Well Infant

8/9/2019 Well Infant

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GENERAL STATE AT THE TIME OF

OBSERVATION

Andre-Thomas, Chesni, and Dargassies (1960) called attention to the fact that

infants react differently in different circumstances. For instance, the infantwho is bombarded with stimuli when naked and possibly slightly chilled orinsecure during a bath may appear to be quite hypertonic. The same infantmay appear much more normal, flexed, and relaxed when warm and secure inthe arms of the mother or nurse. Similarly, being hungry or well-fed will affectthe sucking and rooting reflexes. Crying inhibits some reactions. Serialobservations are therefore extremely important, as they obviously makepossible a finer degree of assessment.

A useful device for recording the state of the infant at the time a particularmanifestation is observed, or the varying states in which the observation is

repeated, is a code developed by Brazelton (1973) and his colleagues. Criteriaincluded in the code are comparable to the descriptions of Prechtl andBeintema (1964).

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 mustbe 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 exceptstartles 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; activitylevel 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.


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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 theextremities, 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 withstimulation [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 thepublic health nurse at the time an untoward symptom is noted can greatly helpthe physician in evaluating the nurse's report.

VITAL SIGNS

Temperature

Usually the first temperature is taken rectally to detect the possible presenceof an imperforate anus. Auxillary temperatures are recommended after that toprovide an early indication that the baby is being subjected to cold stress. Theneonate may be able to maintain a core temperature even when subject tocold stress, so that a normal rectal temperature could be misleading. Normallimits for auxillary temperature are 36.5o to 37.0oC (97.6o to 98.6oF). (If theinfant is in an incubator, the incubator temperatures must also be recorded,since hypothermia can be masked by a high environmental temperature.) Anydeviation 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 ratesof 100 or110 beats per minute. With current monitoring techniques it may bepossible to look at the beat-to-beat variability (this is the rate calculated onthe basis of the time interval between successive R waves).

As with the fetus, newborns usually have a good deal of variability of heartrate. Loss of variability is more likely to be seen in sick neonates.


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Bradycardia, usually defined as a heart rate below 100 beats per minute, maybe normal in some babies, particularly during the latter part of the neonatalperiod. However, bradycardia is a frequent accompaniment of prolonged apneaand seems to accompany hypoxia. Another likely explanation is congenitalheart block, with or without associated cardiac abnormalities. Severe

hypocalcemia is another possible cause.

Tachycardia (increased heart rate) may be due to crying, fever, or earlycardiac failure. Very fast rates (over 200 to 300 beats per minute) are usuallydue to some form of atrial problem (Philip, 1977).

Policies should be clearly defined to guide nurses and medical staff aboutintermediate measures to be followed in the presence of abnormal heart orrespiratory 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 mayhave considerable irregularity when awake.

Premature infants frequently have brief periods of apnea interspersed withbursts of good ventilation (periodic breathing). This is generally considered tobe 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 ofrespirations for longer than 15 to 20 seconds, particularly when accompaniedby bradycardia. It requires careful medical evaluation and management. Philip(1977) points out that apnea seems primarily due to immaturity of therespiratory center and also that a frequent cause of apnea in small prematuresis the passage of a bowel movement (or preceding a hard stool).

Dyspnea: Dyspnea may be associated with cyanosis and can be due to a varietyof causes, including primary pulmonary diseases, central nervous system

disorders, and cardiovascular problems. Abdominal distension (which limitsdiaphragmatic excursion) and certain metabolic problems may cause apnea aswell as dyspnea.

Tachypnea: A respiratory rate exceeding 60 beats per minute is known astachypnea. Although often transient and benign, it may be an early sign ofserious illness, such as congenital heart disease.


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Stridor: A harsh, high-pitched respiratory sound called stridor may be heardupon occasion during the inspiratory or expiratory phase of breathing. A high-pitched noise is more likely to be the result of obstruction at the laryngeallevel, while a low-pitched noise is more likely due to tracheal problems. In anyevent, stridor is caused by intrinsic or extrinsic blockage of the upper airway.

Intermittent or inspiratory stridor should be reported to the medical staff, aswell as other respiratory symptoms, although they tend to be more benign.Continuous stridor warrants immediate medical attention and writtenguidelines should be available for personnel to follow until a physician is inattendance.

Color

Color changes in general tend to indicate physiologic state, maturity, andreaction to temperature changes in the environment. Usually the Caucasianneonate 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 grayishnessare 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, pallorandjaundice may not be as readily visible among those with darker complexions.Observation of the conjunctiva for pallor and the sclera for jaundice mayprovide more accurate information in such Orientals.

Shades of skin color in black babies range from very fair to very dark. Handsand 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 toobserve the overall appearance and then the color of both the mucousmembranes 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 brightred, with a sharp line of demarkation in the midline. This appears anddisappears abruptly, lasting only a few moments. It may recur. The cause ofthe 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 anotherduring delivery. Generalized petechiae are always worthy of report to medicalattention as they may indicate a coagulation abnormality.

Physiologic jaundice (a yellow color) occurs in most newborns on the second orthird day of life. It usually requires no specific treatment, but medicalmonitoring is highly desirable since, following baseline investigations,treatment such as phototherapy may be indicated.


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hospital nursery. However, public health nurses caring for the older babyshould remain alert to the amount of "wobble" as they play with or bathe ayoungster, particularly if there are other reasons to suspect that this is anunusually flabby child.

