infant's potential
for displaying bonding ability. (The interest of the
normal newborn in the human face at 2 days of age
is illustrated in the series of training films available
to help personnel learn to administer the Brazelton
Neonatal Behavioral Scale.) At this age, the infant
can also track a bright object across the midline
and above and below the immediate eye level when
both infant and object are properly positioned to
elicit this response. While first evidence of this
ability can be noted soon after birth, reliable
following of objects is observed more readily when the
infant is 6 to 8 weeks-usually the time of the
public health nurse's home visit or the infant's return to
the physician or clinic for postpartum checkup.
Smiling at 6 to 8 weeks of age in response to the
parent's smile provides relevant evidence of
psychosocial adaptation as well as evidence of proficient
vision and the neuromotor ability to smile.
Greatly disconjugate or ceaselessly roving eye
motions suggests blindness. While the infant may
exhibit problems of convergence (which usually
begins at about 3 months), a constant, fixed
strabismus warrants careful medical appraisal at
any age.
The setting-sun sign, where only the upper part of
the iris appears above the lower lid when the eyes
are at rest, is an observation that should receive
medical attention. The infant's eyes should be
examined also to note whether the cornea of one eye
is larger than the other. This could be a sign of
congenital glaucoma, which can lead to blindness if
not detected and treated very early.
Setting-sun sign
Other abnormalities include a total or partial lack
of pigmentation, a triangular-shaped notch
(palpebral colobomas) in the upper or lower lid, a
bilateral and symmetrical decrease in the size of
the palpebral fissure (blepharophimosis), ptosis
(inability to raise the lid fully), the presence of
dermoid cysts, or other unusual signs (Apt and
Gaffney, 1977). The presence of cataracts may
sometimes be noted in the infant; the nurse should
remain alert to a milky type of film or clouding. As
a child is brought to a slightly stronger light
source (for instance, the nursery window), the nurse
should see if his pupils react by contracting and
do so equally. There are many opportunities to
watch for the blink reflex while cleansing the
child's face.
All babies should be inspected for epicanthic folds
(folds of skin across the inner angles of the eyes).
In a non-Oriental baby, they may be an indication
of Down's syndrome or other congenital disability,
and such a child should have continued followup.
However, epicanthic folds may be a normal
manifestation even in a baby of non-Oriental
parentage.
Unusual placement of the eyes, one eye larger than
the other, unusually heavy brows that meet over
the bridge of the nose, or a wide-eyed and
particularly forlorn gaze are other signs that may be
related to chromosomal aberrations. A single slight
deviation may be found, such as one eye so
slightly smaller than the other that it has neither
medical nor cosmetic significance. Even this minor
observation should be recorded, since, as
previously mentioned, the presence of three or more
minor anomalies indicates that the child should be
under surveillance for a possible major disorder.
The times when the infant is bathed or the face is
cleansed provide excellent opportunities for
inspecting the eyes for such anomalies.
Epicanthic fold
Attention should be given to all symptoms such as
redness, discharge, or swelling about the eyes of
children at any age. Signs of possible visual
difficulty in the older child include holding objects very
close to the face; closing one eye repeatedly or
tilting the head at an unusual angle when attempting
to visualize objects; discomfort when in a brightly
lighted environment; headache, frequent eye
rubbing, or complaints of burning or itching, after
watching television or going to the theater. Unusual
delay in recognizing colors may be another clue to
visual difficulty. Visual or perceptual problems
may be suspected in the older child who lags behind
peers in the ability to stay within lines when
coloring or copying a diamond shape, or in the
ability to catch or bat a ball. The child who is always
tripping and bumping into things may have a visual
or perceptual defect, or the problem may be
rooted in neuromotor or other difficulties.
It is important to have the visual problem
evaluated and diagnosed as early as possible to initiate
treatment, prevent loss of vision, and promote
optimal vision.
Northern and Downs (1974) provided an excellent
review of the literature on hearing in children.
Among others, they cited the findings of Elliot and
Elliot (1964), who confirmed psysiologically that
the human cochlea has normal adult functions after
the 20th week of gestation; and Eisenberg
(1970), who demonstrated that most newborns,
including those with known disabilities of the central
nervous system, can discriminate sound on the basis
of frequency, intensity, and
stimulus-dimensionality, and that speech-like
signals appear remarkably effective in producing
response in newborns.
