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 infant
who is bombarded with stimuli when naked and possibly slightly chilled or
insecure during a bath may appear to be quite hypertonic. The same infant
may appear much more normal, flexed, and relaxed when warm and secure in
the arms of the mother or nurse. Similarly, being hungry or well-fed will affect
the sucking and rooting reflexes. Crying inhibits some reactions. Serial
observations are therefore extremely important, as they obviously make
possible a finer degree of assessment.

A useful device for recording the state of the infant at the time a particular
manifestation is observed, or the varying states in which the observation is
repeated, is a code developed by Brazelton (1973) and his colleagues. Criteria
included in the code are comparable to the descriptions of Prechtl and
Beintema (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 must
be interpreted within the context of the presenting state of consciousness since reactions
may vary markedly as the infant passes from one state to another. Evaluation of reactions
to stimuli which are interpreted within the context of the infant's state of consciousness
may well be the best predictor of the infant's receptivity and ability to respond.

Sleep States

State 1: Deep sleep with regular breathing, eyes closed, no spontaneous activity except
startles or jerky movements at quite regular intervals; external stimuli produce startles
with some delay; suppression of startles is rapid, and state changes are less likely than
from other states; no eye movements.

State 2: Light sleep with eyes closed; rapid eye movements can be observed under closed
lids; low activity level, with random movements and startles or startle equivalents;
movements are likely to be smoother and more monitored than in State 1; responds to
internal and external stimuli with startle equivalents, often with a resulting change of
state; respirations are irregular, sucking movements occur off and on.

Awake States

State 3: Drowsy or semidozing; eyes may be open or closed, eyelids fluttering; activity
level variable, with interspersed, mild startles from time to time; reactive to sensory
stimuli, but response often delayed; state change after stimulation frequently noted;
movements are usually smooth.
State 4: Alert, with bright look; seems to focus attention on source of stimulation, such as
an object to be sucked, or a visual or auditory stimulus; impinging stimuli may break
through, but with some delay in response; motor activity is at a minimum.

State 5: Eyes open; considerable motor activity, with thrusting movements of the
extremities, and even a few spontaneous startles; reactive to external stimulation with
increase in startles or motor activity, but discrete reactions difficult to distinguish because
of general high activity level.

State 6: Crying; characterized by intense crying, which is difficult to break through with
stimulation [Brazelton, 1973, p. 5-8].

Some hospitals use Brazelton's code or similar criteria for uniform coding of the
infant's state. An assessment and description of the state of the infant by the
public health nurse at the time an untoward symptom is noted can greatly help
the physician in evaluating the nurse's report.

VITAL SIGNS
Temperature

Usually the first temperature is taken rectally to detect the possible presence
of an imperforate anus. Auxillary temperatures are recommended after that to
provide an early indication that the baby is being subjected to cold stress. The
neonate may be able to maintain a core temperature even when subject to
cold stress, so that a normal rectal temperature could be misleading. Normal
limits for auxillary temperature are 36.5o to 37.0oC (97.6o to 98.6oF). (If the
infant is in an incubator, the incubator temperatures must also be recorded,
since hypothermia can be masked by a high environmental temperature.) Any
deviation from the normal range merits report to medical attention (Philip,
1977).

Heart Rate

Heart rate is usually monitored by listening to the apex with a stethoscope.

The usual rate is 120-160 beats per minute, but some normal infants have rates
of 100 or110 beats per minute. With current monitoring techniques it may be
possible to look at the beat-to-beat variability (this is the rate calculated on
the basis of the time interval between successive R waves).

As with the fetus, newborns usually have a good deal of variability of heart
rate. Loss of variability is more likely to be seen in sick neonates.
Bradycardia, usually defined as a heart rate below 100 beats per minute, may
be normal in some babies, particularly during the latter part of the neonatal
period. However, bradycardia is a frequent accompaniment of prolonged apnea
and seems to accompany hypoxia. Another likely explanation is congenital
heart block, with or without associated cardiac abnormalities. Severe
hypocalcemia is another possible cause.

Tachycardia (increased heart rate) may be due to crying, fever, or early

cardiac failure. Very fast rates (over 200 to 300 beats per minute) are usually
due to some form of atrial problem (Philip, 1977).

Policies should be clearly defined to guide nurses and medical staff about
intermediate measures to be followed in the presence of abnormal heart or
respiratory symptoms.

Respiration

Respiration rate and pattern (regular or irregular) are assessed by observation of the chest
wall and movements of the abdomen (diaphragmatic movement). The normal rate is
frequently stated to be 30 to 50 breaths per minute, but others use a range of 40 to 60
breaths per minute. Most term newborns breathe regularly while in deep sleep but may
have considerable irregularity when awake.

Premature infants frequently have brief periods of apnea interspersed with

bursts of good ventilation (periodic breathing). This is generally considered to
be the result of an immature respiratory center. Other respiratory problems-
such as dyspnea (hard or difficult breathing) evidenced by grunting, or
retractions or flaring of the alae nasi-are looked for during routine observation.

Apnea: Clinically significant apnea is generally accepted as cessation of

respirations for longer than 15 to 20 seconds, particularly when accompanied
by bradycardia. It requires careful medical evaluation and management. 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.

Color

Color changes in general tend to indicate physiologic state, maturity, and

reaction to temperature changes in the environment. Usually the Caucasian
neonate will be pink in color or perhaps ruddy. Cyanosis of the hands and feet
is normal for several hours after birth, but generalized blueness or grayishness
are signs of inadequate oxygenation. A somewhat pale child may have anemia.
Extreme pallor may indicate a serious condition.

While pallor is also a warning sign in babies of Asian background, pallorand

jaundice may not be as readily visible among those with darker complexions.
Observation of the conjunctiva for pallor and the sclera for jaundice may
provide more accurate information in such Orientals.

Shades of skin color in black babies range from very fair to very dark. Hands
and feet of black babies normally present a dusky appearance for a few hours
after birth. In assessing infants with darker complexions, it may be helpful to
observe the overall appearance and then the color of both the mucous
membranes and the nail beds of the fingers and toes.

Harlequinism is a striking, transient change in the skin color of the newborn.

Typically, one side is normal or a little pale while the other side turns a bright
red, with a sharp line of demarkation in the midline. This appears and
disappears abruptly, lasting only a few moments. It may recur. The cause of
the condition is not known, and it has no serious 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.

MUSCLE TONE
The assessment of tone requires considerable experience and judgment. It is
not expected that the average nurse will necessarily be able to discern subtle
variations, but most nurses soon become aware of generalized hypertonicity
(the extremely "stiff" infant) or hypotonicity (the very "floppy" infant).

Andre-Thomas et al. (1960) call attention to a factor they term "consistency" -

that component of muscle tone which can be assessed by palpating a muscle
and noting the amount of transverse "wobble" obtained when the limb is
shaken. Since the nurse must handle the newborn with some delicacy, it is
doubtful that the consistency factor will be a major part of appraisal in the
hospital nursery. However, public health nurses caring for the older baby
should remain alert to the amount of "wobble" as they play with or bathe a
youngster, particularly if there are other reasons to suspect that this is an
unusually flabby child.

Occasionally, a baby who is apparently normal in every other way will be found
to be very "floppy," that is-so lacking in tone that the head and trunk must be
carefully supported when ever the infant is moved. The limbs appear to have
little or no resistance to passive motion. Sometimes, the phrase "like a little
rag doll" is used to describe a child of this type. While it is possible that such a
child may mature normally, lack of tone may be an indication of Down's
syndrome or other dysfunction, and therefore warrants careful 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).
SPONTANEOUS MOVEMENTS
The normal movements of newborns are jerky and usually alternate in the legs
but are symmetrical in the arms. They may be jittery or tremulous. The limbs
are usually flexed. Premature infants, on the other hand, show greater
tendency to extension of the limbs, and their spontaneous movements may be
writhing and athetotic.

Possible abnormalities include deviations from these characteristics,

asymmetry, or abnormal movements such as myoclonus or convulsions.

BODY POSTURE
The posture of the limbs and trunk at rest is also important in appraisal. The
presence of a "pithed frog" position, marked opisthotonos, or constantly
outflung arms will usually be readily apparent. The asymmetry of brachial palsy
may also be quite obvious. Hemiparesis, on the other hand, is rarely apparent
in the newborn.

In infants born with congenital cerebral lesions, such as porencephaly, the

earliest sign is usually minimal movement of one arm and a greater tendency to
keep that hand clenched than the other. In the legs, a greater tendency toward
external rotation of the hip may suggest a possible hip dislocation, a pyramidal
tract abnormality, or future spastic hemiparesis. Abnormal postures that are
apparent for only brief periods may be due to seizures, which are discussed in a
later section.
Pithed frog position

BASIC REFLEX PATTERNS

This section includes suggestions intended to help sharpen surface observations
for possible anomaly, plus a few highlights on the potential effects of the
abnormal findings on the child or primary caregivers.

Rooting and Sucking Reflexes

A hungry infant will turn the head to the right or left when the cheek is
brushed by a hand or facecloth. If a nipple is touched to the face -whether to
the right or left, above or below the mouth-the lips and tongue will tend to
follow in that direction.

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

These responses usually last until the infant is 3 or 4 months old. However, the
rooting response may persist during sleep until as late as 7 or 8 months. At
later ages, visual stimulation plays a part-babies may root for a bottle but may
not respond to the touch of a finger.

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

While rooting and sucking reflexes are being appraised, attention should also
be given to the possible presence of such anomalies as a particularly small
chin, a face that appears unusually fat in relation to a rather small skull,
peculiar dentition (such as double-fused teeth), a cleft lip or palate, or
asymmetry of the nasolabial folds. Excess salivation, mucus, and frothing
always warrant attention. Feeding problems are discussed later.

The Moro Reflex

The Moro reflex, sometimes termed a "startle" reflex, is a series of movements

by an infant in response to a stimulus. The pattern of movement varies among
infants, and gradually alters during the first few months of life with increasing
maturity. It is not possible, therefore, to give a single description for all ages
and all infants. Mitchell described the reflex in the infant a few days old:

The initial part of the response is extension and abduction of the upper ex- tremities with
extension of the spine and retraction of the head. The forearms are supinated and the
digits tend to extend and fan out, with the exception of the distal phalanges of the index
finger and thumb, which may be C-shaped ... the upper extremities describe an arc-like
movement, bringing the hands towards one another in front of the body, and finally return
to the position of flexion and abduction [Mitchell, 1960, p. 9].

Sometimes there is a slight tremor or even a rhythmic shaking of the limbs. The
movement of the lower extremities is usally less pronounced. Both legs tend to
extend and abduct with the upper extremities, although there may be a slight
movement of flexion first. If the lower extremities are extended when the
stimulus is applied, the flexion movements may be more readily noted.

A sudden jolting movement, such as that produced by striking the mattress or

table on both sides of the infant, will usually cause the startle response.
Occasionally a loud noise may precipitate the reflex. Extension of the head
relative to the trunk or a sudden strong stimulus appear to be the most reliable
means of eliciting the reflex.

Moro reflex

The Moro reflex is strongest during approximately the first 8 weeks of life.
Thereafter, it becomes less pronounced. McGraw (1937) found that most
infants change at about 90 days from the newborn phase to a transitional phase
in which movements become less gross, and at about 130 days to the final
"body-jerk" phase. Persistence of the Moro reflex after the 6th month should be
considered suspicious and deserves careful medical evaluation.

The Moro response is missing or incomplete in the younger premature but

should be readily obtained in any full-term normal baby. Its absence in a
newborn may be due to a central nervous system disorder. Occasionally, an
infant will display the Moro reflex on the first day, but this is followed by
greatly diminished intensity of the response during the ensuing weeks, possibly
because of birth injury or general muscular weakness. Occasionally cerebral
edema or other factors may cause the reflex to be absent on the first day and
gradually develop during the following 4 days. In some cases of cerebral
hemorrhage, the reflex may be present the first day, disappear, and return
slowly after the 6th day. These variations point to the value of public health
nurses following up infants who have been discharged early from the hospital
after delivery.

Asymmetry of response may occasionally be noted in normal full-term infants,

but asymmetry usually suggests fracture of the clavicle or humerus, injury to
the brachial plexus, or neonatal hemiplegia. Paine (1964) points out that a
defective Moro, opisthotonos, and the setting-sun sign of the eyes (only the
upper half of the iris showing above the lower lid) are the principal and
probably indispensable clinical signs of kernicterus in the first week of life.
Whenever such symptoms are noted, the need for medical attention is
immediate and urgent.