Occasionally, a baby who is apparently normal in every other way will be foundto be very "floppy," that is-so lacking in tone that the head and trunk must becarefully supported when ever the infant is moved. The limbs appear to havelittle or no resistance to passive motion. Sometimes, the phrase "like a littlerag doll" is used to describe a child of this type. While it is possible that such achild may mature normally, lack of tone may be an indication of Down'ssyndrome or other dysfunction, and therefore warrants careful followup. Silverand Gabriel (1964) have suggested that certain mental illnesses, such aschildhood schizophrenia, may first signal their presence through generally poormuscle tone as well as persistence of primitive postural responses.

Infants may be found who have such marked extensor tone that they "rearbackwards" and stiffen out as the mother or nurse attempts to hold or feedthem. In some infants, it may be noted during bathing or diapering that one ormore of the limbs seem to "catch" at the midpoint of flexion and extension,suggesting the possible presence of a hyperactive stretch reflex. Or, on internalor external rotation, one or more limbs may offer resistance, and the child mayindicate 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 signalthe presence of cerebral palsy and related disorders have been provided by

Illingworth (1966).

The relevance of such observations and referral to medical attention haveimplications for the primary caregiver, usually the mother, as well as for thechild. Hopefully, medical attention will lead to early diagnosis and theinitiation of appropriate management to remediate or alleviate the child'sproblems early in life. However, even if the difficulties prove to be transientand benign in the long run, the normal process of bonding and attachment maybe interrupted if the child is too stiff or too floppy to initiate self-comfortingbehaviors or invite cuddling. The infant who rears backward when the parentsseek to feed or embrace the baby may be seen as "rejecting" their nurturance.

Insecurity or frustration about their parenting skills may be markedlyexacerbated unless the parents are helped to understand why the baby fails torespond in expected ways. The nurse should help to meet the parents' and theinfant's needs under these circumstances.

The next three sections are based primarily on the neurological appraisal ofinfants as outlined by Paine (1960), Prechtl and Beintema (1964), and Touwen(1976).


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SPONTANEOUS MOVEMENTS

The normal movements of newborns are jerky and usually alternate in the legsbut are symmetrical in the arms. They may be jittery or tremulous. The limbsare usually flexed. Premature infants, on the other hand, show greater

tendency to extension of the limbs, and their spontaneous movements may bewrithing 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. Thepresence of a "pithed frog" position, marked opisthotonos, or constantly

outflung arms will usually be readily apparent. The asymmetry of brachial palsymay also be quite obvious. Hemiparesis, on the other hand, is rarely apparentin the newborn.

In infants born with congenital cerebral lesions, such as porencephaly, theearliest sign is usually minimal movement of one arm and a greater tendency tokeep that hand clenched than the other. In the legs, a greater tendency towardexternal rotation of the hip may suggest a possible hip dislocation, a pyramidaltract abnormality, or future spastic hemiparesis. Abnormal postures that areapparent for only brief periods may be due to seizures, which are discussed in alater section.


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Pithed frog position

BASIC REFLEX PATTERNS

This section includes suggestions intended to help sharpen surface observationsfor possible anomaly, plus a few highlights on the potential effects of theabnormal 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 isbrushed by a hand or facecloth. If a nipple is touched to the face -whether tothe right or left, above or below the mouth-the lips and tongue will tend tofollow in that direction.

These rooting and sucking reflexes should be present in all full-term babies. Asmight be expected, they are more easily elicited before than after a feeding.The reflexes may be absent in small prematures. Absence among full-terminfants suggests depression of the central nervous system from maternalanesthesia, hypoxia, or congenital defect.


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Rooting reflex

These responses usually last until the infant is 3 or 4 months old. However, therooting response may persist during sleep until as late as 7 or 8 months. Atlater ages, visual stimulation plays a part-babies may root for a bottle but maynot respond to the touch of a finger.

Persistence of the response beyond the 7th month, or its reappearance later inlife, warrant thorough medical evaluation.

While rooting and sucking reflexes are being appraised, attention should alsobe given to the possible presence of such anomalies as a particularly smallchin, 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, orasymmetry of the nasolabial folds. Excess salivation, mucus, and frothingalways warrant attention. Feeding problems are discussed later.

The Moro Reflex

The Moro reflex, sometimes termed a "startle" reflex, is a series of movementsby an infant in response to a stimulus. The pattern of movement varies among


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infants, and gradually alters during the first few months of life with increasingmaturity. It is not possible, therefore, to give a single description for all agesand 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 extremities with

extension of the spine and retraction of the head. The forearms are supinated and thedigits 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 toextend and abduct with the upper extremities, although there may be a slightmovement of flexion first. If the lower extremities are extended when thestimulus is applied, the flexion movements may be more readily noted.

A sudden jolting movement, such as that produced by striking the mattress ortable on both sides of the infant, will usually cause the startle response.Occasionally a loud noise may precipitate the reflex. Extension of the headrelative to the trunk or a sudden strong stimulus appear to be the most reliablemeans 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 mostinfants change at about 90 days from the newborn phase to a transitional phasein which movements become less gross, and at about 130 days to the final


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"body-jerk" phase. Persistence of the Moro reflex after the 6th month should beconsidered suspicious and deserves careful medical evaluation.

The Moro response is missing or incomplete in the younger premature butshould be readily obtained in any full-term normal baby. Its absence in a

newborn may be due to a central nervous system disorder. Occasionally, aninfant will display the Moro reflex on the first day, but this is followed bygreatly diminished intensity of the response during the ensuing weeks, possiblybecause of birth injury or general muscular weakness. Occasionally cerebraledema or other factors may cause the reflex to be absent on the first day andgradually develop during the following 4 days. In some cases of cerebralhemorrhage, the reflex may be present the first day, disappear, and returnslowly after the 6th day. These variations point to the value of public healthnurses following up infants who have been discharged early from the hospitalafter delivery.

Asymmetry of response may occasionally be noted in normal full-term infants,but asymmetry usually suggests fracture of the clavicle or humerus, injury tothe brachial plexus, or neonatal hemiplegia. Paine (1964) points out that adefective Moro, opisthotonos, and the setting-sun sign of the eyes (only theupper half of the iris showing above the lower lid) are the principal andprobably indispensable clinical signs of kernicterus in the first week of life.Whenever such symptoms are noted, the need for medical attention isimmediate and urgent.

Paine did not find persistence of the Moro reflex beyond the 6th month in anyof the infants in his series who had homologous retardation of psychic and

motordevelopment. But abnormal persistence was seen occasionally in thepresence of spastic tetraparesis, and in one infant who subsequently developedathetosis. Touwen (1976) points out that it may be hard to differentiate theMoro reflex from a fright response occurring later in life. Nevertheless, theolder child with a persistent Moro is at risk of having this resemblanceoverlooked. As an example, in teaching the child self-feeding, the suddenextension of the arms and opening of the hands, causing the spoon to fly off inone direction and perhaps the food in the other, may be interpreted by thecaregiver or "behavior shaper" as due to volitional, maladaptive behavior. Or itmay be ascribed to the possibility that the child is too retarded to understandwhat 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 backunexpectedly, a sudden flash of sunlight on the spoon, or a loud noise orunexpected jostle of the chair or table.

In the course of routine nursing functions, no matter how gently the infant ishandled, the reflex will be elicited several times in any 24-hour period in ahospital nursery, during the appraisal and demonstration bath carried out in


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the home by the public health nurse, or during the infant's visits to a well-childconference.

If the infant's limbs are free to move, the hospital nurse should be alert for theMoro 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 cribsheet.

The public health nurse should look for the Moro reflex as she puts the infantdown just before or after demonstrating how to bathe the infant.

Extreme care should be exercised at all times in handling distressed orpremature infants, and they should receive more constant and consistentmedical surveillance. However, while feeding, when checking vital signs, and inother circumstances when the infant is subjected to slight movements, thenurse can observe if and when the Moro appears and the characteristics of the

response.

The Asymmetrical Tonic Neck Reflex

Articles by Gesell (1938) and Gesell and Ames (1960) contain descriptions ofthe asymmetrical tonic neck reflex. These authors assert that it is present inpractically all infants during the first 12 weeks of life, often spontaneouslymanifested by the quiescent baby in the supine position as well as duringgeneral postural activity. The asymmetrical tonic neck reflex appears "whenthe infant, lying on the back, turns the head to one side or if the head ispassively 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 theelbow. The lower limbs respond in a similar manner.


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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 neckpattern among newborns. The response tends to be most noticeable between 2and 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 monthsold. Paine (1964), Prechtl and Beintema (1964), and Vassella and Karlsson(1962) agree that, while the tonic neck pattern may be partially imposed on anormal 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 fewinfants under 3 months of age could sustain the asymmetrical tonic neckpattern 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 beapparent from time to time during the first few months of life, persistence ofthe response after the 7th month constitutes an index of suspicion. Responsesthat are completely obligatory or unusually strong on one side or the otherdeserve medical attention at any age.

A persistent asymmetrical tonic neck reflex is potentially a very handicappingdisability. The child is prevented from seeing both hands simultaneously unlessmeasures are instituted to position the head and hands in midline. The effortto bring food or any object to the mouth is also inhibited. The influence of thepattern on the legs obviously poses severe restriction on the ability to achievestanding and walking.


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Since the newborn needs gentle cleansing of the face, neck, and area aroundthe ears several times in a 24-hour period, the nurse has many opportunities towatch for the asymmetrical tonic neck response as she rotates the head of theinfant in supine to cleanse first one side of the face and then the other. Anobservant nurse can discern whether the asymmetrical tonic neck reflex is

present, whether the response is stronger on one side than the other, andwhether it is compulsory or persistent.

If the body response seems dependent on the head position in serialobservations of an infant over 6 months of age, the nurse should ascertainwhether the reflex has persisted. Waving a bright toy first to the right and thento 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 providesopportunity for carefully examining the child's neck to note the possible

presence of torticollis or webbing. A particularly short neck in relation to therest of the body is also worth noting.

Finally, it is of interest to note that the early and normal tendency of theinfant to extend the "face arm" places the hand in an excellent position to beviewed without effort. Even during the first few days and weeks of life, manynormal infants may be observed maintaining attentive eye contact for minutesat a time with the hand they are facing while in this position. "Learning" thatthe hand is there, at the end of the arm, is a first step toward later learningwhat can be done with a hand.

The Neck-Righting Reflex

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 isfollowed by rotation of the shoulders, trunk, and pelvis in the same direction.In the true neck-righting response, there is a momentary delay between thehead rotation and the following of the shoulders, as opposed to the automatic,sudden, and complete body rotation in immediate response to a passive turn ofthe head that may occur in some abnormal states.


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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 undertakingthe more complicated series of maneuvers by which he rolls over and achievessitting (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 infantsby 10 months of age and was gradually covered up by voluntary activity,making the age of its disappearance difficult to gauge. However, they point outthat a neck-righting reflex in which the response is much stronger with thehead to one side than to the other is not seen in normal infants; nor should theresponse at any age be so completely invariable that the baby can be rolledover 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) orwith considerable excess of tone (hypertonicity) and infants with an obligatoryasymmetrical tonic neck reflex would be impeded from demonstrating a normalneck-righting reflex.

