Major Components of Appraisal
(Source: Hanyes, Una (1979) A developmental approach to casefinding: among infants and children. Washington: U.S. Public Health Service. Used by permission)
A considerable amount of new knowledge has surfaced in recent years, resulting in a reappraisal of earlier studies in the fields of neonatology and perinatal nursing. No attempt is made here to review all the pertinent aspects of appraisal in the neonatal period. What follows are merely a few highlights of the appraisal process.
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 Brazelton (1973) and his colleagues. Criteria included in the code are comparable to the descriptions of Prechtl and Beintema (1964).
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.
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. Philip (1977) points out that 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.
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 after effects.
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.
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 followup. 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).
Possible abnormalities include deviations from these characteristics, asymmetry, or abnormal movements such as myoclonus or convulsions.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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).
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.
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:
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:
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. In relatively 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.
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.
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 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.
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: