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Community Health Nursing Assessment of Neurodevelopment in High-risk Infants
Principles and practice Community Health Nursing Assessment of Neurodevelopment in High=riskInfants SUSAN RITCHIE, RIV, MPH, PNP, A N D CAROL WILTGEN TROTTER, RN, MPH, CPNP All infants discharged from designated perinatal center neonatal intensive care units in Illinois are referred for follow-up home visits by community health nurses. These visits provide parental support, teaching, and anticipatory guidance plus physical and developmental assessment of the infant. The maternal and child nursing consultants who coordinate this follow-up program are frequently called upon to assist the community health nurses in physical/developrnentalassessment techniques. The neurodeveloprnentalcomponent of the assessment, including areas of alertness, tone, head circumference,vision and hearing screening, plus primitive reflexes, is described.
Community health nursing follow-up of the high-risk infant has been an integral component of the Illinois Regionalized Perinatal Program (IRPP) since it began in 1975. Every infant hospitalized in a neonatal intensive care unit (NICU) in an Illin’ois perinatal center is referred to a community health nurse for follow-up. This nurse visits the family in the home at periodic intervals, until the infant is 18 months ofiage, to provide parental support, teaching, and anticipatory guidance in addition to physical and developmental assessment of the infant. The assessment of high-risk infants in the home was a new procedure for many community health nurses. Therefore, the maternalchild health nursing consultants within the Illinois Department of Public Health developed guidelines to assist the community health nurses in the process. Although the guidelines include all of the elements of a comprehensive assessSubmitted: October 1982. Accepted with revisions: April 1983.
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ment (Table l), those that relate to the neurological evaluation and development of the infant (neurodevelopment) are of particular concern to the community health nurses. Saigal et al., in a study of infants treated in a regional perinatal center, found a 16.8%, incidence of neurological handicap including cerebral palsy, hydrocephalus, microcephaly , blindness, deafness, and mental retardation.’ Because the neurodevelopmental assessment is of extreme importance in the follow-up of high-risk infants due to their increased risk of developmental disabilities, teaching community health nurses these procedures is emphasized. The nursing consultants begin this teaching by stressing familiar nursing observations of the infant’s alertness and movement. Assessment of head control, eye coordination, and obligatory reflexes are added to build a good foundation in the neurodevelopmental assessment process that can be performed by community health nurses in the home.
NEURODEVELOPMENTAL ASSESSMENT Neurodevelopmental assessment of the infant in the home offers many positive benefits to the nurse and family. Observing the infant interact with parents, siblings, and familiar objects in the infant’s usual setting is essential to the nurse’s understanding of developmental progress. The relaxed, unhurried atmosphere of a home visit creates a situation where parents a r e sufficiently at ease to discuss concerns they might otherwise be reluctant to express. Parents enjoy being included in the evaluation process. The nurse should find a convenient place to perform the assessment where parents can watch and participate comfortably; often this is a kitchen table, firm soFd, or bassinet. The essential elements of the neurodevelopmental assessment include alertness, tone, head, sensory status, obligatory reflexes (Moro and asymmetrical tonic neck), a n d developmental milestones. The nurse
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Table 1. Elements of Comprehensive Infant Assessment
1. History 2. Physical examination 3. Vision and auditory assessment 4. Developmental screening 5. Nutritional assessment 6. Observation of infant behavior and parent-child interaction
can demonstrate and explain these elements to parents in a way that points o u t positive aspects of the child’s development. Alertness
Before the actual hands-on portion of the assessment begins, the community health nurse can learn a great deal by observing the infant playing and sleeping, or being cuddled and fed. In the course of these activities, the nurse can appraise the infant’s alerting and orienting behavior in response to stimulating objects and parents’ voices. Normal alerting and orienting behavior results in fixation of the infant’s gaze on the care giver. At the same time, oral reflexes (rooting and sucking),
present during the feeding process, provide valuable information about the infant’s neurological development. A strong suck, hand-tomouth movement, or an interested gaze are indications of normal infant response that the nurse can share with parents. Preterm infants may have a weaker suck and somewhat less active movements than full-term infants. The nurse should discuss these variations with parents in an effort to assure them that such differences are expected. Tone
From the first moment that the nurse picks up the infant, she begins her assessment of posture, head control, muscle consistency,and the range of motion, all of which are components of tone. Because these aspects are difficult to describe and because they vary greatly from infant to infant, tone evaluation is complex. Haynes states that although the assessment of tone requires quite a bit of practice, nurses soon learn to distinguish generalized hypertonicity (the extremely stiff infant) and hypotonicity (the very floppy infant).* Posture
Figure 1. Full-term infant fully flexed.
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Flexor tone predominates in the normal newborn. When in the prone position, infants lie with arms and knees flexed and drawn slightly up underneath their body. When supine, all four extremities remain semiflexed and symmetrical (Figure 1). Gently extending the extremities will result in a quick, recoil movement back to the flexed position. During the third and fourth month, extensor tone begins to increase. By the fifth and sixth month, the trunk is fully extended when the infant is prone, and when supine soles of the feet are able to come together or rest on the supporting surface. At about this time, and throughout the first year, the infant can be seen bringing the feet to
Figure 2. Seven-month-old infant demonstrating greater neuromuscular control.
hand, mouth, and the opposite knee (Figure 2). Preterm infants normally display less tone than fullterm infants. When preterm infants are supine, their legs may be flexed but in a position of wide abduction until they are almost flat against the supporting surface (frog-like posture). The upper limbs are often extended. As the infant approaches 40 weeks, the posture becomes more like that of a normal newborn.3 The lack of tone observed in some early preterm infants may also be present in some children with Down’s Syndrome or other constellations involving mental deficiency.* Extensor tone in the growing infant may be early evidence of damage to the central nervous system secondary to perinatal insult. Infants with such abnormality may hold their legs in a fully extended and very stiff position, possibly crossing (scissoring) when supine or suspended vertically. Parents may be aware of these problems because stiffness causes inability to separate the infant’s legs which, in turn, makes diapering difficult.The arms may be flexed, very hypertonic, and drawn across the body.