Posture in Ventral Suspension and the Landau Reflex

All normal neonates display some evidence of tone when suspended in theprone position. The nurse may observe this when the baby is turned to proneduring the nursery admission cleansing procedure. Public health nurses mayassess tone as they weigh and measure the baby at well-child clinics or whilebathing the child at home. As the newborn infant is turned to prone, with thetrunk or abdomen supported, the legs should be flexed. While the head maysag below the horizontal and the spine be slightly convex, the infant should notbe completely limp and collapse into an inverted U.


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As the baby becomes a little older, the head and spine are maintained in amore nearly horizontal plane. There is a gradual increase in the tendency toelevate 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 thespine 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 6months. The spine was at least slightly concave in approximately half of the 8-month-olds, but concavity was noted universally at 10 months. Many physiciansdesignate this posture, with the back slightly arched, as a "positive Landau"(Touwen, 1976). Dissolution of the reflex is difficult to ascertain since it isgradually covered up by struggling or other voluntary activity.

The Landau reflex is tested in a different way by others. While holding theinfant in ventral suspension with the head, spine, and legs extended, the nursethen passively flexes the head forward. The reflex is considered present if thewhole 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 thatholding the infant in ventral suspension provides more useful information thanelicitation 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 andthe infant's response. Whatever the infant's age, his limp collapse into aninverted U when held in ventral suspension should be called to immediatemedical 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 withthe optical placing reaction of the hands. Touwen (1976) calls attention to anddescribes the difference between the two.

In each instance, the infant is held in vertical suspension and suddenly loweredtoward a flat surface. The normal positive response is a forward extension ofboth arms and dorsiflexion of the infant's hands during the movement. Thedifference between the two is that, in the optical placing reaction, the infantis permitted to see where he is going. This response may be noted as early as 3months of age. In the true test for the parachute response, the maneuver is thesame 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 about6 or even 9 months of age. Touwen (1976) suggests that the earlier appearanceof the positive response, when the child can anticipate visually that he is goingdown to a flat surface, illustrates the reinforcing effect of visual on vestibularinput. Since the older infant tends to smile or chuckle under anticipatorycircumstances but may be frightened when unexpectedly plunged, the formeris usually the method of choice by the nurse in eliciting the presence of the


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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 responsebegins a little later; it will be noted in most infants by 9 months and in allnormal 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 waselicited. An asymmetrical or absent response warrants medical appraisal.

Parachute reflex

Public health nurses are alerted to watch fathers at play with their children, asthe game of "so high" or "airplane" may provide the opportunities to observe forthe presence and character of the parachute reflex, as well as for extensortone in ventral suspension. Nurses who have developed a warm rapport withthe child and family may themselves play with the infant in this fashion, sincemost infants respond with great glee.


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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 orat the base of the child's toes. The palmar grasp response weakens as the handbecomes less continuously fisted, merging, sometime after 2 months, into thevoluntary 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 awhile thereafter. Possible abnormality may be suspected in asymmetry ofresponse. While there is a tendency to fisting in the neonate, this should not beevident at all times. Serial observation of infants in the nursery should revealrelaxation of both hands at some point, usually during or right after feeding, orperhaps when asleep. These appraisals provide additional opportunities fordetecting 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 feetis always worth noting, particularly if occurring in a female child, as it maysignal the presence of a chromosomal abnormality (X. 0. Turner's syndrome).


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Simian palm crease

Traction Response

Physicians test the traction response by placing the infant in supine, thendrawing him up by the hands to a sitting position. Normally, assistance by theshoulder muscles can be felt and seen. The newborn's head lags behind anddrops forward suddenly when the upright posture is reached. Even in thenewborn period, however, there should be sufficient head control to bring itback upright, and greater control is expected with age. The nurse in testing theneonate may gently raise the infant from supine in this way, in order to note

the presence, absence, or asymmetry of response; but she should avoidreaching the midline point, which causes the head to drop forward suddenly.

Supporting Reaction

The supporting reaction is elicited by holding the infant vertically and allowinghis feet to make firm contact with a table top or other firm surface. The"standing" posture includes some flexion of the hip and knee. Automaticstepping may also be observed when the newborn is inclined forward whilebeing supported in this position. During the first 4 months of life, the crouchingposition gradually diminishes; this is followed by increase in support, so that

normal infants will usually support a substantial propor- tion of their weight by10 months (Paine, 1964).


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Supporting reaction and stepping

In this supported standing position, it is to be expected that a few infants willstand on their toes from time to time or occasionally cross or "scissor" theirlegs. However, consistent standing on the tips of the toes or scissoring of thelegs after 4 months of age may be considered an index of suspicion warrantingmedical attention. A club foot or a deformity at the knee or hip may alsobecome 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


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As a rough guide, the baby can be expected to reach and grasp with the wholehand at 4 or 5 months, grasp with thumb and two fingers at 7 months, and pickup small objects with thumb and forefinger (pincer grasp) at 9 months. Paineet al. (1964) found that the pincer grasp was obtainable in 52 percent of theirseries 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 atendency to ulnar deviation, deserves medical appraisal, as do athetosis,consistent avoiding reflexes, or a developmental lag of 3 months in attainingpincer grasp.

Sitting

The ages at which the infant sits with some support, sits alone, stands, andwalks correlate to a considerable degree with the ages at which changes takeplace 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 indexof suspicion.

