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Traction in the newborn
T h e ]ournal o[ P E D I A T R I C S
1123
Traction in the newborn A description o[ the variation in 200 newborn in[ants
The response to traction is described in 200 newborn in[ants in an effort to establish the variation in response. A review o[ previous studies o[ the response is presented to determine the significance o[ the variations in newborn in[ants and its predictive value o[ later neurologic disorders.
J.
T. Jabbour, M.D.,* and
OKLAHOMA
J.
W. Clark
GITY, OKLA.
T R A C T I O N, the act of drawing a supine infant to a sitting position, permits the examiner to evaluate the resistance of the infant? During the first 4 months of life, an infant exhibits involuntary resistance when pulled to a sitting position. Between the fourth and eighth months of life, involuntary resistance decreases and voluntary assistance of neck, arm, shoulder, and trunk muscles may be observed. By 8 months of age, the infant may pull to a standing position?, 3, 4 Various investigators have recorded these characteristic responses of infants during the first year of life? -5 Donovan, Coues, and Paine 6 recently suggested that the response to traction may reflect the presence of central nervous system abnormality. This paper describes the variation of the response to tracFrom the Department o[ Pediatrics and the Children's Memorial Hospital, University o[ Oklahoma School o[ Medicine. Supported in part by Training Grant in Pediatric Neurology, No. 5 T1 5387-02, [rom the National Institutes o[ Neurological Diseases and Blindness. *Address, Child Development Center, 22 N. Pauline, Memphis, Tenn.
tion in 200 randomly selected infants, utilizing a standard method of examination. METHODS
AND MATERIALS
Two hundred newborn infants ranging in age from 6 hours to 5 days were examined in the newborn nursery of the University of Oklahoma Medical Center. Criteria for selection of the infants were: (1) a full-term pregnancy, (2) a birth weight of 2,500 grams or more, and (3) no evidence on routine newborn examination of systemic or neurologic disease. The infant's prenatal and perinatal histories were unknown to the examiners. Three successive maneuvers were performed on each fully awake, supine infant by each of two different examiners alternately. While one examined, the other observed and recorded. Thus, 6 separate responses were evaluated in each infant. The examination was performed while the infant was lying in a plastic bassinet. The examiner's thumbs were inserted into the ulnar side of the infant's palm and the infant was then pulled to a 45 degree angle and to a sitting position.
1 1 2 4 Jabbour and Clark
December 1965
RESULTS
This p e r m i t t e d evaluation of the ~ a s p response, e x a m i n a t i o n of the h e a d a n d back, a n d appraisal of the resistance of the infant. Patterns of response to traction were as follows: (1) d u r i n g the rise or sit the head lagged, flexed, or was in line (Fig. 1); (2) the h a n d grasp was either present or absent; (3) d u r i n g the rise the back was either inclined, 6; round, C; or flexed, / , indicating varying degrees of flexor resistance; or extended, indicating either decreased flexor or increased extensor resistance (Fig. 2). T h e arms a n d legs were either extended or flexed d u r i n g the rise and sitting positions ( T a b l e I ) . Postures in the sitting position were also recorded as indicative of the infant's resistance (Fig. 2).
I n 70 p e r cent of the infants, the h e a d lagged d u r i n g the rise a n d sit phases of the response, while in 13 p e r cent the head was in line d u r i n g the rise a n d d u r i n g the sitting phase. O t h e r h e a d responses are listed in
T a b l e I I . Description of the response to traction in 200 n e w b o r n infants
t % t No. Head Lags, rise and sit In line rise and sit Lags, rise and in line sit In line rise and sit
70 13 12 5
Back 6 Rise and sit 6 Rise and C sit C Rise and sit ) Rise and ) sit / Rise and 6 sit / Rise and / sit 6 Rise and ) sit 6 Rise and / sit / Rise and C sit ) Rise and C sit
66 132 23 46 4 8 1.5 3 1 2 0.5 1 1 2 2 4 0.5 1 1 2
Arms Flexion rise-flexion sit Extension rise-extension sit Extension rise-flexion sit Flexion rise-extension sit
36 31 30 3
72 62 60 6
Legs Flexion rise-flexion sit Extension rise-extension sit Extension rise-flexion sit Other
62 23 11 4
124 46 22 8
T a b l e I. P a t t e r n of response to t r a c t i o n in the n e w b o r n
I Head
Back
Rise
I
Sit
Lagged In line
Lagged In line Flexed
Inclined Round Flexed Extended
6 C / )
Extremities
Flexed
or
Extended
Hand grasp
Present
or
Absent
HEAD
IN
TRACTION
140 26 24 10
RESPONSE III
Head position
Logs rise
In line rise
Lags on rise
Lags sit
Lags during sit
In line sit
In line rise and sit
Number
140
26
24
10
Percent
7O
13
12 I
5 II 9
Fig. 1. Various positions of the head (lag, in line, and forward) observed in 200 newborn infants during traction.