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Figure 5. Landau reflex in nine-month-old infant.
Figure 3. Six-week-old infant in ventral suspension.
The ventral suspension posture is important in the evaluation of tone. When normal newborns are held underneath the chest and abdomen in the nurse’s palm, they should display some evidence of head extension of a few seconds duration (Figure 3.) Also, some extension in the hips, although not as likely, may be seen. Only in the earliest preterm infants is it “normal”
to observe the infant in an inverted “ U ” or “rag doll” posture over the nurse’s hands. The extension of head and hips will continue to develop throughout the early months of an infant’s life, and by six to nine months the infant is developing extension in both of these areas (Figure 4). Most infants, by the age of 12 months, have developed a position of hip extension including the
Figure 4. Six-month-old infant displaying improved muscular control.
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arching of the spine into a concave posture-a positive Landau reflex (Figure 5 ) . Head Control
The infant’s ability to control head movements is a factor in tone evaluation. When a normal newborn is grasped by the hands and pulled to a sitting position, the head will lag behind the body (Figure 6A). However, when a sitting position is reached, the normal infant should make attempts to hold the head upright (Figures 6B, C). This movement can be performed in the home on the assessment surface or while the nurse holds the infant on her lap. The nurse should reassure parents that this procedure does not hurt the infant but, in fact, is a useful developmental exercise the parents may wish to do while playing with their infant. During the next few months, neck tone and head control increase. By the fourth month of age, when pulled to a sitting position, the infant is able to keep the head on the same plane as the body (Figures 7A, B, C). In preterm infants, this development of head control may be somewhat delayed. This is also true in infants with neurological abnormalities affecting motor development.
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Figures 6A,B,C. Normal head lag in a six-week-old infant.
Muscle Consistency Muscle consistency, assessed by gently squeezing the muscle mass between the finger and thumb, is probably the most subjective part of the evaluation of tone. In a normal newborn, this muscle mass is firm to touch. By two to six months, the muscles begin to feel more flabby.4 The early preterm infant has very little muscle mass and it is generally quite soft to touch. A more descriptive way of saying this is that the skin of preterm infants appears too large for their bodies.
Range of iblotion Limb movement in the normal newborn should be spontaneous and equal. The upper extremities generally move symmetrically, while the lower extremities move alternately.5 Slightlyjerky newborn
movements are replaced by smoother and more coordinated attempts in the three- to fourmonth-old infant. In observing the infant’s movement, the nurse should direct her attention to the hands. In the newborn, the hands are often seen in a clenched fist position. As the infant reaches three to four months of age the hands are seen to open spontaneously with greater frequency. Persistence of the clenched fist in the young infant or fisting with the thumb entrapped in the palm (corticol thumbing) beyond the fourth month should alert the nurse to a possible neurological abnormality.
Head Head Circunzference Head circumference is perhaps the most readily accessible measure
of brain g r ~ w t hDuring .~ a followup home visit, community health nurses obtain head circumference using a paper or metal tape placed over the most prominent part of the occiput and mid-forehead (supraorbital ridges). Three measurements are taken with the reading made at mid-forehead, right and left sides. The largest circumfer- ~ circumence is r e ~ o r d e d . ~Head ference must be recorded at every encounter the nurse has with the high-risk infant. Each time, the measurement should be plotted on standardized growth charts. Those developed by, the National Center for Health Statistics are recommended.’ The nurse is encouraged to take these charts on the visit with her and plot the measurement. These can be explained and shared with parents. Head circumference
Figures ’IA,B,C. Improved head control in six-month-old infant.
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greater than the 95th percentile or less than the fifth percentile (in fullterm infants) in the absence of a corresponding height and weight measurement or a head circumference that rapidly changes percentile levels should be brought to the attention of the primary care giver. Preterm infants may display head circumferences below the fifth percentile if plotted on a standard fullterm growth chart. Two other techniques are suggested for graphing head circumferences of preterm infants. The first technique is to plot the measurement on a fullterm growth chart after adjusting for prematurity.' (Adjusting for prematurity: Chronological age in weeks - weeks of prematurity = adjusted age in weeks.) This is not an ideal solution because preterm infants experience more rapid head growth than full-term infants in the first two months of postnatal life. Thus, the head circumference of preterm infants when plotted on a full-term growth chart may appear to grow too r a ~ i d l yThe . ~ second and. preferable technique is using growth charts especially designed for preterm infants that account for both prematurity and rapid head growth."." These charts are intended for use in the f i r 3 year of life. Fontanels and Sutures
The nurse should pay particular attention to assessing the size of the anterior and posterior fontanels. Posterior fontanels, which are often difficultto detect even in the newborn period, normally close by the second or third month of life and anterior fontanels normally close sometime between the sixth and 18th month (later in children with Down 's Syndrome). Font an e 1s should be measured with the fingertip and recorded in centimeter units. An anterior-posterior and lateral measurement should be taken (Figures 8, 9). Fontanels should be observed for bulging,
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Figure 8. Palpation for anterior fontanel.
which may indicate an increase in intracranial pressure, or a depression, which may indicate severe dehydration. T h e coronal and sagittal sutures may be overlapping, slightly separated, or have prominent ridges after birth. However, these newborn variations should not be palpable after the fifth or sixth month. Sensory Status Hearing
The assessment of hearing is often difficult in the young infant. The nurse may begin the hearing evaluation by asking the parents how the infant responds to common household noises such as a telephone ringing, dog barking, or door slamming. For the actual assessment, the nurse may use a familiar toy. The nurse needs to attract the infant's attention with the toy and ring the bell out of sight of the infant (Figure 10). This should be done on both sides to assess each of the infant's ears. T h e response will vary depending on the developmental age of the child from a subtle eye blinking and/or movement change in the newborn to a more definite localization response (turning to or reaching out for the bell) in the five- and sixmonth-old. The hearing response, as well as other sensory status indicators (vision and reaction to
Figure 9. Anatomical representation of coronal (horizontal) and sagittal (vertical) sutures and anterior fontanel.
painful stimuli), will vary also with the infant's ability to disregard repeated stimuli. This normal habitation response of infants to repeated stimuli may be confusing to the novice examiner but is an important observation in the neurodevelopmental assessment of the infant. Vision A penlight is used to determine pupil equality and reaction to light. T h e nurse may need to carry the infant into a dark bedroom to ap-
Figure 10. Public health nurse assessing hearing in a nine-month-old infant.