One useful criterion for judging whether or not a child is truly "sitting withoutsupport" is to note whether or not he can sit with a fairly straight back and turnthe head or rotate the body without losing balance. Another useful test is toplay with the child, at some time when he is happy and comfortable, while hesits on a hard surface. When the child is given a slight push to one side or theother, it should be noted whether or not he "instinctively" reaches out oneither side for support, and whether the head and trunk curve slightly to theopposite 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 babywill not develop the ability to guard against falling backward by protectiveextension of the arms to the rear until about 12 months of age.

Once the child develops reasonable security in sitting, there will be a tendencyto use the hands more effectively. Therefore, in appraising the child's ability touse the hands while sitting, it is always wise to note first if the child needslateral or posterior support. It may be that the child can use the hands to holdor transfer a block or toy, but is prevented from doing so by a need to use armsand hands for support. It is possible, for instance, for a child with cerebralpalsy 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 securearm, back, and foot supports before the needed hand skills can bedemonstrated. If these factors are overlooked, the situation can prove quitefrustrating and may be inappropriately interpreted.

Locomotion


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About half of all normal infants begin to creep or crawl between 6 and 12months of age; by 12 months the infant should be able to pull erect, and by 18months begin walking independently. Failure to walk independently after 1 8months 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 dueto a variety of specific causes, which may be of a motor, sensory, or emotionalkind (Denhoff and Robinault, 1960; Silver and Gabriel, 1964). An overall lag inseveral developmental aspects may be due to cerebral palsy, mentalretardation, or related cerebral dysfunctions. A peculiar method of creeping orcrawling may also warrant special evaluation, e.g., some children with cerebralpalsy develop a bunny hop, wherein both knees are drawn up simultaneouslyunder 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 hyperkineticbehavior syndrome (Laufer and Denhoff, 1957). It is of interest to note thatchildren who later manifest hyperkinetic behavior disorder (characterized byinvoluntary and constant overactivity) may be significantly advanced inachievement of the milestones of motor development. Such children may climbout of the crib before 1 year of age and walk early. Parental histories alsoindicate that some of these children cannot be kept in the playpen, get intoeverything, run rather than walk, find it intolerable to sit quietly (even at mealtimes), are hyperirritable, cry readily, and wake several times during the night.Such symptoms warrant referral for thorough professional appraisal, for thesake of both the child and the family. However, some children who manifest

hyperkinetic behavior patterns in later childhood display no evidence of thisdisorder during infancy.

The child who is greatly accelerated in phases of growth and developmentmight be evidencing a generally superior endowment. However, an individualof superior endowment may have a normal developmental course or even bedelayed in some aspects. The nurse must remain objective at all times and beguided by the general rule that a deviation of 3 months in the achievement ofdevelopmental milestones constitutes a valid reason for referral to medicalattention.

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 theface-to-face (or "en face") position within minutes after natural delivery canprovide initial evidence of an infant's state of vision at birth. This is also one of


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the most effective means of helping a mother begin to develop the normalattachment and bonding process with her infant.

Increased attention is now being given to bonding and to encouraging thefather to be present when the baby is delivered. A slight delay in instilling

prophylactic medication (to prevent infection) in the infant's eyes, pluspositioning the mother and child in the en face position as soon as the child isbreathing properly, enhances the infant's potential for displaying bondingability. (The interest of the normal newborn in the human face at 2 days of ageis illustrated in the series of training films available to help personnel learn toadminister the Brazelton Neonatal Behavioral Scale.) At this age, the infant canalso track a bright object across the midline and above and below theimmediate eye level when both infant and object are properly positioned toelicit this response. While first evidence of this ability can be noted soon afterbirth, reliable following of objects is observed more readily when the infant is6 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 to8 weeks of age in response to the parent's smile provides relevant evidence ofpsychosocial adaptation as well as evidence of proficient vision and theneuromotor ability to smile.

Detection of Visual Abnormality

Greatly disconjugate or ceaselessly roving eye motions suggests blindness.While the infant may exhibit problems of convergence (which usually begins atabout 3 months), a constant, fixed strabismus warrants careful medicalappraisal at any age.

The setting-sun sign, where only the upper part of the iris appears above thelower lid when the eyes are at rest, is an observation that should receivemedical attention. The infant's eyes should be examined also to note whetherthe cornea of one eye is larger than the other. This could be a sign ofcongenital glaucoma, which can lead to blindness if not detected and treatedvery early.


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Setting-sun sign

Other abnormalities include a total or partial lack of pigmentation, atriangular-shaped notch (palpebral colobomas) in the upper or lower lid, abilateral and symmetrical decrease in the size of the palpebral fissure(blepharophimosis), ptosis (inability to raise the lid fully), the presence ofdermoid cysts, or other unusual signs (Apt and Gaffney, 1977). The presence ofcataracts may sometimes be noted in the infant; the nurse should remain alertto a milky type of film or clouding. As a child is brought to a slightly strongerlight source (for instance, the nursery window), the nurse should see if his

pupils react by contracting and do so equally. There are many opportunities towatch for the blink reflex while cleansing the child's face.

All babies should be inspected for epicanthic folds (folds of skin across theinner angles of the eyes). In a non-Oriental baby, they may be an indication ofDown's syndrome or other congenital disability, and such a child should havecontinued followup. However, epicanthic folds may be a normal manifestationeven in a baby of non-Oriental parentage.