Paine did not find persistence of the Moro reflex beyond the 6th month in any
of the infants in his series who had homologous retardation of psychic and
motordevelopment. But abnormal persistence was seen occasionally in the
presence of spastic tetraparesis, and in one infant who subsequently developed
athetosis. Touwen (1976) points out that it may be hard to differentiate the
Moro reflex from a fright response occurring later in life. Nevertheless, the
older child with a persistent Moro is at risk of having this resemblance
overlooked. As an example, in teaching the child self-feeding, the sudden
extension of the arms and opening of the hands, causing the spoon to fly off in
one direction and perhaps the food in the other, may be interpreted by the
caregiver or "behavior shaper" as due to volitional, maladaptive behavior. Or it
may be ascribed to the possibility that the child is too retarded to understand
what is expected of him. In fact, this behavior may be due to elicitation of the
Moro by lack of ability to maintain the head erect so that it drops back
unexpectedly, a sudden flash of sunlight on the spoon, or a loud noise or
unexpected jostle of the chair or table.

In the course of routine nursing functions, no matter how gently the infant is
handled, the reflex will be elicited several times in any 24-hour period in a
hospital nursery, during the appraisal and demonstration bath carried out in
the home by the public health nurse, or during the infant's visits to a well-child
conference.

If the infant's limbs are free to move, the hospital nurse should be alert for the
Moro response when she rolls the bassinet to display the infant at the nursery
window or when she replaces the infant in the bassinet after changing the crib
sheet.

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

Extreme care should be exercised at all times in handling distressed or

premature infants, and they should receive more constant and consistent
medical surveillance. However, while feeding, when checking vital signs, and in
other circumstances when the infant is subjected to slight movements, the
nurse can observe if and when the Moro appears and the characteristics of the
response.

The Asymmetrical Tonic Neck Reflex

Articles by Gesell (1938) and Gesell and Ames (1960) contain descriptions of
the asymmetrical tonic neck reflex. These authors assert that it is present in
practically all infants during the first 12 weeks of life, often spontaneously
manifested by the quiescent baby in the supine position as well as during
general postural activity. The asymmetrical tonic neck reflex appears "when
the infant, lying on the back, turns the head to one side or if the head is
passively rotated to one side." The infant tends to assume a "fencing" position-
with his face toward the extended arm, while the other arm flexes at the
elbow. The lower limbs respond in a similar manner.
Asymmetrical tonic neck reflex

Paine (1960), Prechtl and Beintema (1964), and Andre-Thomas et al. (1960)
have pointed out, however, that there is no constant asymmetrical tonic neck
pattern among newborns. The response tends to be most noticeable between 2
and 4 months of age, being replaced by symmetrical head and arm positions
(when the baby is in supine position) by the time the infant is 5 or 6 months
old. Paine (1964), Prechtl and Beintema (1964), and Vassella and Karlsson
(1962) agree that, while the tonic neck pattern may be partially imposed on a
normal infant by passive rotation of the head, this is not a consistent response.

A study of 66 normal infants during their first year of life found that a few
infants under 3 months of age could sustain the asymmetrical tonic neck
pattern for more than 30 seconds, but none demonstrated an imposable,
sustained response (Paine et al., 1964).

The studies indicate that while the asymmetrical tonic neck posture may be
apparent from time to time during the first few months of life, persistence of
the response after the 7th month constitutes an index of suspicion. Responses
that are completely obligatory or unusually strong on one side or the other
deserve medical attention at any age.

A persistent asymmetrical tonic neck reflex is potentially a very handicapping

disability. The child is prevented from seeing both hands simultaneously unless
measures are instituted to position the head and hands in midline. The effort
to bring food or any object to the mouth is also inhibited. The influence of the
pattern on the legs obviously poses severe restriction on the ability to achieve
standing and walking.
Since the newborn needs gentle cleansing of the face, neck, and area around
the ears several times in a 24-hour period, the nurse has many opportunities to
watch for the asymmetrical tonic neck response as she rotates the head of the
infant in supine to cleanse first one side of the face and then the other. An
observant nurse can discern whether the asymmetrical tonic neck reflex is
present, whether the response is stronger on one side than the other, and
whether it is compulsory or persistent.

If the body response seems dependent on the head position in serial

observations of an infant over 6 months of age, the nurse should ascertain
whether the reflex has persisted. Waving a bright toy first to the right and then
to the left of the child is an effective way to elicit active rotation of the head.
With young infants it is a bit easier to use a passive head rotation maneuver.

Observation for the asymmetrical tonic neck reflex pattern provides

opportunity for carefully examining the child's neck to note the possible
presence of torticollis or webbing. A particularly short neck in relation to the
rest of the body is also worth noting.

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

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

The nurse may observe the two-step righting response in the normal child of 1
or 2 years, as he voluntarily gets up to a sitting position from the supine. First,
he turns the head, then the shoulders, trunk, and pelvis, before undertaking
the more complicated series of maneuvers by which he rolls over and achieves
sitting (and/or rises from the floor in the quadrupedal manner). Paine et al.
(1964) found that the neck-righting reflex was obtainable in all normal infants
by 10 months of age and was gradually covered up by voluntary activity,
making the age of its disappearance difficult to gauge. However, they point out
that a neck-righting reflex in which the response is much stronger with the
head to one side than to the other is not seen in normal infants; nor should the
response at any age be so completely invariable that the baby can be rolled
over and over. Stereotyped reflexes of this type are considered pathologic and
are often found in infants with cerebral palsy.

It also is relevant to note that infants with low muscle tone (hypotonicity) or
with considerable excess of tone (hypertonicity) and infants with an obligatory
asymmetrical tonic neck reflex would be impeded from demonstrating a normal
neck-righting reflex.