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Figure 11. Six-month-old infant visually tracking doll.
preciate the pupillary reaction. The pupils will then dilate to a considerable degree making the pupillary reaction to the penlight easier to detect. Furthermore, the very young infant is more likely to open his or her eyes in a dark room. Holding the infant in a vertical position may also help.
Figure 12. Raising head to elicit Moro reflex.
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The penlight or bright-colored toy can also be used to assess the visual response through tracking. Tracking is the ability of an infant to fixate on and follow an object with his or her eyes through space. Until the infant is approximately four months of age, the light or object is moved in a horizontal arc of 180" while the infant is lying supine (Figure 1 1 ) . Vertical tracking is usually developed by the sixth month of age. At this point, with the infant held in a sitting position, the stimulus is moved in an "H" formation to assess tracking. Not only does the neurological assessment of the eye include evaluation of the infant's ability to focus on and track an object, but also observation for the presence of nystagmus (rapid alternating eye movements) or other unusual deviations. An infant's eyes may wander for the first six months of life, however, any eye crossing after this age is cause for medical referral.
Primitive Reflexes The nurse is able to continue observation of the infant's neurological responses through assessment
of primitive reflexes. These may be the earliest indication of the presence of significant motor disability.'' Therefore, it is essential that these reflexes be tested on each home visit. In addition to the rooting and sucking reflex previously cited, two primitive reflexes predictive of later neurologic abnormality are the Moro and asymmetric tonic neck reflex. Both can be easily assessed by the nurse during a home visit.
Moro Although the young infant may spontaneously demonstrate a startle reaction to the familiar loud noises mentioned in the previous section, the nurse should elicit the infant's Moro response kinetically. Three principle methods are used to do this.
1 . With the infant lying supine on a soft supporting surface such as a firm sofa or carpeted floor, the nurse raises the head to approximately a 30" angle in relation to the trunk. At this point, the nurse's hands are rapidly dropped underneath the infant (Figure 12). 2. With the infant lying supine, the nurse holds the hands and raises the body until the neck is approximately in a 45" angle of extension. The occiput remains against the supporting surface. At this point, the nurse releases the infant's hands (Figure 13). 3. With the infant lying supine in the arm of the nurse with the head resting on the palm, the head is bent forward approximately 45" and rapidly dropped. This method is usually used when no supporting surface is available (Figure 14). The full response consists of 1) abduction or an outflinging of the arms and shoulders, 2) extension of
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the arms at the elbow and opening of the hands, and 3) adduction of the arms to the midline. During the extension phase when the hands open, the thumb and index finger may assume a “C” shape. Saint Anne Dargassies observed that while not all infants assume the “C” formation, the vast majority of infants do open their hands during elicitation.?’The infant whose hands remain closed during the abduction phase is suspect. Crying may occur following the elicitation of this reflex. The Moro reflex should be present from the 28th week of gestation. However, in the small preterm infant, the arms may fall backward onto the supporting surface during the adduction phase. This is due to a lack of strength in the mass muscle. Persistence of this reflex beyond the sixth month, or excessive reaction during the time when it is present, should arouse suspicion of neurologic abnormality. Asymmetry observed during elicitation is also cause for concern and can be sometimes seen in infants with hemiparesis, brachial plexus injury, or fractured clavicle. Absence of the Moro response during the first months of life may indicate severe central nervous system depression.
A$ninetric
Figure 13. Raising shoulders to elicit Moro reflex.
and by two to three months of age, the reflex is at its peak and the infant may assume this posture spontaneously when lying supine. Generally, the ATNR is elicited less frequently after the fourth to fifth month and should be integrated by six months of age. Persistence of this reflex beyond the sixth month or an obligatory response in the earlier months (an infant who is
“caught” in this “fencing” position and unable to move out of it) are cause for concern. Mothers may view extreme ATNR responses as rejection by the infant. During feeding, the infant’s head turns toward the mother causing extension of the arm on the face side. T h e mother may interpret this movement as the baby trying to push her away.
Tonic Neck Reflex
Evaluation of the asymmetric tonic neck reflex (ATNR) is important in the identification of cerebral motor problems in infants. To elicit the reflex, the nurse passively rotates the head to one side and then the other. T h e response seen should be an extension of the arm on the face side of the body and a flexion of the arm on the occiput side of the body. The legs will exhibit a similar change in tone; however, this component is often visible to a lesser degree (Figure 15). This reflex is seen in some normal newborns. By one month of age, most infants exhibit the ATNR
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Figure 14. Position for eliciting Moro reflex on examiner’s arm.
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The items on both the Wheel and R.S.A. are based on ages when most infants born at term achieve the various tasks. Therefore, the nurse needs to adjust the infant’s age for prematurity when appropriate for the first years of life, as previously demonstrated.
Approach to the Infant
Figure 15. Asymmetric tonic neck reflex in six-week-old infant.