Volume 67 Number 6
Traction in the newborn
1125
Back contour during rise and sitting positions:
& 6 ~ inclined
A C--round
/--flexed in lumbar area
)--extended
C
D
Fig. 2. Variations of contour of the back observed during traction.
Table I I and Fig. 1. The back contour was inclined in 66 per cent of the infants during the rise and sit, while in 23 per cent the back contour was inclined during the rise and round during the sit phase of the response. Other positions of the back are recorded in Figs. 2 and 3. T h e limb positions are recorded in Table
II. One third of the infants demonstrated flexion; a third, extension; and a third, a mixture of flexion and extension of the upper limbs during the rise and sitting phases of the response. In contrast to this, the lower limbs were flexed in 62 per cent of the infants, extended in 23 per cent, and a small number were both extended and flexed dur-
1126
Jabbour and Clark
BACK
Back position
December 1965
IN
6 - - rise
TRACTION
6--rise
RESPONSE
C--sit
C--rise and sit
Others rise and sit
46
8
14
23
4
7
and sit Number
132
Percent
66 I
I
I
I
Fig. 3. Type of back contour during traction in 200 newborn infants.
ing the rise and sitting phases of the response (Table I I ) . All but one infant had a hand grasp response. No effort was made to measure the degree of response. Table I I I illustrates the influence of age on the response to traction. Increased resistance was evident during the first 24 hours of life and then gradually decreased,
DISCUSSION Previous studies of infant's response to traction. Recent interest in the neurologic evaluation of the newborn as a means to detect cerebral dysfunction has encouraged study of many reflexes and responses of the infant, a-6 The variation of response to traction has been evaluated in several previous studies (Table IV).1-~ In the original motion pictures of postural development studied by McGraw, 1,717 observations of traction in 82 infants ranging in age from a few minutes to 2~2 years demonstrated three separate phases of the response? Phase A. The newborn or passive phase (birth to 4 months) was manifest when no resistance to gravitational force was present. When the infant was pulled by his hands from the supine to the sitting position, the head dropped backward to the intrascapular spine. In the sitting position, the head fell
forward and the chin rested on the chest. The extremities, both upper and lower, did not assist in the maneuver. The head dropped backward and the spine assumed a position of extension. Phase B. The orthotonic phase characterized the 2 to 6 month infant, who was less passive when pulled by his hands to the sitting position. The cervical region exhibited better control and the head was in line with the body. In younger infants, as the body assumed a vertical position, the head occasionally dropped backward. The infant made no effort to aid in pulling himself up. The lower extremities remained flexed, abducted and inactive. Phase C. Voluntary flexion occurred during further development of the infant (4 to 9 months). As the infant was pulled up, the head stayed in line with the body. Flexion of the head, trunk, and upper and lower extremities was observed. This series of observations established the sequence of response to traction. A study similar to the present investigation was performed by Knop, 2 who utilized a different method of evaluating newborn resistance. She examined 698 newborns at 24 hours and again at 8 days of age for a specific reaction to an applied force which was termed "the dynamics of newly born infants." The infant was placed on his back on the examination table with the lower
Volume 67
Number 6
Traction in the newborn
1127
T a b l e I I I . T h e i n f l u e n c e o f a g e ( h o u r s ) o n t h e r e s p o n s e to t r a c t i o n i n t h e n e w b o r n
Age (hr.)
6.12 % Head Lags, rise and sit In line rise and lags sit Lags, rise and in line sit In line rise and sit
56 28 I1 5
Total
t
13.24
25-48
No.
%
I No.