Stechler (1964) found that unexpected noise at a
level of 70 decibels above audiometric zero elicited
a variety of responses from newborns, depending
upon the dimensions of the stimulus. If the sound
reached its maximum intensity within a fraction of
a second, the newborn closed his eyes, startled,
and showed an increase in heart rate. On the other
hand, if the sound did not reach its maximum until
at least 2 seconds had elapsed, the newborn was
more likely to open his eyes, look around, and
show an increase in heart rate. The first reaction
was interpreted as a defensive one, the second as a
display of interest.
The Brazelton training films illustrate the arousal
state of an infant as young as 2 days of age,
produced by sound made while the infant is in a
light sleep state. They also depict the way a normal
infant responds by turning the head to the sound of
the human voice, and the difference in response
to a high-pitched and a low-pitched voice. The
films further show the response of the infant in a light
sleep state to the ringing of a bell and the
subsequent ability of the normal infant to habituate to the
sound, that is-to resume the sleep state in the
presence of a continuously ringing bell.
There is a marked contrast between the ability of
the normal neonate to accommodate to sound in
this way and the plight of many disabled infants
who cannot. Infants with developmental problems
frequently have some trouble getting to sleep and
are easily startled into wakefulness by sounds
within the normal range of customary noises in the
environment. Such infants are deprived of sleep
they really need. They tend to be hard to comfort.
Meanwhile, the primary caregivers (usually the
parents) become increasingly anxious and frustrated
in their attempts to comfort the infant. Deprived
of their own needed rest and sleep, they become
increasingly fatigued and irritable. It is not
surprising that such circumstances can strain the
normal attachment and bonding process between
parents and child.
Hearing is also a learned behavior, which involves
not only sensitivity to and discrimination among
various sounds but also understanding,
interpretation, storage, recall, and usually an appropriate
motor response. The child with normal motor
development relates to many sounds in the
environment. Normal response at about 6 months
involves a turn of the head in the direction of the
sound. The child is more apt to respond if the
sound is a familiar one (a favorite toy, a spoon rattling
in a dish at feeding time); the sound is made at a
level horizontal with the ears; the sound is made
reasonably near the child; and the environment is
relatively quiet. By 7 or 8 months of age (and often
earlier), the normal infant will have
"learned" to listen.
Hearing assessment and screening must be done with
great care, especially if the infant is visually
oriented. Handicapped children or children with
language delay need to be evaluated by an
audiologist.
Detection of Hearing Abnormality
The following factors contribute to a high risk of
deafness or hearing loss at birth:
1.
A family history of deafness
2.
Hyperbilirubinemia
3.
Congenital rubella syndrome
4.
Defects of the ears, nose, or throat
5.
Birth weight 1500 gm or less
As soon as possible after the child is born, the
ears should be inspected for the presence of any
deformity, asymmetry, unusually low placement,
peculiar slant, cosmetically significant protrusion,
skin tags, or other anomalies. The area immediately
in front of the ear should be well examined for
the presence of a dermal sinus. It is possible for
even a pinhole size opening to be an avenue for
serious infection by staphylococci or other
organisms. The external size of the sinus gives no
indication of its possible depth into vital body
tissues. The demonstration bath provides a particularly
good opportunity for surface inspection of the ears
by the public health nurse.
Hilson (1966) has called attention to the fact that
a malformed ear may signal the presence of an
associated anomaly of the genitourinary tract. He
further states that genitourinary malformations are
the commonest anomalies found in the population
over the age of 5 years. A malformed ear,
therefore, should alert the nurse working with the
older child to the need for additional assessment.
Congenital anomalies of the mouth or nose may also
be associated with anomaly in the basic
structure of the middle ear or the external ear,
with possible deleterious effects on equilibrium and
hearing.
Gesell (1941) listed a variety of signs suggestive
of deafness or hearing loss. He categorized the signs
as problems that may be due to illness or trauma in
the postnatal period, problems that may have
been present at birth but overlooked during
infancy, and problems in which hearing loss is
progressive. Many of these signs relate to speech.
I. Hearing and comprehension of speech
1.
General indifference to sound
2.
Lack of response to spoken word
3.
Response to noises as opposed to voice
II. Vocalizations and sound production
1.
Monotonal quality
2.
Indistinct
3.
Lessened laughter
4.
Meager experimental sound play and squealing
5.
Vocal play for vibratory sensation
6.
Head-banging, foot-stamping for vibratory sensation
7.
Yelling, screeching to express pleasure, annoyance or need
III. Visual attention and reciprocal comprehension
1.