Developmental Milestones An extremely vital component of the neurological assessment is the review of developmental milestones. Community health nurses are generally familiar with the ages when infants normally reach various developmental landmarks. However, it is often difficult to recall these in an organized, logical way when they are needed. A variety of standardized developmental screening tools that provide objective guidelines are available for the nurse to use. The IRPP suggests two such guidelines (both are item lists based on standardized evaluation scales rather than scored screening tests and both were designed for nurses as an adjunct to health assessment in the community setting): 1. Guide to Normal Milestones of Development (Wheel).‘ This convenient device is available in the back of the book, A Developmental Approach to Casefinding. Developed in 1967 and revised in 1979, the Wheel includes basic reflexes plus major milestones from 0 to 36 months. 2. Reactions, Skills and Abilities (R.S.A.) Virginia State Health Department.I3 This guide consists of a checklist-type form and manual designed to assess growth and development from 0 to 10 years of age.
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A most important, and often most difficult, aspect of the assessment of the infant is the order in which the nurse performs the assessment. In all situations, observation of the infant’s general alertness, posture, and symmetry of spontaneous movements should precede any hands-on activity. Generally, those elements of the exam requiring the most manipulation of the infant, such as head control, ventral suspension, and the Moro reflex, should be performed towards the end of the visit. These elements tend to upset the infant (and parent) and, if performed early in the visit, may interfere with the remaining parts of the exam.
NURSING IMPLICATIONS AND REFERRAL Following each home visit, the community health nurse should discuss findings and recommendations with the parents. This discussion should stress positive aspects of the child’s development and reinforce good parenting techniques. T h e nurse needs to help parents of preterm infants understand that neurodevelopment should be viewed on the basis of the infants’ adjusted age. Developmental concerns should be mentioned cautiously after more than one observation of the infant’s behavior has been made. Appropriate infant stimulation teaching must be included in parental discussions.
In the IRPP, a report of all community health nursing home visits is sent to the neonatal intensive care unit at the perinatal center. In this way, nurses who cared for the infant on the unit can be aware of the infant’s progress. In most perinatal centers, infants ideally return to a multidisciplinary team follow-up clinic. Home visit reports areshared with this team. In addition, these reports are sent to the primary care physician in the local community. Community health nurses should use both the resources of follow-up clinics and primary physicians to refer concerns on neurodevelopment.
SUMMARY Community health nursing follow-up of high-risk infants should be an integral part of all regionalized perinatal programs. One aspect of the follow-up process has been highlighted for two reasons: 1) the neurodevelopmental sequelae experienced by high-risk infants can frequently be prevented or diminished if identified early and 2) to provide community health nurses who have had opportunities to develop limited physical assessment skills with a preliminary guide for initiating the assessment process. The more often physical assessment techniques are performed, the more familiar the nurse will become with normal infant variations. Only with that background will an appreciation for the normal variations be developed.
REFERENCES 1. Saigal S, Rosenbaum P, Stoskopf B, Milner R. Follow-up of infants 501 to 1,500 gm birth weight delivered to residents of a geographically defined region with perinatal intensive care facilities. J Pediatr 1982;lOOr606-13. 2. Haynes U. A developmental approach to casefinding. (PHED), HSA, 75-5403, U.S. Department
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of Health and Human Services,
weight
1979.
1970;77:11.
infants.
J
3. Saint Anne Dargassies S. Neuro-
9. Sher PK, Brown SB. A longitudinal
logical development in the full term and premature neonate. Amsterdam: Excerpta Medica, 1979. 4. Paine R, Oppe T. Neurological examination of children. London: Heinnemann Medical Books, Ltd.,
study of head growth in preterm infants: normal rates for head growth. Dev Med Child Neurol
1966. 5. Powell ML. Assessment of the newborn. In: Powell ML, ed. Assessment and management of developmental changes and problems in children. 2nd ed. St. Louis: CV Mosby, 198 1:16-47. 6. Brown MS, Murphy MA. Ambulatory pediatric for nurses. New York: McGraw-Hill, 1974. 7. Growth charts, monthly vital statistics report. Hyattsville, MD: National Center for Health Statistics, 1976; DHEW publication no. (HRA) 76-1 120, vol. 25, no. 3. 8. Babson S. Growth of low birth
more information contact: Paul Prince, PhD, Bureau of Maternal Child Health, Commonwealth of Virginia Department of Health, Richmond, VA 23219.)
Pediatr
1975;17:705-10. 10. Lubchenco LO, Hansman C, Boyd E. Intrauterine growth in length and head circumference as estimated from live births at gestational ages 26-42 weeks. Pediatrics
Address for correspondence: Susan Ritchie, RN, 1200 Dorsey Ave. #9, Morgantown, WV 26505.
1966;37:403. 1 1 . Babson S. Growth graphs for clinical assessments of infants of varying gestational age. J Pediatr
1967;89:814-20. 12. Capute AJ. ldentifying cerebral palsy in infancy through study of primitive reflex profiles. Pediatr Ann 1979;8:34-42. 13. Commonwealth of Virginia Department of Health. Reaction, skills. and abilities manual. Unpublished manuscript, 1981. (For
Susan Ritchie is a pediatric nurse practitioner in the Department of Pediatrics at West Virginia University. Ms. Ritchie is a member of Sigma Theta Tau, the American Public Health Association, and ANA. Carol Wiltgen Trotter is the coordinator of the Neonatal Nurse Clinician Program at St. John's Mercy Medical Center in St. Louis, Missouri. Ms. Trotter is a member of NAACOG. the National Perinatal Association, and Sigma Theta Tau
CHILD DEVELOPMENT FELLOWSHIPS
Applications for 1985-1 986 Congressional Science Fellowships in Child Development are being invited by the Society for Research in Child Development. Scientists and professionals at the post-doctoral level with interests in child development and public policy may apply. Early and midcareer applicants are encouraged. The fellowships offer an opportunity for participants to spend one year as a member of a Congressionalstaff. The 1985-1 986 fellowship year begins September 1, 1985. Deadline for receipt of application materials is November 1, 1984. Contact Dr. Barbara Everett, Director, Washington Liaison Office, Society for Research in Child Development, 100 North Carolina Ave., SE, Suite 1, Washington, DC 20003, (202) 543-9582.