Posture in Ventral Suspension and the Landau Reflex

All normal neonates display some evidence of tone when suspended in the
prone position. The nurse may observe this when the baby is turned to prone
during the nursery admission cleansing procedure. Public health nurses may
assess tone as they weigh and measure the baby at well-child clinics or while
bathing the child at home. As the newborn infant is turned to prone, with the
trunk or abdomen supported, the legs should be flexed. While the head may
sag below the horizontal and the spine be slightly convex, the infant should not
be completely limp and collapse into an inverted U.
As the baby becomes a little older, the head and spine are maintained in a
more nearly horizontal plane. There is a gradual increase in the tendency to
elevate the head as if to look up, while the spine remains straight. Still later,
there is elevation of the head well above the horizontal and arching of the
spine in a concave position. Paine et al. (1964) found that the head was above
the horizontal in 55 percent of their series at 4 months and in 95 percent at 6
months. The spine was at least slightly concave in approximately half of the 8-
month-olds, but concavity was noted universally at 10 months. Many physicians
designate this posture, with the back slightly arched, as a "positive Landau"
(Touwen, 1976). Dissolution of the reflex is difficult to ascertain since it is
gradually covered up by struggling or other voluntary activity.

The Landau reflex is tested in a different way by others. While holding the
infant in ventral suspension with the head, spine, and legs extended, the nurse
then passively flexes the head forward. The reflex is considered present if the
whole body then flexes. The reflex may be seen as early as 3 to 4 months but
should be present after 7 months of age. In general, the nurse will find that
holding the infant in ventral suspension provides more useful information than
elicitation of the Landau by means of passive flexion of the head. In any event,
the nurse's report to the physicians should describe exactly what was done and
the infant's response. Whatever the infant's age, his limp collapse into an
inverted U when held in ventral suspension should be called to immediate
medical attention.

The Parachute Reflex and Optical Placing of the Hands

There is a tendency to refer to the parachute reflex when the behaviors being
elicited and the reactions being described are actually those associated with
the optical placing reaction of the hands. Touwen (1976) calls attention to and
describes the difference between the two.

In each instance, the infant is held in vertical suspension and suddenly lowered
toward a flat surface. The normal positive response is a forward extension of
both arms and dorsiflexion of the infant's hands during the movement. The
difference between the two is that, in the optical placing reaction, the infant
is permitted to see where he is going. This response may be noted as early as 3
months of age. In the true test for the parachute response, the maneuver is the
same but the child's visual attention is first attracted to a bright toy displayed
in front of and a little above him and he is then suddenly plunged downward.
Under these circumstances the parachute response may not be seen until about
6 or even 9 months of age. Touwen (1976) suggests that the earlier appearance
of the positive response, when the child can anticipate visually that he is going
down to a flat surface, illustrates the reinforcing effect of visual on vestibular
input. Since the older infant tends to smile or chuckle under anticipatory
circumstances but may be frightened when unexpectedly plunged, the former
is usually the method of choice by the nurse in eliciting the presence of the
reflex. If the child is plunged sideward as well as downward to the flat surface,
the influence of the optical factors is reduced. Under these circumstances,
partial response may be noted as early as 3 months. The complete response
begins a little later; it will be noted in most infants by 9 months and in all
normal infants by 12 months (Paine et al., 1964). In any event, the nurse
should describe in her report exactly the way in which the parachute was
elicited. An asymmetrical or absent response warrants medical appraisal.

Parachute reflex

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

"Palmar and Plantar Grasp

Palmar and plantar grasp are strong automatic reflexes in full-term newborns.
They are elicited by the observer placing a finger firmly in the child's palm or
at the base of the child's toes. The palmar grasp response weakens as the hand
becomes less continuously fisted, merging, sometime after 2 months, into the
voluntary ability to release an object held in the hand. The plantar response
disappears at about 8 or 9 months, though it may persist during sleep for a
while thereafter. Possible abnormality may be suspected in asymmetry of
response. While there is a tendency to fisting in the neonate, this should not be
evident at all times. Serial observation of infants in the nursery should reveal
relaxation of both hands at some point, usually during or right after feeding, or
perhaps when asleep. These appraisals provide additional opportunities for
detecting abnormalities of color such as cyanosis of the extremities, edema,
simian palm crease (a straight line rather than an M-shape across the palm),
and possible malformations of the hands and feet. Persistent edema of the feet
is always worth noting, particularly if occurring in a female child, as it may
signal the presence of a chromosomal abnormality (X. 0. Turner's syndrome).
Simian palm crease

Traction Response

Physicians test the traction response by placing the infant in supine, then
drawing him up by the hands to a sitting position. Normally, assistance by the
shoulder muscles can be felt and seen. The newborn's head lags behind and
drops forward suddenly when the upright posture is reached. Even in the
newborn period, however, there should be sufficient head control to bring it
back upright, and greater control is expected with age. The nurse in testing the
neonate may gently raise the infant from supine in this way, in order to note
the presence, absence, or asymmetry of response; but she should avoid
reaching the midline point, which causes the head to drop forward suddenly.

Supporting Reaction

The supporting reaction is elicited by holding the infant vertically and allowing
his feet to make firm contact with a table top or other firm surface. The
"standing" posture includes some flexion of the hip and knee. Automatic
stepping may also be observed when the newborn is inclined forward while
being supported in this position. During the first 4 months of life, the crouching
position gradually diminishes; this is followed by increase in support, so that
normal infants will usually support a substantial propor- tion of their weight by
10 months (Paine, 1964).
Supporting reaction and stepping

In this supported standing position, it is to be expected that a few infants will

stand on their toes from time to time or occasionally cross or "scissor" their
legs. However, consistent standing on the tips of the toes or scissoring of the
legs after 4 months of age may be considered an index of suspicion warranting
medical attention. A club foot or a deformity at the knee or hip may also
become apparent while the supporting reaction is being appraised.

By the age of 6 months, the supporting reaction is less easily demonstrable,

and by 10 or 11 months, it is difficult to distinguish from voluntary standing.

LATER STAGES IN NEUROLOGICAL

MATURATION
Hand Function
As a rough guide, the baby can be expected to reach and grasp with the whole
hand at 4 or 5 months, grasp with thumb and two fingers at 7 months, and pick
up small objects with thumb and forefinger (pincer grasp) at 9 months. Paine
et al. (1964) found that the pincer grasp was obtainable in 52 percent of their
series at 8 months but was not universally present until 12 months.

Any unusual use or disuse of the hand(s), or peculiar hand positions, such as a
tendency to ulnar deviation, deserves medical appraisal, as do athetosis,
consistent avoiding reflexes, or a developmental lag of 3 months in attaining
pincer grasp.

Sitting

The ages at which the infant sits with some support, sits alone, stands, and
walks correlate to a considerable degree with the ages at which changes take
place in postural reflexes. Sitting usually takes place at about 6 or 7 months,
with inability to sit unsupported after the age of 9 months constituting an index
of suspicion.