I0 5 2 1
55 14 24 7
16 4 7 2
18
%
.I
I N~
78 12 5 5
t
59 9 4 4
29
5o-154 %
I U~
72 12 13 3
55 9 10 3
76
77
Back 6 Rise and sit 6 Rise and C sit C Rise and sit Other
39 50 -I1
7 9 -2
69 21 I0 --
20 6 3 --
62 25 1 12
47 I9 1 9
75 16 4 5
58 t2 3 4
Arms Flexion rise-flexion sit Extension rise-flexion sit Extension rise-extension sit Flexion rise-extension sit
44 28 22 6
8 5 4 1
45 31 17 7
13 9 5 2
29 38 20 3
30 29 15 2
27 23 48 2
12 18 37 1
Legs Flexion rise-flexion sit Extension rise-extension sit Extension rise-flexion sit Other
89 11 ---
16 2 ---
48 28 I7 7
14 8 5 2
66 13 14 7
50 I0 11 5
56 35 8 1
43 27 6 1
T a b l e I V . F e a t u r e s of t h e r e s p o n s e to t r a c t i o n ~-5
Investigator
McGraw I No. of infants Observations Head (Rise and sit) Newborn (0-4 months) Orthotonic (2-6 months) Voluntary (4-9 months) Back Newborn (0-4 months) Orthotonic (2-6 months) Voluntary (4-9 months) Extremities Newborn ( 0-4 months) ( 2-6 months)
Knop ~
]abbour and Clark
82
698
200
1,717
1,396
1,200
Dropped back- Dropped ward, flopped backward forward held up In line
Lagged or in line flexed
In line
Inclined
Inclined or round
IThomas A,,ar~I and Dargassiess
lltingworth 4
Lagged
Lagged
In line
Lifted
Assist
Raised spontaneously Round
Straight Straight
Straight or flexed
Straight
Flexed or straight
Paine 5
Lagged then fell forward
1 1 2 8 ]abbour and Clark
limbs apart and his buttocks braced against a small upholstered support. The examiner then held the infant by his hands and gently pulled him to the sitting position. In the next procedure, the infant was returned to the supine position and the examiner slowly pulled on the feet to straighten the infant's lower limbs. The infant's responses to the two procedures were rated according to their activity. At one extreme, the child's body was limp, the head fell back by its own weight, the upper limbs were straightened without noticeable resistance from the baby, and the lower limbs followed the pull of the examiner's hand. At the other extreme, the child resisted, his body exhibited strong muscular tension, and he actively lifted and held up his head. The upper limbs were flexed at the elbow and the pull on the lower limbs produced intense flexor contraction at the knee. Of the 698 infants examined by Knop, 25 were classified as Grade 1 or as least active; 465 as Grade 2; 192 as Grade 3; and 6 as Grade 4 or most active. Toxemia, diabetes mellitus, or syphilis in the mother, or heart murmur, CNS disease, mongolism, atelectasis, or respiratory difficulty in the child were related to the infant's "dynamics." The accumulation of these abnormalities in the children in Grade 1 (the limp child) and their absence in those in Grade 4 (the tense or hypertonic infant) was noted. There was a greater prevalence of males in the higher grades. No definite correlation could be established between the baby's weight and the dynamics. The relation of the mother's labor and the method of delivery to the grading of the dynamics was inconclusive. Only 13 per cent changed from one grade to the next between the first and second examination. Two babies made a change of two grades. Knop 2 concluded that dynamics was an inherent quality not decisively aItered by outside factors. The passive and spontaneous sitting responses of the infant were described by Andr6-Thomas and Dargassies. 3 For the first few weeks, the head lagged, in about 3 months the head was kept in line with the trunk, but the infant displayed little par-
December 1965
ticipation appreciated by the examiner. At 6 months of age, the infant raised himself by pulling against the examiner's fingers. A descriptive sequence of the response was reported by Illingworth 4 in 1960. His analysis of the newborn response, although similar to that of Andr6-Thomas, Dargassies and McGraw, revealed that when the infant was pulled to the sitting position, complete head lag was noted, although the sitting infant lifted the chin momentarily. In the sitting position the back was round. By 12 weeks of age, minimal head lag was described; this disappeared by 20 weeks of age. When the 24-week-old infant was pulled off a couch, he lifted the head, while at 28 weeks he raised it spontaneously. By 24 weeks of age, the back was straightening and the head and back were erect and in line. There was no description of the extremities in this study. According to Paine, 5 the response to traction was accompanied by assistance of the infant's shoulder muscles. The newborn infant's head lagged behind, then fell forward suddenly when the upright posture was reached. In some instances during the neonatal period, head control sufficient to bring it back upright was observed. With increased age, greater control of the head, back, and extremities occurred in the infant. S I G N I F I C A N C E OF T R A C T I O N IN T H E N E W B O R N
The variation of the newborn responses to traction seem dependent upon increased or decreased pull of the infant, which may be termed flexor tone. It would seem, as pointed out by Knop 2 and later by Donovan, Coues, and Paine, 6 that hypotonia (decreased flexion) probably occurs more often than suspected and represents CNS dysfunction. In the neonatal period, conventional neurologic signs either singly or in combination have a limited predictive value of latent central nervous system abnormality. In the evaluation of the response, therefore, hypotonia appears to be of prognostic significance and may indicate an unfavorable future for the infant. 2-6 The significance of hypertonia has not as yet been evaluated.