Augmented visual vigilance and attentiveness
2.
Alertness to gesture and movement
3.
Marked imitativeness in play
4.
Vehemence of gestures
IV. Social rapport and adaptations
1.
Subnormal rapport in vocal nursery games
2.
Intensified preoccupation with things rather than persons
3.
Inquiring, sometimes confused or thwarted facial expression
4.
Puzzled and unhappy episodes in social situations
5.
Suspicious alertness, alternating with cooperation
6.
Markedly reactive to praise and affection
V. Emotional behavior
1.
Tantrums to call attention to self or need
2.
Tensions, tantrums, resistances due to lack of comprehension
3.
Frequent obstinacies, teasing tendencies
4.
Irritability at not making self understood
5.
Explosions due to self-vexation
6.
Impulsive and avalanche initiatives
Some of these behaviors may signal the presence of
dysfunctions of psychosocial origin, disorders of
perception, or other problems not specifically
related to hearing loss. Again, the point is to be
objective in observation, precise in recording, and
concerned about referral for medical attention.
The early detection of hearing abnormality or lack
of response has particular relevance to language
acquisition, since this is a time-locked function
with the most crucial periods being the first 2 years of
life. If hearing loss is detected early,
amplification may be started as early as the first month.
Concomitantly, special attention can also be
directed to use of the other sensory avenues for learning
(sight, touch, smell, and taste).
Normal Speech Development
During the first hours and days of life, the
nature, pitch, intensity, and frequency of the infant's cry are
important components in a nursing appraisal because
the cry has a great significance in terms of the
infant's state of health. Physicians rely heavily
upon the skilled pediatric nurse to detect and report
without delay the high-pitched cry of the possibly
brain-injured, the mewing sound characteristic of
some chromosomal abnormality, the very feeble cry
of the weak, or the grunt that denotes
respiratory distress. Current studies and
recordings are seeking more precise means to distinguish
the cries that indicate various states in the
infant.
Except for crying, the very young baby may make
comparatively few sounds besides slight "noises in
the throat." However, by 2 months the baby is
vocalizing a little. By 3 months, chuckles may be
added to the cooing noises; and by 4 months, the
child may laugh aloud. Babbling is usually noted by
6 months; approximately 50 percent of babies will
babble in two or more sounds by this age.
"Normal" speech and language development
covers a range of age levels. Some babies develop
speech and use language effectively at an early
age. Many babies say "mama" or "dada" at 9 months,
add two or three words at the age of 1 year, use
about 10 words at 18 months, and say two- or
three-word sentences at 2 years of age. An infant's
ability to use language early is associated with
early development of cognitive skills and with
continuous language stimulation.
A child may be delayed in reaching speech and
language developmental mileposts for a number of
reasons. If organic or neurologic factors can be
ruled out, suspect a lack of motivation and/or
stimulation. Delay or deviation in speech and
language development maybe manifested as an
articulation problem, in which the toddler does not
"say his sounds right"; as a stuttering problem, in
which the normal non-fluencies of language learners
are replaced with tense repetitions or
prolongations of words or sentences; a too fast or
too slow rate of speech; a voice level that is too
high or too low in pitch or too loud or too soft in
volume.
Parents, other child care givers, and child health
providers can play an important role in providing
models of speech and language. Rather than request
repeatedly that the child say certain words and
phrases, adults can repeat examples of the desired
pronunciation or sentence structure.
Just as normal speech and language development
covers a range of behaviors, disordered speech
and language runs the gamut from an occasional
mispronounced word or garbled syntax, to frequent
unintelligible gibberish. The effects of maturation
and stimulation are important in the development of
intelligible speech and language patterns. If a
child between 2-1/2 and 4 years of age has a speech
and language pattern that is deviant enough to make
communication difficult or impossible, an
evaluation by a speech, language, and hearing
specialist is indicated.
Specific Learning Disability
Increased attention is being given to the
recognition of the learning disabled child. Out of every 100
school children of normal intelligence, an
estimated 5 to 10 percent have a specific learning disability
(SLD) and/or hyperactivity and other developmental
deficiencies that require special interventions.
A variety of terms is used to describe these
children. Specific learning disability is defined under the
Education for All Handicapped Children provisions
of the 1975 amendments to Public Law 94-142
as "a disorder in one or more of the basic
psychological processes involved in understanding or in
using language spoken or written, which may
manifest itself in imperfect ability to listen, think, speak,
read, write, spell, or do mathematical
calculations. Such disorders include such conditions as
perceptual handicaps, brain injury, minimal brain
dysfunction, dyslexia, and develop- mental
aphasia."