One useful criterion for judging whether or not a child is truly "sitting without
support" is to note whether or not he can sit with a fairly straight back and turn
the head or rotate the body without losing balance. Another useful test is to
play with the child, at some time when he is happy and comfortable, while he
sits on a hard surface. When the child is given a slight push to one side or the
other, it should be noted whether or not he "instinctively" reaches out on
either side for support, and whether the head and trunk curve slightly to the
opposite side to counterbalance the impending fall. If balance is maintained in
this way, the infant can be termed well able to "sit alone." As a rule the baby
will not develop the ability to guard against falling backward by protective
extension of the arms to the rear until about 12 months of age.

Once the child develops reasonable security in sitting, there will be a tendency
to use the hands more effectively. Therefore, in appraising the child's ability to
use the hands while sitting, it is always wise to note first if the child needs
lateral or posterior support. It may be that the child can use the hands to hold
or transfer a block or toy, but is prevented from doing so by a need to use arms
and hands for support. It is possible, for instance, for a child with cerebral
palsy to have sufficient hand function, intelligence, and interest to learn to eat
without assistance but be unusually delayed in developing sitting balance.
Under such circumstances the child may need to be positioned with secure
arm, back, and foot supports before the needed hand skills can be
demonstrated. If these factors are overlooked, the situation can prove quite
frustrating and may be inappropriately interpreted.

Locomotion
About half of all normal infants begin to creep or crawl between 6 and 12
months of age; by 12 months the infant should be able to pull erect, and by 18
months begin walking independently. Failure to walk independently after 1 8
months of age constitutes an index of suspicion.

By the age of 3 years, the child should have achieved motor independence,
including walking up stairs. Delays in single items of development may be due
to a variety of specific causes, which may be of a motor, sensory, or emotional
kind (Denhoff and Robinault, 1960; Silver and Gabriel, 1964). An overall lag in
several developmental aspects may be due to cerebral palsy, mental
retardation, or related cerebral dysfunctions. A peculiar method of creeping or
crawling may also warrant special evaluation, e.g., some children with cerebral
palsy develop a bunny hop, wherein both knees are drawn up simultaneously
under the trunk, followed by an awkward push forward.

A type of cerebral dysfunction has been described by different investigators as

brain-damage disorder, minimal neurological handicap, or the hyperkinetic
behavior syndrome (Laufer and Denhoff, 1957). It is of interest to note that
children who later manifest hyperkinetic behavior disorder (characterized by
involuntary and constant overactivity) may be significantly advanced in
achievement of the milestones of motor development. Such children may climb
out of the crib before 1 year of age and walk early. Parental histories also
indicate that some of these children cannot be kept in the playpen, get into
everything, run rather than walk, find it intolerable to sit quietly (even at meal
times), are hyperirritable, cry readily, and wake several times during the night.
Such symptoms warrant referral for thorough professional appraisal, for the
sake of both the child and the family. However, some children who manifest
hyperkinetic behavior patterns in later childhood display no evidence of this
disorder during infancy.

The child who is greatly accelerated in phases of growth and development

might be evidencing a generally superior endowment. However, an individual
of superior endowment may have a normal developmental course or even be
delayed in some aspects. The nurse must remain objective at all times and be
guided by the general rule that a deviation of 3 months in the achievement of
developmental milestones constitutes a valid reason for referral to medical
attention.

THE SENSES, SENSE ORGANS, AND SPEECH

Normal Visual Development

The infant's ability to fix his or her eyes upon the face of the mother in the
face-to-face (or "en face") position within minutes after natural delivery can
provide initial evidence of an infant's state of vision at birth. This is also one of
the most effective means of helping a mother begin to develop the normal
attachment and bonding process with her infant.

Increased attention is now being given to bonding and to encouraging the

father to be present when the baby is delivered. A slight delay in instilling
prophylactic medication (to prevent infection) in the infant's eyes, plus
positioning the mother and child in the en face position as soon as the child is
breathing properly, enhances the infant's potential for displaying bonding
ability. (The interest of the normal newborn in the human face at 2 days of age
is illustrated in the series of training films available to help personnel learn to
administer the Brazelton Neonatal Behavioral Scale.) At this age, the infant can
also track a bright object across the midline and above and below the
immediate eye level when both infant and object are properly positioned to
elicit this response. While first evidence of this ability can be noted soon after
birth, reliable following of objects is observed more readily when the infant is
6 to 8 weeks-usually the time of the public health nurse's home visit or the
infant's return to the physician or clinic for postpartum checkup. Smiling at 6 to
8 weeks of age in response to the parent's smile provides relevant evidence of
psychosocial adaptation as well as evidence of proficient vision and the
neuromotor ability to smile.

Detection of Visual Abnormality

Greatly disconjugate or ceaselessly roving eye motions suggests blindness.

While the infant may exhibit problems of convergence (which usually begins at
about 3 months), a constant, fixed strabismus warrants careful medical
appraisal at any age.

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

Other abnormalities include a total or partial lack of pigmentation, a

triangular-shaped notch (palpebral colobomas) in the upper or lower lid, a
bilateral and symmetrical decrease in the size of the palpebral fissure
(blepharophimosis), ptosis (inability to raise the lid fully), the presence of
dermoid cysts, or other unusual signs (Apt and Gaffney, 1977). The presence of
cataracts may sometimes be noted in the infant; the nurse should remain alert
to a milky type of film or clouding. As a child is brought to a slightly stronger
light source (for instance, the nursery window), the nurse should see if his
pupils react by contracting and do so equally. There are many opportunities to
watch for the blink reflex while cleansing the child's face.

All babies should be inspected for epicanthic folds (folds of skin across the
inner angles of the eyes). In a non-Oriental baby, they may be an indication of
Down's syndrome or other congenital disability, and such a child should have
continued followup. However, epicanthic folds may be a normal manifestation
even in a baby of non-Oriental parentage.
Unusual placement of the eyes, one eye larger than the other, unusually heavy
brows that meet over the bridge of the nose, or a wide-eyed and particularly
forlorn gaze are other signs that may be related to chromosomal aberrations. A
single slight deviation may be found, such as one eye so slightly smaller than
the other that it has neither medical nor cosmetic significance. Even this minor
observation should be recorded, since, as previously mentioned, the presence
of three or more minor anomalies indicates that the child should be under
surveillance for a possible major disorder. The times when the infant is bathed
or the face is cleansed provide excellent opportunities for inspecting the eyes
for such anomalies.