MATERNAL-CHILD HEALTH
"Women and Children: Health Care/Health Risks 1984" is the theme of an upcoming conference in Knoxville, Tennessee, sponsored by Planned Parenthood of East Tennessee. The meeting will be held September 7-9, 1984, at the Knoxville Hilton. CEUs under AMA Category I will be available. For further information, contact: Department of Conferences, Universityof Tennessee, 2016 Lake Ave.. Knoxville,TN 37996, (615) 974-5261.
July/August 1984 JOGN Nursing
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Community health nursing follow-up of the high-risk infant has been an integral component of the Illinois Regionalized Perinatal Program (IRPP) since it began in 1975. Every infant hospitalized in a neonatal intensive care unit (NICU) in an Illin’ois perinatal center is referred to a community health nurse for follow-up. This nurse visits the family in the home at periodic intervals, until the infant is 18 months ofiage, to provide parental support, teaching, and anticipatory guidance in addition to physical and developmental assessment of the infant. The assessment of high-risk infants in the home was a new procedure for many community health nurses. Therefore, the maternalchild health nursing consultants within the Illinois Department of Public Health developed guidelines to assist the community health nurses in the process. Although the guidelines include all of the elements of a comprehensive assessSubmitted: October 1982. Accepted with revisions: April 1983.
July/August 1984JOGN Nursing
ment (Table l), those that relate to the neurological evaluation and development of the infant (neurodevelopment) are of particular concern to the community health nurses. Saigal et al., in a study of infants treated in a regional perinatal center, found a 16.8%, incidence of neurological handicap including cerebral palsy, hydrocephalus, microcephaly , blindness, deafness, and mental retardation.’ Because the neurodevelopmental assessment is of extreme importance in the follow-up of high-risk infants due to their increased risk of developmental disabilities, teaching community health nurses these procedures is emphasized. The nursing consultants begin this teaching by stressing familiar nursing observations of the infant’s alertness and movement. Assessment of head control, eye coordination, and obligatory reflexes are added to build a good foundation in the neurodevelopmental assessment process that can be performed by community health nurses in the home.
NEURODEVELOPMENTAL ASSESSMENT Neurodevelopmental assessment of the infant in the home offers many positive benefits to the nurse and family. Observing the infant interact with parents, siblings, and familiar objects in the infant’s usual setting is essential to the nurse’s understanding of developmental progress. The relaxed, unhurried atmosphere of a home visit creates a situation where parents a r e sufficiently at ease to discuss concerns they might otherwise be reluctant to express. Parents enjoy being included in the evaluation process. The nurse should find a convenient place to perform the assessment where parents can watch and participate comfortably; often this is a kitchen table, firm soFd, or bassinet. The essential elements of the neurodevelopmental assessment include alertness, tone, head, sensory status, obligatory reflexes (Moro and asymmetrical tonic neck), a n d developmental milestones. The nurse
243
Table 1. Elements of Comprehensive Infant Assessment
1. History 2. Physical examination 3. Vision and auditory assessment 4. Developmental screening 5. Nutritional assessment 6. Observation of infant behavior and parent-child interaction
can demonstrate and explain these elements to parents in a way that points o u t positive aspects of the child’s development. Alertness
Before the actual hands-on portion of the assessment begins, the community health nurse can learn a great deal by observing the infant playing and sleeping, or being cuddled and fed. In the course of these activities, the nurse can appraise the infant’s alerting and orienting behavior in response to stimulating objects and parents’ voices. Normal alerting and orienting behavior results in fixation of the infant’s gaze on the care giver. At the same time, oral reflexes (rooting and sucking),
present during the feeding process, provide valuable information about the infant’s neurological development. A strong suck, hand-tomouth movement, or an interested gaze are indications of normal infant response that the nurse can share with parents. Preterm infants may have a weaker suck and somewhat less active movements than full-term infants. The nurse should discuss these variations with parents in an effort to assure them that such differences are expected. Tone
From the first moment that the nurse picks up the infant, she begins her assessment of posture, head control, muscle consistency,and the range of motion, all of which are components of tone. Because these aspects are difficult to describe and because they vary greatly from infant to infant, tone evaluation is complex. Haynes states that although the assessment of tone requires quite a bit of practice, nurses soon learn to distinguish generalized hypertonicity (the extremely stiff infant) and hypotonicity (the very floppy infant).* Posture
Figure 1. Full-term infant fully flexed.
244
Flexor tone predominates in the normal newborn. When in the prone position, infants lie with arms and knees flexed and drawn slightly up underneath their body. When supine, all four extremities remain semiflexed and symmetrical (Figure 1). Gently extending the extremities will result in a quick, recoil movement back to the flexed position. During the third and fourth month, extensor tone begins to increase. By the fifth and sixth month, the trunk is fully extended when the infant is prone, and when supine soles of the feet are able to come together or rest on the supporting surface. At about this time, and throughout the first year, the infant can be seen bringing the feet to
Figure 2. Seven-month-old infant demonstrating greater neuromuscular control.
hand, mouth, and the opposite knee (Figure 2). Preterm infants normally display less tone than fullterm infants. When preterm infants are supine, their legs may be flexed but in a position of wide abduction until they are almost flat against the supporting surface (frog-like posture). The upper limbs are often extended. As the infant approaches 40 weeks, the posture becomes more like that of a normal newborn.3 The lack of tone observed in some early preterm infants may also be present in some children with Down’s Syndrome or other constellations involving mental deficiency.* Extensor tone in the growing infant may be early evidence of damage to the central nervous system secondary to perinatal insult. Infants with such abnormality may hold their legs in a fully extended and very stiff position, possibly crossing (scissoring) when supine or suspended vertically. Parents may be aware of these problems because stiffness causes inability to separate the infant’s legs which, in turn, makes diapering difficult.The arms may be flexed, very hypertonic, and drawn across the body.
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Figure 5. Landau reflex in nine-month-old infant.
Figure 3. Six-week-old infant in ventral suspension.