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Unusual placement of the eyes, one eye larger than the other, unusually heavybrows that meet over the bridge of the nose, or a wide-eyed and particularlyforlorn gaze are other signs that may be related to chromosomal aberrations. Asingle slight deviation may be found, such as one eye so slightly smaller thanthe other that it has neither medical nor cosmetic significance. Even this minor

observation should be recorded, since, as previously mentioned, the presenceof three or more minor anomalies indicates that the child should be undersurveillance for a possible major disorder. The times when the infant is bathedor the face is cleansed provide excellent opportunities for inspecting the eyesfor such anomalies.

Epicanthic fold

Attention should be given to all symptoms such as redness, discharge, orswelling about the eyes of children at any age. Signs of possible visual difficultyin the older child include holding objects very close to the face; closing oneeye repeatedly or tilting the head at an unusual angle when attempting tovisualize objects; discomfort when in a brightly lighted environment;headache, frequent eye rubbing, or complaints of burning or itching, afterwatching television or going to the theater. Unusual delay in recognizing colorsmay be another clue to visual difficulty. Visual or perceptual problems may besuspected in the older child who lags behind peers in the ability to stay withinlines 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 avisual or perceptual defect, or the problem may be rooted in neuromotor orother difficulties.

It is important to have the visual problem evaluated and diagnosed as early aspossible to initiate treatment, prevent loss of vision, and promote optimalvision.


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Normal Hearing Development

Northern and Downs (1974) provided an excellent review of the literature onhearing 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), whodemonstrated that most newborns, including those with known disabilities ofthe central nervous system, can discriminate sound on the basis of frequency,intensity, and stimulus-dimensionality, and that speech-like signals appearremarkably effective in producing response in newborns.

Stechler (1964) found that unexpected noise at a level of 70 decibels aboveaudiometric zero elicited a variety of responses from newborns, dependingupon the dimensions of the stimulus. If the sound reached its maximumintensity 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 morelikely to open his eyes, look around, and show an increase in heart rate. Thefirst reaction was interpreted as a defensive one, the second as a display ofinterest.

The Brazelton training films illustrate the arousal state of an infant as young as2 days of age, produced by sound made while the infant is in a light sleepstate. They also depict the way a normal infant responds by turning the head tothe sound of the human voice, and the difference in response to a high-pitchedand a low-pitched voice. The films further show the response of the infant in alight 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 inthe presence of a continuously ringing bell.

There is a marked contrast between the ability of the normal neonate toaccommodate to sound in this way and the plight of many disabled infants whocannot. Infants with developmental problems frequently have some troublegetting to sleep and are easily startled into wakefulness by sounds within thenormal range of customary noises in the environment. Such infants aredeprived of sleep they really need. They tend to be hard to comfort.Meanwhile, the primary caregivers (usually the parents) become increasinglyanxious and frustrated in their attempts to comfort the infant. Deprived of

their own needed rest and sleep, they become increasingly fatigued andirritable. It is not surprising that such circumstances can strain the normalattachment and bonding process between parents and child.

Hearing is also a learned behavior, which involves not only sensitivity to anddiscrimination among various sounds but also understanding, interpretation,storage, recall, and usually an appropriate motor response. The child withnormal motor development relates to many sounds in the environment. Normal


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response at about 6 months involves a turn of the head in the direction of thesound. The child is more apt to respond if the sound is a familiar one (afavorite toy, a spoon rattling in a dish at feeding time); the sound is made at alevel 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 ifthe infant is visually oriented. Handicapped children or children with languagedelay need to be evaluated by an audiologist.

Detection of Hearing Abnormality

The following factors contribute to a high risk of deafness or hearing loss atbirth:

1. A family history of deafness

2. Hyperbilirubinemia3. Congenital rubella syndrome4. Defects of the ears, nose, or throat5. Birthweight 1500 gm or less

As soon as possible after the child is born, the ears should be inspected for thepresence of any deformity, asymmetry, unusually low placement, peculiarslant, cosmetically significant protrusion, skin tags, or other anomalies. Thearea immediately in front of the ear should be well examined for the presenceof a dermal sinus. It is possible for even a pinhole size opening to be an avenuefor serious infection by staphylococci or other organisms. The external size ofthe sinus gives no indication of its possible depth into vital body tissues. The

demonstration bath provides a particularly good opportunity for surfaceinspection of the ears by the public health nurse.

Hilson (1966) has called attention to the fact that a malformed ear may signalthe presence of an associated anomaly of the genitourinary tract. He furtherstates that genitourinary malformations are the commonest anomalies found inthe population over the age of 5 years. A malformed ear, therefore, shouldalert the nurse working with the older child to the need for additionalassessment.

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, withpossible deleterious effects on equilibrium and hearing.

Gesell (1941) listed a variety of signs suggestive of deafness or hearing loss. Hecategorized the signs as problems that may be due to illness or trauma in thepostnatal period, problems that may have been present at birth but overlookedduring infancy, and problems in which hearing loss is progressive. Many of thesesigns relate to speech.


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During the first hours and days of life, the nature, pitch, intensity, andfrequency of the infant's cry are important components in a nursing appraisalbecause 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 reportwithout delay the high-pitched cry of the possibly brain-injured, the mewing

sound characteristic of some chromosomal abnormality, the very feeble cry ofthe weak, or the grunt that denotes respiratory distress. Current studies andrecordings are seeking more precise means to distinguish the cries that indicatevarious states in the infant.

Except for crying, the very young baby may make comparatively few soundsbesides slight "noises in the throat." However, by 2 months the baby isvocalizing 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 6months; approximately 50 percent of babies will babble in two or more soundsby this age.