Epicanthic fold

Attention should be given to all symptoms such as redness, discharge, or

swelling about the eyes of children at any age. Signs of possible visual difficulty
in the older child include holding objects very close to the face; closing one
eye repeatedly or tilting the head at an unusual angle when attempting to
visualize objects; discomfort when in a brightly lighted environment;
headache, frequent eye rubbing, or complaints of burning or itching, after
watching television or going to the theater. Unusual delay in recognizing colors
may be another clue to visual difficulty. Visual or perceptual problems may be
suspected in the older child who lags behind peers in the ability to stay within
lines when coloring or copying a diamond shape, or in the ability to catch or
bat a ball. The child who is always tripping and bumping into things may have a
visual or perceptual defect, or the problem may be rooted in neuromotor or
other difficulties.

It is important to have the visual problem evaluated and diagnosed as early as

possible to initiate treatment, prevent loss of vision, and promote optimal
vision.
Normal Hearing Development

Northern and Downs (1974) provided an excellent review of the literature on

hearing in children. Among others, they cited the findings of Elliot and Elliot
(1964), who confirmed psysiologically that the human cochlea has normal adult
functions after the 20th week of gestation; and Eisenberg (1970), who
demonstrated that most newborns, including those with known disabilities of
the central nervous system, can discriminate sound on the basis of frequency,
intensity, and stimulus-dimensionality, and that speech-like signals appear
remarkably effective in producing response in newborns.

Stechler (1964) found that unexpected noise at a level of 70 decibels above

audiometric zero elicited a variety of responses from newborns, depending
upon the dimensions of the stimulus. If the sound reached its maximum
intensity within a fraction of a second, the newborn closed his eyes, startled,
and showed an increase in heart rate. On the other hand, if the sound did not
reach its maximum until at least 2 seconds had elapsed, the newborn was more
likely to open his eyes, look around, and show an increase in heart rate. The
first reaction was interpreted as a defensive one, the second as a display of
interest.

The Brazelton training films illustrate the arousal state of an infant as young as
2 days of age, produced by sound made while the infant is in a light sleep
state. They also depict the way a normal infant responds by turning the head to
the sound of the human voice, and the difference in response to a high-pitched
and a low-pitched voice. The films further show the response of the infant in a
light sleep state to the ringing of a bell and the subsequent ability of the
normal infant to habituate to the sound, that is-to resume the sleep state in
the presence of a continuously ringing bell.

There is a marked contrast between the ability of the normal neonate to

accommodate to sound in this way and the plight of many disabled infants who
cannot. Infants with developmental problems frequently have some trouble
getting to sleep and are easily startled into wakefulness by sounds within the
normal range of customary noises in the environment. Such infants are
deprived of sleep they really need. They tend to be hard to comfort.
Meanwhile, the primary caregivers (usually the parents) become increasingly
anxious and frustrated in their attempts to comfort the infant. Deprived of
their own needed rest and sleep, they become increasingly fatigued and
irritable. It is not surprising that such circumstances can strain the normal
attachment and bonding process between parents and child.

Hearing is also a learned behavior, which involves not only sensitivity to and
discrimination among various sounds but also understanding, interpretation,
storage, recall, and usually an appropriate motor response. The child with
normal motor development relates to many sounds in the environment. Normal
response at about 6 months involves a turn of the head in the direction of the
sound. The child is more apt to respond if the sound is a familiar one (a
favorite toy, a spoon rattling in a dish at feeding time); the sound is made at a
level horizontal with the ears; the sound is made reasonably near the child;
and the environment is relatively quiet. By 7 or 8 months of age (and often
earlier), the normal infant will have "learned" to listen.

Hearing assessment and screening must be done with great care, especially if
the infant is visually oriented. Handicapped children or children with language
delay need to be evaluated by an audiologist.

Detection of Hearing Abnormality

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

birth:
1. A family history of deafness
2. Hyperbilirubinemia
3. Congenital rubella syndrome
4. Defects of the ears, nose, or throat
5. Birthweight 1500 gm or less
As soon as possible after the child is born, the ears should be inspected for the
presence of any deformity, asymmetry, unusually low placement, peculiar
slant, cosmetically significant protrusion, skin tags, or other anomalies. The
area immediately in front of the ear should be well examined for the presence
of a dermal sinus. It is possible for even a pinhole size opening to be an avenue
for serious infection by staphylococci or other organisms. The external size of
the sinus gives no indication of its possible depth into vital body tissues. The
demonstration bath provides a particularly good opportunity for surface
inspection of the ears by the public health nurse.

Hilson (1966) has called attention to the fact that a malformed ear may signal
the presence of an associated anomaly of the genitourinary tract. He further
states that genitourinary malformations are the commonest anomalies found in
the population over the age of 5 years. A malformed ear, therefore, should
alert the nurse working with the older child to the need for additional
assessment.

Congenital anomalies of the mouth or nose may also be associated with

anomaly in the basic structure of the middle ear or the external ear, with
possible deleterious effects on equilibrium and hearing.

Gesell (1941) listed a variety of signs suggestive of deafness or hearing loss. He

categorized the signs as problems that may be due to illness or trauma in the
postnatal period, problems that may have been present at birth but overlooked
during infancy, and problems in which hearing loss is progressive. Many of these
signs relate to speech.
 I. Hearing and comprehension of speech
1. General indifference to sound
2. Lack of response to spoken word
3. Response to noises as opposed to voice
II. Vocalizations and sound production
1. Monotonal quality
2. Indistinct
3. Lessened laughter
4. Meager experimental sound play and squealing
5. Vocal play for vibratory sensation
6. Head-banging, foot-stamping for vibratory sensation
7. Yelling, screeching to express pleasure, annoyance or need
III. Visual attention and reciprocal comprehension
1. Augmented visual vigilance and attentiveness
2. Alertness to gesture and movement
3. Marked imitativeness in play
4. Vehemence of gestures
IV. Social rapport and adaptations
1. Subnormal rapport in vocal nursery games
2. Intensified preoccupation with things rather than persons
3. Inquiring, sometimes confused or thwarted facial expression
4. Puzzled and unhappy episodes in social situations
5. Suspicious alertness, alternating with cooperation
6. Markedly reactive to praise and affection
V. Emotional behavior
1. Tantrums to call attention to self or need
2. Tensions, tantrums, resistances due to lack of comprehension
3. Frequent obstinacies, teasing tendencies
4. Irritability at not making self understood
5. Explosions due to self-vexation
6. Impulsive and avalanche initiatives

Some of these behaviors may signal the presence of dysfunctions of

psychosocial origin, disorders of perception, or other problems not specifically
related to hearing loss. Again, the point is to be objective in observation,
precise in recording, and concerned about referral for medical attention.