The definition does not include children who have
learning problems that are primarily the result of
visual, hearing, or motor handicaps, of mental
retardation, of emotional disturbance, or of
environmental, cultural, or economic disadvantage.
However, children with the excluded handicaps
may have concomitant SLD with resultant multiple
handicaps affecting their psychosocial and
educational adjustment.
SLD focuses on outcomes of impaired CNS functioning
whereas minimal brain dysfunction focuses
on neurodevelopmental and etiological aspects.
Dyslexia simply means "difficulty with reading" and is
one type of learning disability. A small percentage
of these children have only hyperactivity,
impulsiveness, and short attention span, which are
sometimes referred to as the hyperkinetic
syndrome. Another small percentage have a pure form
of learning disability with few other signs.
Most children have mixed patterns of hyperkinetic
syndrome and specific learning disability that may
vary from mild to severe.
Central nervous system dysfunctions in these
children occur as a unique individual profile of deficits
and assets:
1. Short attention span
2. Distractibility
3. Hyperactivity
4. Impulsiveness
5. Labile emotions
6. Poor motor integration
7. Deficits in the perception of space,
form, movement, and time
8. Disorders of language or symbol
development.
The concern with these children is that there
should be early identification, remediation, and
treatment to allow the child to reach his maximum
potential and prevent emotional or psychiatric
maladjustments. The nurse has an important role in
identifying these children; referring them for
formal evaluation and diagnosis; assisting parents
and the children in understanding the disability and
obtaining the necessary therapies, and in
interpreting their problems and needs to teachers and
counselors.
Inspection of the Mouth and Nose
The infant's nose and mouth should be carefully
examined for any apparent anomaly. The feeding
situation provides many opportunities to inspect
both. Whereas a cleft lip is immediately apparent, a
partially cleft palate may escape detection until a
child is several years old or
even-rarely-kindergarten age.
Rosenstein (1977) has pointed out that any child
with malformations of the face, particularly of the
mouth, jaw, or nose, is at risk of having
associated dental problems. During the period of tooth
formation in utero, any systemic disturbance or
trauma can affect gum formation, enamel matrix
formation, dental formation, or calcification. The
type and extent of resulting defects will depend
upon the gestational age at which the deviation
took place, and the duration and severity of the injury
or disturbance. Postnatal accidents and injuries to
the teeth and adjacent structure (such as a bad fall
or a blow on the mouth or jaws) create problems
when secondary teeth are in the process of
formation. There are also a variety of genetic
defects that can cause teeth to be translucent,
discolored, irregularly arranged, absent, or
malformed in whole or in part. It has been found that
mothers treated with certain antibiotics, such as
tetracycline, may give birth to infants whose teeth
will be discolored when they erupt; and children
treated with a tetracycline-type drug after birth may
exhibit similar discoloration of the teeth. Several
developmental disabilities affect the gums as well as
the teeth.
The eruption of primary teeth usually takes place
in the following sequence:
Eruption Of Primary Teeth
|
Type of Tooth |
Eruption (age in months) |
|
|
|
Lower |
Upper |
|
1.
Central incisor |
6-10 |
8-12 |
|
2.
Lateral incisor |
10-16 |
. 9-13 |
|
3.
First molar |
14-18 |
13-19 |
|
4.
Cuspid |
17-23 |
16-22 |
|
5.
Second molar |
23-31 |
25-33 |
A good way to remember this sequence is that teeth
erupt at about 4-month intervals. As in all other
aspects of development, there is a normal range of
variability in the rate of tooth eruption. Inrelatively rare circumstances, a
single central incisor may be present at birth. It is also within normal
limits, although rare, for eruption of the first
tooth to be delayed until the infant is 12 months old.
When the child's overall rate of development is
normal, one need not be overly concerned if the first
tooth does not erupt until that age. However, if
the eruption is delayed beyond 12 months or if any
abnormalities of the teeth are noted, a dentist
should be consulted.
Some infants and young children develop dental
problems as a consequence of serious difficulties in
sucking, swallowing, use of the tongue, excessive
drooling, or grinding of the teeth.