"Normal" speech and language development covers a range of age levels. Somebabies develop speech and use language effectively at an early age. Manybabies say "mama" or "dada" at 9 months, add two or three words at the age of1 year, use about 10 words at 18 months, and say two- or three-word sentencesat 2 years of age. An infant's ability to use language early is associated withearly development of cognitive skills and with continuous language stimulation.

A child may be delayed in reaching speech and language developmentalmileposts for a number of reasons. If organic or neurologic factors can be ruledout, suspect a lack of motivation and/or stimulation. Delay or deviation in

speech and language development maybe manifested as an articulationproblem, in which the toddler does not "say his sounds right"; as a stutteringproblem, in which the normal non-fluencies of language learners are replacedwith tense repetitions or prolongations of words or sentences; a too fast or tooslow rate of speech; a voice level that is too high or too low in pitch or tooloud or too soft in volume.

Parents, other child care givers, and child health providers can play animportant role in providing models of speech and language. Rather thanrequest repeatedly that the child say certain words and phrases, adults canrepeat 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 occasionalmispronounced word or garbled syntax, to frequent unintelligible gibberish.The effects of maturation and stimulation are important in the development ofintelligible speech and language patterns. If a child between 2-1/2 and 4 yearsof age has a speech and language pattern that is deviant enough to make


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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 disabledchild. Out of every 100 school children of normal intelligence, an estimated 5to 10 percent have a specific learning disability (SLD) and/or hyperactivity andother developmental deficiencies that require special interventions.

A variety of terms is used to describe these children. Specific learning disabilityis defined under the Education for All Handicapped Children provisions of the1975 amendments to Public Law 94-142 as "a disorder in one or more of thebasic psychological processes involved in understanding or in using languagespoken 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 developmental aphasia."

The definition does not include children who have learning problems that areprimarily the result of visual, hearing, or motor handicaps, of mentalretardation, of emotional disturbance, or of environmental, cultural, oreconomic disadvantage. However, children with the excluded handicaps mayhave concomitant SLD with resultant multiple handicaps affecting theirpsychosocial and educational adjustment.

SLD focuses on outcomes of impaired CNS functioning whereas minimal brain

dysfunction focuses on neurodevelopmental and etiological aspects. Dyslexiasimply means "difficulty with reading" and is one type of learning disability. Asmall percentage of these children have only hyperactivity, impulsiveness, andshort attention span, which are sometimes referred to as the hyperkineticsyndrome. Another small percentage have a pure form of learning disabilitywith few other signs. Most children have mixed patterns of hyperkineticsyndrome and specific learning disability that may vary from mild to severe.

Central nervous system dysfunctions in these children occur as a uniqueindividual profile of deficits and assets:

1. Short attention span2. Distractibility3. Hyperactivity4. Impulsiveness5. Labile emotions6. Poor motor integration7. Deficits in the perception of space, form, movement, and time8. Disorders of language or symbol development.


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The concern with these children is that there should be early identification,remediation, and treatment to allow the child to reach his maximum potentialand prevent emotional or psychiatric maladjustments. The nurse has animportant role in identifying these children; referring them for formalevaluation and diagnosis; assisting parents and the children in understanding

the disability and obtaining the necessary therapies, and in interpreting theirproblems and needs to teachers and counselors.

Inspection of the Mouth and Nose

The infant's nose and mouth should be carefully examined for any apparentanomaly. The feeding situation provides many opportunities to inspect both.Whereas a cleft lip is immediately apparent, a partially cleft palate mayescape detection until a child is several years old or even-rarely-kindergartenage.

Rosenstein (1977) has pointed out that any child with malformations of theface, particularly of the mouth, jaw, or nose, is at risk of having associateddental problems. During the period of tooth formation in utero, any systemicdisturbance or trauma can affect gum formation, enamel matrix formation,dental formation, or calcification. The type and extent of resulting defects willdepend upon the gestational age at which the deviation took place, and theduration and severity of the injury or disturbance. Postnatal accidents andinjuries to the teeth and adjacent structure (such as a bad fall or a blow on themouth or jaws) create problems when secondary teeth are in the process offormation. There are also a variety of genetic defects that can cause teeth tobe translucent, discolored, irregularly arranged, absent, or malformed in whole

or in part. It has been found that mothers treated with certain antibiotics, suchas tetracycline, may give birth to infants whose teeth will be discolored whenthey erupt; and children treated with a tetracycline-type drug after birth mayexhibit similar discoloration of the teeth. Several developmental disabilitiesaffect 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 ToothEruption (age in months)

Lower Upper1. 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


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A good way to remember this sequence is that teeth erupt at about 4-monthintervals. As in all other aspects of development, there is a normal range ofvariability in the rate of tooth eruption. In relatively rare circumstances, asingle 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 neednot 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 abnormalitiesof the teeth are noted, a dentist should be consulted.

Some infants and young children develop dental problems as a consequence ofserious difficulties in sucking, swallowing, use of the tongue, excessivedrooling, or grinding of the teeth.

After the baby's teeth have erupted, bottle feeding of sweetened infantformula or sweetened fruit-flavored drinks contributes to nursing bottle caries.

This form of caries may develop after prolonged nursing on bottles ofsweetened fluids at bedtime, which allows sugar to remain in contact with thebaby's teeth during the night.