The ventral suspension posture is important in the evaluation of tone. When normal newborns are held underneath the chest and abdomen in the nurse’s palm, they should display some evidence of head extension of a few seconds duration (Figure 3.) Also, some extension in the hips, although not as likely, may be seen. Only in the earliest preterm infants is it “normal”
to observe the infant in an inverted “ U ” or “rag doll” posture over the nurse’s hands. The extension of head and hips will continue to develop throughout the early months of an infant’s life, and by six to nine months the infant is developing extension in both of these areas (Figure 4). Most infants, by the age of 12 months, have developed a position of hip extension including the
Figure 4. Six-month-old infant displaying improved muscular control.
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arching of the spine into a concave posture-a positive Landau reflex (Figure 5 ) . Head Control
The infant’s ability to control head movements is a factor in tone evaluation. When a normal newborn is grasped by the hands and pulled to a sitting position, the head will lag behind the body (Figure 6A). However, when a sitting position is reached, the normal infant should make attempts to hold the head upright (Figures 6B, C). This movement can be performed in the home on the assessment surface or while the nurse holds the infant on her lap. The nurse should reassure parents that this procedure does not hurt the infant but, in fact, is a useful developmental exercise the parents may wish to do while playing with their infant. During the next few months, neck tone and head control increase. By the fourth month of age, when pulled to a sitting position, the infant is able to keep the head on the same plane as the body (Figures 7A, B, C). In preterm infants, this development of head control may be somewhat delayed. This is also true in infants with neurological abnormalities affecting motor development.
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Figures 6A,B,C. Normal head lag in a six-week-old infant.
Muscle Consistency Muscle consistency, assessed by gently squeezing the muscle mass between the finger and thumb, is probably the most subjective part of the evaluation of tone. In a normal newborn, this muscle mass is firm to touch. By two to six months, the muscles begin to feel more flabby.4 The early preterm infant has very little muscle mass and it is generally quite soft to touch. A more descriptive way of saying this is that the skin of preterm infants appears too large for their bodies.
Range of iblotion Limb movement in the normal newborn should be spontaneous and equal. The upper extremities generally move symmetrically, while the lower extremities move alternately.5 Slightlyjerky newborn
movements are replaced by smoother and more coordinated attempts in the three- to fourmonth-old infant. In observing the infant’s movement, the nurse should direct her attention to the hands. In the newborn, the hands are often seen in a clenched fist position. As the infant reaches three to four months of age the hands are seen to open spontaneously with greater frequency. Persistence of the clenched fist in the young infant or fisting with the thumb entrapped in the palm (corticol thumbing) beyond the fourth month should alert the nurse to a possible neurological abnormality.
Head Head Circunzference Head circumference is perhaps the most readily accessible measure
of brain g r ~ w t hDuring .~ a followup home visit, community health nurses obtain head circumference using a paper or metal tape placed over the most prominent part of the occiput and mid-forehead (supraorbital ridges). Three measurements are taken with the reading made at mid-forehead, right and left sides. The largest circumfer- ~ circumence is r e ~ o r d e d . ~Head ference must be recorded at every encounter the nurse has with the high-risk infant. Each time, the measurement should be plotted on standardized growth charts. Those developed by, the National Center for Health Statistics are recommended.’ The nurse is encouraged to take these charts on the visit with her and plot the measurement. These can be explained and shared with parents. Head circumference
Figures ’IA,B,C. Improved head control in six-month-old infant.
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greater than the 95th percentile or less than the fifth percentile (in fullterm infants) in the absence of a corresponding height and weight measurement or a head circumference that rapidly changes percentile levels should be brought to the attention of the primary care giver. Preterm infants may display head circumferences below the fifth percentile if plotted on a standard fullterm growth chart. Two other techniques are suggested for graphing head circumferences of preterm infants. The first technique is to plot the measurement on a fullterm growth chart after adjusting for prematurity.' (Adjusting for prematurity: Chronological age in weeks - weeks of prematurity = adjusted age in weeks.) This is not an ideal solution because preterm infants experience more rapid head growth than full-term infants in the first two months of postnatal life. Thus, the head circumference of preterm infants when plotted on a full-term growth chart may appear to grow too r a ~ i d l yThe . ~ second and. preferable technique is using growth charts especially designed for preterm infants that account for both prematurity and rapid head growth."." These charts are intended for use in the f i r 3 year of life. Fontanels and Sutures
The nurse should pay particular attention to assessing the size of the anterior and posterior fontanels. Posterior fontanels, which are often difficultto detect even in the newborn period, normally close by the second or third month of life and anterior fontanels normally close sometime between the sixth and 18th month (later in children with Down 's Syndrome). Font an e 1s should be measured with the fingertip and recorded in centimeter units. An anterior-posterior and lateral measurement should be taken (Figures 8, 9). Fontanels should be observed for bulging,
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Figure 8. Palpation for anterior fontanel.
which may indicate an increase in intracranial pressure, or a depression, which may indicate severe dehydration. T h e coronal and sagittal sutures may be overlapping, slightly separated, or have prominent ridges after birth. However, these newborn variations should not be palpable after the fifth or sixth month. Sensory Status Hearing
The assessment of hearing is often difficult in the young infant. The nurse may begin the hearing evaluation by asking the parents how the infant responds to common household noises such as a telephone ringing, dog barking, or door slamming. For the actual assessment, the nurse may use a familiar toy. The nurse needs to attract the infant's attention with the toy and ring the bell out of sight of the infant (Figure 10). This should be done on both sides to assess each of the infant's ears. T h e response will vary depending on the developmental age of the child from a subtle eye blinking and/or movement change in the newborn to a more definite localization response (turning to or reaching out for the bell) in the five- and sixmonth-old. The hearing response, as well as other sensory status indicators (vision and reaction to
Figure 9. Anatomical representation of coronal (horizontal) and sagittal (vertical) sutures and anterior fontanel.
painful stimuli), will vary also with the infant's ability to disregard repeated stimuli. This normal habitation response of infants to repeated stimuli may be confusing to the novice examiner but is an important observation in the neurodevelopmental assessment of the infant. Vision A penlight is used to determine pupil equality and reaction to light. T h e nurse may need to carry the infant into a dark bedroom to ap-
Figure 10. Public health nurse assessing hearing in a nine-month-old infant.