After the baby's teeth have erupted, bottle feeding
of sweetened infant formula or sweetened
fruit-flavored drinks contributes to nursing bottle
caries. This form of caries may develop after
prolonged nursing on bottles of sweetened fluids at
bedtime, which allows sugar to remain in contact
with the baby's teeth during the night.
Phibbs (1977) has stated that most newborns are
nose breathers. If the nose is obstructed and they
are not provoked to cry, many infants will not open
their mouths to breathe and may become very
hypoxic. This is why strict attention is paid to
clearing the infant's nose immediately after birth.
Unilateral or bilateral choanal atresia is rare, as
are masses, such as an encephalocele protruding in
the nasopharynx. Severe obstruction from causes of
this type should be promptly identified and
treated medically. Signs of profuse mucopurulent,
blood-tinged nasal discharge may be present at
birth or develop in the neonatal period due to
syphills. In such cases, there may be accompanying
syphilitic lesions in the mouth. Secondary
infections of the nose are not infrequent in this type of
discharge and may lead to destruction of the
bridge, commonly referred to as a "saddle nose." An
unusually beaked nose may be associated with a
variety of congenital defects.
Normal Development of Taste and Smell
Some infants indicate awareness of taste by facial
expression. A piece of sugar usually elicits sucking
and smacking of the lips. Salt, on the other hand,
tends to produce a grimace and little or no sucking;
Andre'-Thomas(1960) notes that the baby may also
protrude the tongue to "get rid of it." These
reactions are most marked after a feeding.
It is not easy to assess the baby's ability to
taste or smell and it is usually of little importance to do so
during infancy. If the baby has a sucking problem,
however, the ability to elicit appropriate responses
to certain taste and olfactory stimuli may be vital
to his or her welfare. Haynes (1968) observed that
considerable success in feeding could be achieved
with some infants who have aberrant
suck-and-swallow patterns by instituting carefully
selected taste, olfactory, or other stimulus into the
feeding process. A drop of honey applied to the tip
of the bottle nipple, chilling of the nipple, and
careful administration of light whiffs of aromatic
spirits of ammonia coupled with appropriate
positioning of the infant-are some of the measures
which enhanced sucking and achieved adequate
nutrition. The work of Pratt, Nelson, and others
(1938), although carried out over 40 years ago, is
still a useful reference when the presence or
absence of smell and taste needs to be determined
during infancy.
SLEEP PATTERNS
There is considerable variability in the sleep
patterns of the neonate. Wolff (1959) and Brazelton
(1961) have pointed out the wide range of
spontaneous jerks and twitches that are entirely within
normal limits, even though they may occasionally
awaken the child. The studies of Parmalee, Schultz,
and Disbrow (1961) indicated that infants do not
sleep 19 to 22 hours per day as previously
believed. The 75 infants they studied during the
first 3 days of life were awake on an average of 7 to
8 out of 24 hours, that is-they slept 65 to 70
percent of the time. The longest wakeful period ranged
on the average from 1.9 to 2.3 hours. The sex of
the child seemed to have no influence upon these
patterns.
A nurse who finds that a baby is sleeping only
about 16 hours out of the 24 should determine if this is
a normal pattern for this baby. The mother should
be given this information before she goes home
with the child to avoid anxiety over the apparent
"sleeplessness."
Sometimes, unusual patterns of sleep, drowsiness,
or listlessness, or an opposite pattern of excessive
wakefulness, irritability, and crying may be significant
indications that all is not well with a child.
Marked and consistent deviations along these lines
rarely escape early detection. However, the
infant in the hospital nursery has many caregivers.
Increasing use of part-time staff, plus the fact that
the entire personnel in a nursery changes several
times in a 24-hour period, suggests that sharpened
observations and reasonably detailed records are
needed to detect the more subtle deviations of this
type. An infant may appear a bit fussy or unresponsive
at times during any one tour of duty without
arousing concern. A cumulative record of such
behavior repeated throughout a 24-hour period,
however, can aid in the detection of a significant
underlying difficulty which might otherwise escape
attention during the normally brief hospital stay
of mothers and babies after delivery.
After discharge from the hospital, the young or
inexperienced mother may be disturbed by her
infant's irritability but fail to report it because
she thinks the behavior is due to her own inadequacy.
Another mother may rejoice that her infant is
unusually "good" without realizing that he is actually
abnormally listless or drowsy. Therefore, when such
behavior is noted in a child at a well-baby
conference or pediatric clinic, public health
personnel should take particular care to obtain a
reasonably complete assessment of the child's
behavior in the course of a home followup program.