Phibbs (1977) has stated that most newborns are nose breathers. If the nose isobstructed and they are not provoked to cry, many infants will not open theirmouths to breathe and may become very hypoxic. This is why strict attention ispaid to clearing the infant's nose immediately after birth. Unilateral orbilateral choanal atresia is rare, as are masses, such as an encephaloceleprotruding in the nasopharynx. Severe obstruction from causes of this typeshould be promptly identified and treated medically. Signs of profuse

mucopurulent, blood-tinged nasal discharge may be present at birth or developin the neonatal period due to syphills. In such cases, there may beaccompanying syphilitic lesions in the mouth. Secondary infections of the noseare not infrequent in this type of discharge and may lead to destruction of thebridge, commonly referred to as a "saddle nose." An unusually beaked nose maybe 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 sugarusually 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 thatthe baby may also protrude the tongue to "get rid of it." These reactions aremost marked after a feeding.

It is not easy to assess the baby's ability to taste or smell and it is usually oflittle importance to do so during infancy. If the baby has a sucking problem,however, the ability to elicit appropriate responses to certain taste andolfactory stimuli may be vital to his or her welfare. Haynes (1968) observed


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that considerable success in feeding could be achieved with some infants whohave aberrant suck-and-swallow patterns by instituting carefully selectedtaste, olfactory, or other stimulus into the feeding process. A drop of honeyapplied to the tip of the bottle nipple, chilling of the nipple, and carefuladministration of light whiffs of aromatic spirits of ammonia coupled with

appropriate positioning of the infant-are some of the measures which enhancedsucking and achieved adequate nutrition. The work of Pratt, Nelson, and others(1938), although carried out over 40 years ago, is still a useful reference whenthe presence or absence of smell and taste needs to be determined duringinfancy.

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 spontaneousjerks 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 previouslybelieved. The 75 infants they studied during the first 3 days of life were awakeon an average of 7 to 8 out of 24 hours, that is-they slept 65 to 70 percent ofthe time. The longest wakeful period ranged on the average from 1.9 to 2.3hours. 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 24should determine if this is a normal pattern for this baby. The mother shouldbe given this information before she goes home with the child to avoid anxietyover the apparent "sleeplessness."

Sometimes, unusual patterns of sleep, drowsiness, or listlessness, or anopposite pattern of excessive wakefulness, irritability, and crying may besignificant indications that all is not well with a child. Marked and consistentdeviations along these lines rarely escape early detection. However, the infantin 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 a24-hour period, suggests that sharpened observations and reasonably detailedrecords are needed to detect the more subtle deviations of this type. An infantmay appear a bit fussy or unresponsive at times during any one tour of dutywithout arousing concern. A cumulative record of such behavior repeatedthroughout a 24-hour period, however, can aid in the detection of a significantunderlying difficulty which might otherwise escape attention during thenormally brief hospital stay of mothers and babies after delivery.

After discharge from the hospital, the young or inexperienced mother may bedisturbed by her infant's irritability but fail to report it because she thinks thebehavior is due to her own inadequacy. Another mother may rejoice that her


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infant is unusually "good" without realizing that he is actually abnormallylistless or drowsy. Therefore, when such behavior is noted in a child at a well-baby conference or pediatric clinic, public health personnel should takeparticular care to obtain a reasonably complete assessment of the child'sbehavior in the course of a home followup program.

INFANTILE SEIZURES (SPASMS

The infant may experience a seizure or other episode, accompanied by anunusual position. The seizure may subside before the physician makes rounds inthe 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 suchepisode.

Infantile myocionic seizures may be evidenced by a sudden contraction of theflexer 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 thehands pulled to either side of the head, so that the seizure may resemble theMoro reflex. A sharp cry may precede or accompany the seizure. The face mayassume a momentary blank or shock-like expression. In some instances, asudden noise, some manipulation, or feeding precipitates the attacks; inothers, the attacks occur just before the onset of true sleep or immediately onwaking. Apneic episodes, episodic nystagmus, episodic changes in tone and/orcolor and episodic sneezing may be seizure manifestations.

Petit mal, minor motor, psychomotor, and grand mal seizures may all occurduring infancy, but the minor motor type is most common. Baird (1963) has

called attention to abdominal epilepsy in infants and young children. This is apossibility of particular importance to the public health nurse in her homefollowup of infants who are not under regular medical surveillance and whohave unusually persistent or severe episodes of so-called "colic." A helpfulreference 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 Societyin association with Heinemann Medical Books, and available from J. B.Lippincott Co., Philadelphia.

INSPECTION OF THE FONTANELSThe fontanels should not be bulging, deeply depressed, excessively wide, orexcessively narrow in the early months. Normally, the anterior fontanel closessome time between the 6th and 18th months. If the fontanels barely admit thetip of a finger before the child is 6 months of age, show little evidence ofclosure by 12 months, or are bulging or depressed, medical evaluation shouldbe obtained.


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BODY MEASUREMENTS

It is important that serial assessments be made and recorded on every infantand young child. Changes in physical growth may be the first indication of anunderlying problem.

Head circumference measured at occiput-supraorbital ridges is approximately13 to 14 inches at birth. As a general rule, there is a 2-inch increase during thefirst 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 about4 additional inches by about 20 years of age.

If an infant's rate of growth in head circumference changes by one or morestandard 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 yearof age. The head-chest relationship is then equal until about 18 months, whenchest size begins to exceed head size.

The National Center for Health Statistics (NCHS) and the Center for DiseaseControl (CDC) of the U.S. Public Health Service jointly developed growth chartsin 1976 to use in recording the body measurements of an individual child over aperiod of time. These charts are based on extensive studies of the growthpatterns of American boys and girls from birth to 18 years of age and includelines that indicate selected percentiles of growth. Charts for ages birth to 36months are designed to record length for age, weight for age, head

circumference for age, and weight for length. Charts for ages 2 to 18 yearsinclude stature for age, weight for age, and weight for stature.

Documents

Well Infant