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Figure 11. Six-month-old infant visually tracking doll.
preciate the pupillary reaction. The pupils will then dilate to a considerable degree making the pupillary reaction to the penlight easier to detect. Furthermore, the very young infant is more likely to open his or her eyes in a dark room. Holding the infant in a vertical position may also help.
Figure 12. Raising head to elicit Moro reflex.
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The penlight or bright-colored toy can also be used to assess the visual response through tracking. Tracking is the ability of an infant to fixate on and follow an object with his or her eyes through space. Until the infant is approximately four months of age, the light or object is moved in a horizontal arc of 180" while the infant is lying supine (Figure 1 1 ) . Vertical tracking is usually developed by the sixth month of age. At this point, with the infant held in a sitting position, the stimulus is moved in an "H" formation to assess tracking. Not only does the neurological assessment of the eye include evaluation of the infant's ability to focus on and track an object, but also observation for the presence of nystagmus (rapid alternating eye movements) or other unusual deviations. An infant's eyes may wander for the first six months of life, however, any eye crossing after this age is cause for medical referral.
Primitive Reflexes The nurse is able to continue observation of the infant's neurological responses through assessment
of primitive reflexes. These may be the earliest indication of the presence of significant motor disability.'' Therefore, it is essential that these reflexes be tested on each home visit. In addition to the rooting and sucking reflex previously cited, two primitive reflexes predictive of later neurologic abnormality are the Moro and asymmetric tonic neck reflex. Both can be easily assessed by the nurse during a home visit.
Moro Although the young infant may spontaneously demonstrate a startle reaction to the familiar loud noises mentioned in the previous section, the nurse should elicit the infant's Moro response kinetically. Three principle methods are used to do this.
1 . With the infant lying supine on a soft supporting surface such as a firm sofa or carpeted floor, the nurse raises the head to approximately a 30" angle in relation to the trunk. At this point, the nurse's hands are rapidly dropped underneath the infant (Figure 12). 2. With the infant lying supine, the nurse holds the hands and raises the body until the neck is approximately in a 45" angle of extension. The occiput remains against the supporting surface. At this point, the nurse releases the infant's hands (Figure 13). 3. With the infant lying supine in the arm of the nurse with the head resting on the palm, the head is bent forward approximately 45" and rapidly dropped. This method is usually used when no supporting surface is available (Figure 14). The full response consists of 1) abduction or an outflinging of the arms and shoulders, 2) extension of
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the arms at the elbow and opening of the hands, and 3) adduction of the arms to the midline. During the extension phase when the hands open, the thumb and index finger may assume a “C” shape. Saint Anne Dargassies observed that while not all infants assume the “C” formation, the vast majority of infants do open their hands during elicitation.?’The infant whose hands remain closed during the abduction phase is suspect. Crying may occur following the elicitation of this reflex. The Moro reflex should be present from the 28th week of gestation. However, in the small preterm infant, the arms may fall backward onto the supporting surface during the adduction phase. This is due to a lack of strength in the mass muscle. Persistence of this reflex beyond the sixth month, or excessive reaction during the time when it is present, should arouse suspicion of neurologic abnormality. Asymmetry observed during elicitation is also cause for concern and can be sometimes seen in infants with hemiparesis, brachial plexus injury, or fractured clavicle. Absence of the Moro response during the first months of life may indicate severe central nervous system depression.
A$ninetric
Figure 13. Raising shoulders to elicit Moro reflex.
and by two to three months of age, the reflex is at its peak and the infant may assume this posture spontaneously when lying supine. Generally, the ATNR is elicited less frequently after the fourth to fifth month and should be integrated by six months of age. Persistence of this reflex beyond the sixth month or an obligatory response in the earlier months (an infant who is
“caught” in this “fencing” position and unable to move out of it) are cause for concern. Mothers may view extreme ATNR responses as rejection by the infant. During feeding, the infant’s head turns toward the mother causing extension of the arm on the face side. T h e mother may interpret this movement as the baby trying to push her away.
Tonic Neck Reflex
Evaluation of the asymmetric tonic neck reflex (ATNR) is important in the identification of cerebral motor problems in infants. To elicit the reflex, the nurse passively rotates the head to one side and then the other. T h e response seen should be an extension of the arm on the face side of the body and a flexion of the arm on the occiput side of the body. The legs will exhibit a similar change in tone; however, this component is often visible to a lesser degree (Figure 15). This reflex is seen in some normal newborns. By one month of age, most infants exhibit the ATNR
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Figure 14. Position for eliciting Moro reflex on examiner’s arm.
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The items on both the Wheel and R.S.A. are based on ages when most infants born at term achieve the various tasks. Therefore, the nurse needs to adjust the infant’s age for prematurity when appropriate for the first years of life, as previously demonstrated.
Approach to the Infant
Figure 15. Asymmetric tonic neck reflex in six-week-old infant.
Developmental Milestones An extremely vital component of the neurological assessment is the review of developmental milestones. Community health nurses are generally familiar with the ages when infants normally reach various developmental landmarks. However, it is often difficult to recall these in an organized, logical way when they are needed. A variety of standardized developmental screening tools that provide objective guidelines are available for the nurse to use. The IRPP suggests two such guidelines (both are item lists based on standardized evaluation scales rather than scored screening tests and both were designed for nurses as an adjunct to health assessment in the community setting): 1. Guide to Normal Milestones of Development (Wheel).‘ This convenient device is available in the back of the book, A Developmental Approach to Casefinding. Developed in 1967 and revised in 1979, the Wheel includes basic reflexes plus major milestones from 0 to 36 months. 2. Reactions, Skills and Abilities (R.S.A.) Virginia State Health Department.I3 This guide consists of a checklist-type form and manual designed to assess growth and development from 0 to 10 years of age.