INFANTILE SEIZURES (SPASMS)
The infant may experience a seizure or other
episode, accompanied by an unusual position. The
seizure may subside before the physician makes
rounds in the hospital or sees the child at the office,
a clinic, or well-child conference. The nurse
should therefore always be alert for, and carefully
record, any such episode.
Infantile myocionic seizures may be evidenced by a
sudden contraction of the flexer muscles of the
trunk, possibly accompanied by abrupt flexion of
arms to the chest and thighs to the trunk. The
forearms may be retracted and the hands pulled to
either side of the head, so that the seizure may
resemble the Moro reflex. A sharp cry may precede
or accompany the seizure. The face may
assume a momentary blank or shock-like expression.
In some instances, a sudden noise, some
manipulation, or feeding precipitates the attacks;
in others, the attacks occur just before the onset of
true sleep or immediately on waking. Apneic
episodes, episodic nystagmus, episodic changes in tone
and/or color and episodic sneezing may be seizure
manifestations.
Petit mal, minor motor, psychomotor, and grand mal
seizures may all occur during infancy, but the
minor motor type is most common. Baird (1963) has
called attention to abdominal epilepsy in infants
and young children. This is a possibility of
particular importance to the public health nurse in her
home followup of infants who are not under regular
medical surveillance and who have unusually
persistent or severe episodes of so-called
"colic." A helpful reference on infant spasms or seizures,
which includes excellent illustrations, is
"Infantile Spasms"-No. 15 in the series "Clinics in
Developmental Medicine," published by the
Medical Education and Information Unit of the Spastics
Society in association with Heinemann Medical
Books, and available from J. B. Lippincott Co.,
Philadelphia.
INSPECTION OF THE FONTANELS
The fontanels should not be bulging, deeply
depressed, excessively wide, or excessively narrow in
the early months. Normally, the anterior fontanel
closes some time between the 6th and 18th months.
If the fontanels barely admit the tip of a finger
before the child is 6 months of age, show little
evidence of closure by 12 months, or are bulging or
depressed, medical evaluation should be
obtained.
BODY MEASUREMENTS
It is important that serial assessments be made and
recorded on every infant and young child.
Changes in physical growth may be the first
indication of an underlying problem.
Head circumference measured at occiput-supraorbital
ridges is approximately 13 to 14 inches at
birth. As a general rule, there is a 2-inch
increase during the first 4 months and another 2-inch
increase by the time the infant is 1 year old. From
that time on, growth of the head is exceedingly
slow, totaling only about 4 additional inches by
about 20 years of age.
If an infant's rate of growth in head circumference
changes by one or more standard deviations, a
referral should be made.
Chest circumference is measured at the level of the
nipples with the baby lying outstretched. Head
size usually exceeds chest size by 1 inch until
about 1 year of age. The head-chest relationship is then
equal until about 18 months, when chest size begins
to exceed head size.
The National Center for Health Statistics (NCHS)
and the Center for Disease Control (CDC) of the
U.S. Public Health Service jointly developed growth
charts in 1976 to use in recording the body
measurements of an individual child over a period
of time. These charts are based on extensive
studies of the growth patterns of American boys and
girls from birth to 18 years of age and include
lines that indicate selected percentiles of growth.
Charts for ages birth to 36 months are designed to
record length for age, weight for age, head
circumference for age, and weight for length. Charts for
ages 2 to 18 years include stature for age, weight
for age, and weight for stature. Copies of the
charts are shown on the following pages.
Supplies of growth charts are not available from
CDC, NCHS, the Bureau of Community Health
Services, or other agencies of the U.S. Government.
Several pharmaceutical companies have reprinted the
growth charts as a service to medical and
health professionals for use in clinics and
hospitals. Generally, charts are supplied in reasonable
quantities to such professionals upon request to
local sales or educational representatives or territory
managers of the pharmaceutical company. To obtain
the name of the representative or other
information about how to order the charts, write to
the following:
If you have any questions
about this material, you can email them here.
Please make sure that you include your email
address. If you need to reach Dr. Hammer, his email
address is:
ehammer@cortex.ama.ttuhsc.edu
Last Updated on 9/25/95 by
sean@cortex.ama.ttuhsc.edu. With SPECIAL THANKS to
Carrie Garms for the initial scan and edits and to
Paige Denison for the final edit (Ed, she is ready for your test :))--sean.