The early detection of hearing abnormality or lack of response has particular

relevance to language acquisition, since this is a time-locked function with the
most crucial periods being the first 2 years of life. If hearing loss is detected
early, amplification may be started as early as the first month. Concomitantly,
special attention can also be directed to use of the other sensory avenues for
learning (sight, touch, smell, and taste).

Normal Speech Development

During the first hours and days of life, the nature, pitch, intensity, and
frequency of the infant's cry are important components in a nursing appraisal
because the cry has a great significance in terms of the infant's state of health.
Physicians rely heavily upon the skilled pediatric nurse to detect and report
without delay the high-pitched cry of the possibly brain-injured, the mewing
sound characteristic of some chromosomal abnormality, the very feeble cry of
the weak, or the grunt that denotes respiratory distress. Current studies and
recordings are seeking more precise means to distinguish the cries that indicate
various states in the infant.

Except for crying, the very young baby may make comparatively few sounds
besides slight "noises in the throat." However, by 2 months the baby is
vocalizing a little. By 3 months, chuckles may be added to the cooing noises;
and by 4 months, the child may laugh aloud. Babbling is usually noted by 6
months; approximately 50 percent of babies will babble in two or more sounds
by this age.

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

A child may be delayed in reaching speech and language developmental

mileposts for a number of reasons. If organic or neurologic factors can be ruled
out, suspect a lack of motivation and/or stimulation. Delay or deviation in
speech and language development maybe manifested as an articulation
problem, in which the toddler does not "say his sounds right"; as a stuttering
problem, in which the normal non-fluencies of language learners are replaced
with tense repetitions or prolongations of words or sentences; a too fast or too
slow rate of speech; a voice level that is too high or too low in pitch or too
loud or too soft in volume.

Parents, other child care givers, and child health providers can play an
important role in providing models of speech and language. Rather than
request repeatedly that the child say certain words and phrases, adults can
repeat examples of the desired pronunciation or sentence structure.

Just as normal speech and language development covers a range of behaviors,

disordered speech and language runs the gamut from an occasional
mispronounced word or garbled syntax, to frequent unintelligible gibberish.
The effects of maturation and stimulation are important in the development of
intelligible speech and language patterns. If a child between 2-1/2 and 4 years
of age has a speech and language pattern that is deviant enough to make
communication difficult or impossible, an evaluation by a speech, language,
and hearing specialist is indicated.

Specific Learning Disability

Increased attention is being given to the recognition of the learning disabled

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

A variety of terms is used to describe these children. Specific learning disability

is defined under the Education for All Handicapped Children provisions of the
1975 amendments to Public Law 94-142 as "a disorder in one or more of the
basic psychological processes involved in understanding or in using language
spoken or written, which may manifest itself in imperfect ability to listen,
think, speak, read, write, spell, or do mathematical calculations. Such
disorders include such conditions as perceptual handicaps, brain injury,
minimal brain dysfunction, dyslexia, and develop- mental aphasia."

The definition does not include children who have learning problems that are
primarily the result of visual, hearing, or motor handicaps, of mental
retardation, of emotional disturbance, or of environmental, cultural, or
economic disadvantage. However, children with the excluded handicaps may
have concomitant SLD with resultant multiple handicaps affecting their
psychosocial and educational adjustment.

SLD focuses on outcomes of impaired CNS functioning whereas minimal brain

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

Central nervous system dysfunctions in these children occur as a unique

individual profile of deficits and assets:

1. Short attention span

2. Distractibility
3. Hyperactivity
4. Impulsiveness
5. Labile emotions
6. Poor motor integration
7. Deficits in the perception of space, form, movement, and time
8. Disorders of language or symbol development.
The concern with these children is that there should be early identification,
remediation, and treatment to allow the child to reach his maximum potential
and prevent emotional or psychiatric maladjustments. The nurse has an
important role in identifying these children; referring them for formal
evaluation and diagnosis; assisting parents and the children in understanding
the disability and obtaining the necessary therapies, and in interpreting their
problems and needs to teachers and counselors.

Inspection of the Mouth and Nose

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

Rosenstein (1977) has pointed out that any child with malformations of the
face, particularly of the mouth, jaw, or nose, is at risk of having associated
dental problems. During the period of tooth formation in utero, any systemic
disturbance or trauma can affect gum formation, enamel matrix formation,
dental formation, or calcification. The type and extent of resulting defects will
depend upon the gestational age at which the deviation took place, and the
duration and severity of the injury or disturbance. Postnatal accidents and
injuries to the teeth and adjacent structure (such as a bad fall or a blow on the
mouth or jaws) create problems when secondary teeth are in the process of
formation. There are also a variety of genetic defects that can cause teeth to
be translucent, discolored, irregularly arranged, absent, or malformed in whole
or in part. It has been found that mothers treated with certain antibiotics, such
as tetracycline, may give birth to infants whose teeth will be discolored when
they erupt; and children treated with a tetracycline-type drug after birth may
exhibit similar discoloration of the teeth. Several developmental disabilities
affect the gums as well as the teeth.

The eruption of primary teeth usually takes place in the following sequence:

Eruption Of Primary Teeth

Eruption (age in months)
Type of Tooth
Lower Upper
1. Central incisor 6-10 8-12
2. Lateral incisor 10-16 9-13
3. First molar 14-18 13-19
4. Cuspid 17-23 16-22
5. Second molar 23-31 25-33
A good way to remember this sequence is that teeth erupt at about 4-month
intervals. As in all other aspects of development, there is a normal range of
variability in the rate of tooth eruption. 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.

Normal Development of Taste and Smell

Some infants indicate awareness of taste by facial expression. A piece of sugar

usually elicits sucking and smacking of the lips. Salt, on the other hand, tends
to produce a grimace and little or no sucking; Andre'-Thomas(1960) notes that
the baby may also protrude the tongue to "get rid of it." These reactions are
most marked after a feeding.