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A most important, and often most difficult, aspect of the assessment of the infant is the order in which the nurse performs the assessment. In all situations, observation of the infant’s general alertness, posture, and symmetry of spontaneous movements should precede any hands-on activity. Generally, those elements of the exam requiring the most manipulation of the infant, such as head control, ventral suspension, and the Moro reflex, should be performed towards the end of the visit. These elements tend to upset the infant (and parent) and, if performed early in the visit, may interfere with the remaining parts of the exam.
NURSING IMPLICATIONS AND REFERRAL Following each home visit, the community health nurse should discuss findings and recommendations with the parents. This discussion should stress positive aspects of the child’s development and reinforce good parenting techniques. T h e nurse needs to help parents of preterm infants understand that neurodevelopment should be viewed on the basis of the infants’ adjusted age. Developmental concerns should be mentioned cautiously after more than one observation of the infant’s behavior has been made. Appropriate infant stimulation teaching must be included in parental discussions.
In the IRPP, a report of all community health nursing home visits is sent to the neonatal intensive care unit at the perinatal center. In this way, nurses who cared for the infant on the unit can be aware of the infant’s progress. In most perinatal centers, infants ideally return to a multidisciplinary team follow-up clinic. Home visit reports areshared with this team. In addition, these reports are sent to the primary care physician in the local community. Community health nurses should use both the resources of follow-up clinics and primary physicians to refer concerns on neurodevelopment.
SUMMARY Community health nursing follow-up of high-risk infants should be an integral part of all regionalized perinatal programs. One aspect of the follow-up process has been highlighted for two reasons: 1) the neurodevelopmental sequelae experienced by high-risk infants can frequently be prevented or diminished if identified early and 2) to provide community health nurses who have had opportunities to develop limited physical assessment skills with a preliminary guide for initiating the assessment process. The more often physical assessment techniques are performed, the more familiar the nurse will become with normal infant variations. Only with that background will an appreciation for the normal variations be developed.
REFERENCES 1. Saigal S, Rosenbaum P, Stoskopf B, Milner R. Follow-up of infants 501 to 1,500 gm birth weight delivered to residents of a geographically defined region with perinatal intensive care facilities. J Pediatr 1982;lOOr606-13. 2. Haynes U. A developmental approach to casefinding. (PHED), HSA, 75-5403, U.S. Department
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of Health and Human Services,
weight
1979.
1970;77:11.
infants.
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3. Saint Anne Dargassies S. Neuro-
9. Sher PK, Brown SB. A longitudinal
logical development in the full term and premature neonate. Amsterdam: Excerpta Medica, 1979. 4. Paine R, Oppe T. Neurological examination of children. London: Heinnemann Medical Books, Ltd.,
study of head growth in preterm infants: normal rates for head growth. Dev Med Child Neurol
1966. 5. Powell ML. Assessment of the newborn. In: Powell ML, ed. Assessment and management of developmental changes and problems in children. 2nd ed. St. Louis: CV Mosby, 198 1:16-47. 6. Brown MS, Murphy MA. Ambulatory pediatric for nurses. New York: McGraw-Hill, 1974. 7. Growth charts, monthly vital statistics report. Hyattsville, MD: National Center for Health Statistics, 1976; DHEW publication no. (HRA) 76-1 120, vol. 25, no. 3. 8. Babson S. Growth of low birth
more information contact: Paul Prince, PhD, Bureau of Maternal Child Health, Commonwealth of Virginia Department of Health, Richmond, VA 23219.)
Pediatr
1975;17:705-10. 10. Lubchenco LO, Hansman C, Boyd E. Intrauterine growth in length and head circumference as estimated from live births at gestational ages 26-42 weeks. Pediatrics
Address for correspondence: Susan Ritchie, RN, 1200 Dorsey Ave. #9, Morgantown, WV 26505.
1966;37:403. 1 1 . Babson S. Growth graphs for clinical assessments of infants of varying gestational age. J Pediatr
1967;89:814-20. 12. Capute AJ. ldentifying cerebral palsy in infancy through study of primitive reflex profiles. Pediatr Ann 1979;8:34-42. 13. Commonwealth of Virginia Department of Health. Reaction, skills. and abilities manual. Unpublished manuscript, 1981. (For
Susan Ritchie is a pediatric nurse practitioner in the Department of Pediatrics at West Virginia University. Ms. Ritchie is a member of Sigma Theta Tau, the American Public Health Association, and ANA. Carol Wiltgen Trotter is the coordinator of the Neonatal Nurse Clinician Program at St. John's Mercy Medical Center in St. Louis, Missouri. Ms. Trotter is a member of NAACOG. the National Perinatal Association, and Sigma Theta Tau
CHILD DEVELOPMENT FELLOWSHIPS
Applications for 1985-1 986 Congressional Science Fellowships in Child Development are being invited by the Society for Research in Child Development. Scientists and professionals at the post-doctoral level with interests in child development and public policy may apply. Early and midcareer applicants are encouraged. The fellowships offer an opportunity for participants to spend one year as a member of a Congressionalstaff. The 1985-1 986 fellowship year begins September 1, 1985. Deadline for receipt of application materials is November 1, 1984. Contact Dr. Barbara Everett, Director, Washington Liaison Office, Society for Research in Child Development, 100 North Carolina Ave., SE, Suite 1, Washington, DC 20003, (202) 543-9582.
MATERNAL-CHILD HEALTH
"Women and Children: Health Care/Health Risks 1984" is the theme of an upcoming conference in Knoxville, Tennessee, sponsored by Planned Parenthood of East Tennessee. The meeting will be held September 7-9, 1984, at the Knoxville Hilton. CEUs under AMA Category I will be available. For further information, contact: Department of Conferences, Universityof Tennessee, 2016 Lake Ave.. Knoxville,TN 37996, (615) 974-5261.
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