It is not easy to assess the baby's ability to taste or smell and it is usually of
little importance to do so during infancy. If the baby has a sucking problem,
however, the ability to elicit appropriate responses to certain taste and
olfactory stimuli may be vital to his or her welfare. Haynes (1968) observed
that considerable success in feeding could be achieved with some infants who
have aberrant suck-and-swallow patterns by instituting carefully selected
taste, olfactory, or other stimulus into the feeding process. A drop of honey
applied to the tip of the bottle nipple, chilling of the nipple, and careful
administration of light whiffs of aromatic spirits of ammonia coupled with
appropriate positioning of the infant-are some of the measures which enhanced
sucking and achieved adequate nutrition. The work of Pratt, Nelson, and others
(1938), although carried out over 40 years ago, is still a useful reference when
the presence or absence of smell and taste needs to be determined during
infancy.

SLEEP PATTERNS
There is considerable variability in the sleep patterns of the neonate. Wolff
(1959) and Brazelton (1961) have pointed out the wide range of spontaneous
jerks and twitches that are entirely within normal limits, even though they may
occasionally awaken the child. The studies of Parmalee, Schultz, and Disbrow
(1961) indicated that infants do not sleep 19 to 22 hours per day as previously
believed. The 75 infants they studied during the first 3 days of life were awake
on an average of 7 to 8 out of 24 hours, that is-they slept 65 to 70 percent of
the time. The longest wakeful period ranged on the average from 1.9 to 2.3
hours. The sex of the child seemed to have no influence upon these patterns.

A nurse who finds that a baby is sleeping only about 16 hours out of the 24
should determine if this is a normal pattern for this baby. The mother should
be given this information before she goes home with the child to avoid anxiety
over the apparent "sleeplessness."

Sometimes, unusual patterns of sleep, drowsiness, or listlessness, or an

opposite pattern of excessive wakefulness, irritability, and crying may be
significant indications that all is not well with a child. Marked and consistent
deviations along these lines rarely escape early detection. However, the infant
in the hospital nursery has many caregivers. Increasing use of part-time staff,
plus the fact that the entire personnel in a nursery changes several times in a
24-hour period, suggests that sharpened observations and reasonably detailed
records are needed to detect the more subtle deviations of this type. An infant
may appear a bit fussy or unresponsive at times during any one tour of duty
without arousing concern. A cumulative record of such behavior repeated
throughout a 24-hour period, however, can aid in the detection of a significant
underlying difficulty which might otherwise escape attention during the
normally brief hospital stay of mothers and babies after delivery.

After discharge from the hospital, the young or inexperienced mother may be
disturbed by her infant's irritability but fail to report it because she thinks the
behavior is due to her own inadequacy. Another mother may rejoice that her
infant is unusually "good" without realizing that he is actually abnormally
listless or drowsy. Therefore, when such behavior is noted in a child at a well-
baby conference or pediatric clinic, public health personnel should take
particular care to obtain a reasonably complete assessment of the child's
behavior in the course of a home followup program.

INFANTILE SEIZURES (SPASMS

The infant may experience a seizure or other episode, accompanied by an
unusual position. The seizure may subside before the physician makes rounds in
the hospital or sees the child at the office, a clinic, or well-child conference.
The nurse should therefore always be alert for, and carefully record, any such
episode.

Infantile myocionic seizures may be evidenced by a sudden contraction of the

flexer muscles of the trunk, possibly accompanied by abrupt flexion of arms to
the chest and thighs to the trunk. The forearms may be retracted and the
hands pulled to either side of the head, so that the seizure may resemble the
Moro reflex. A sharp cry may precede or accompany the seizure. The face may
assume a momentary blank or shock-like expression. In some instances, a
sudden noise, some manipulation, or feeding precipitates the attacks; in
others, the attacks occur just before the onset of true sleep or immediately on
waking. Apneic episodes, episodic nystagmus, episodic changes in tone and/or
color and episodic sneezing may be seizure manifestations.

Petit mal, minor motor, psychomotor, and grand mal seizures may all occur
during infancy, but the minor motor type is most common. Baird (1963) has
called attention to abdominal epilepsy in infants and young children. This is a
possibility of particular importance to the public health nurse in her home
followup of infants who are not under regular medical surveillance and who
have unusually persistent or severe episodes of so-called "colic." A helpful
reference on infant spasms or seizures, which includes excellent illustrations, is
"Infantile Spasms"-No. 15 in the series "Clinics in Developmental Medicine,"
published by the Medical Education and Information Unit of the Spastics Society
in association with Heinemann Medical Books, and available from J. B.
Lippincott Co., Philadelphia.

INSPECTION OF THE FONTANELS

The fontanels should not be bulging, deeply depressed, excessively wide, or
excessively narrow in the early months. Normally, the anterior fontanel closes
some time between the 6th and 18th months. If the fontanels barely admit the
tip of a finger before the child is 6 months of age, show little evidence of
closure by 12 months, or are bulging or depressed, medical evaluation should
be obtained.
BODY MEASUREMENTS
It is important that serial assessments be made and recorded on every infant
and young child. Changes in physical growth may be the first indication of an
underlying problem.

Head circumference measured at occiput-supraorbital ridges is approximately

13 to 14 inches at birth. As a general rule, there is a 2-inch increase during the
first 4 months and another 2-inch increase by the time the infant is 1 year old.
From that time on, growth of the head is exceedingly slow, totaling only about
4 additional inches by about 20 years of age.

If an infant's rate of growth in head circumference changes by one or more

standard deviations, a referral should be made.

Chest circumference is measured at the level of the nipples with the baby lying
outstretched. Head size usually exceeds chest size by 1 inch until about 1 year
of age. The head-chest relationship is then equal until about 18 months, when
chest size begins to exceed head size.

The National Center for Health Statistics (NCHS) and the Center for Disease
Control (CDC) of the U.S. Public Health Service jointly developed growth charts
in 1976 to use in recording the body measurements of an individual child over a
period of time. These charts are based on extensive studies of the growth
patterns of American boys and girls from birth to 18 years of age and include
lines that indicate selected percentiles of growth. Charts for ages birth to 36
months are designed to record length for age, weight for age, head
circumference for age, and weight for length. Charts for ages 2 to 18 years
include stature for age, weight for age, and weight for stature.