Volume 67 Number 6
The response to traction permits the physician to evaluate the infant's head control, facial symmetry, grasp response, and the tone of the extremities and trunk muscles. The relationship of a normal newborn response to rnyelinization of the posterior columns, cerebellum, or other brain stem and cerebral structures is unknown. The precise localization of the systems influencing the variation of the response to traction in normal and abnormal infants has not been defined. The responses of newborn as well as older infants described by K n o p 2 and McGraw 1 were similar to the variation of the response observed in the present study. While it is worthy of notice that the newborn infant may manifest responses similar to those of infants up to 6 months of age, the significance of the variations are not known. The response to traction in the infant from 12 hours to 5 days of age demonstrates that the head lagged during the rise and sit, the back contour was inclined or round, and the extremities were extended or flexed in over 66 per cent of newborns evaluated during the first 5 days of life. The response was related, as seen in Table II, to the age of the infant. Infants 2 to 5 days of age exhibited less flexor tone than infants from 6 to 24 hours of age. The transitory phase of increased resistance was probably related to the infant's adaptation during the first 24 hours of life. 7 Other variations of control of head, back, and extremities occur less frequently and may be influenced by disturbances of pregnancy, labor, delivery, or by underlying disease in the infant. The previous studies by McGraw and K n o p suggest a similar pattern of response to traction and the present standard method of evaluation supports these observations. The fact that the response permits the physician to detect infants with neuro-
Traction in the newborn
1129
logic dysfunction will probably establish traction as a worthwhile part of the examination of the newborn and infant. 6 SUMMARY Standardized traction studies of 200 newborn infants were made in order to describe the variation in response during the first 5 days of life. The predominant response included head lag, inclined or round back, and flexed extremities in almost all infants examined during the newborn period. Infants under 1 day of age exhibited greater flexor tone whim infants from 2 to 5 days of age exhibited less flexor tone. The relation of the variations of the response to underlying cerebral dysfunction is reviewed. Further studies utilizing a standard method of traction in infants relating such factors as type of delivery, anesthesia, and birth weight, correlated with neurologic development, may establish the predictive value of the response. REFERENCES
1. McGraw, M. B.: The neuromuscular maturation of the human infant, New York, 1943, Columbia Press. 2. Knop, C.: The dynamics of newly born babies, J. PEDIAT.29: 721, 1946. 3. Andr6-Thomas, Chesni Yves, and Dargassles, S. Saint-Anne: Neurological examination of the infant, London, 1960, Little Club Clinic No. 1, National Spastic Society. 4. Illingworth, R. S.: The development of the infant and young child, London, 1960, E. & S. Livingstone, Ltd. 5. Paine, R. S.: Neurologlc examination of infants and children, Pediat. Clin. North America 7: 471, 1960. 6. Donovan, D. E., Coues, P., and Paine, R. S.: The prognostic implication of neurologlc abnormalities in the neonatal period, Neurology 19: 910, 1962. 7. Dotson, E., and Desmond, M.: The evaluation of muscle tonus in the newborn, Neurology 14: 464, 1964.
1123
Traction in the newborn A description o[ the variation in 200 newborn in[ants
The response to traction is described in 200 newborn in[ants in an effort to establish the variation in response. A review o[ previous studies o[ the response is presented to determine the significance o[ the variations in newborn in[ants and its predictive value o[ later neurologic disorders.
J.
T. Jabbour, M.D.,* and
OKLAHOMA
J.
W. Clark
GITY, OKLA.
T R A C T I O N, the act of drawing a supine infant to a sitting position, permits the examiner to evaluate the resistance of the infant? During the first 4 months of life, an infant exhibits involuntary resistance when pulled to a sitting position. Between the fourth and eighth months of life, involuntary resistance decreases and voluntary assistance of neck, arm, shoulder, and trunk muscles may be observed. By 8 months of age, the infant may pull to a standing position?, 3, 4 Various investigators have recorded these characteristic responses of infants during the first year of life? -5 Donovan, Coues, and Paine 6 recently suggested that the response to traction may reflect the presence of central nervous system abnormality. This paper describes the variation of the response to tracFrom the Department o[ Pediatrics and the Children's Memorial Hospital, University o[ Oklahoma School o[ Medicine. Supported in part by Training Grant in Pediatric Neurology, No. 5 T1 5387-02, [rom the National Institutes o[ Neurological Diseases and Blindness. *Address, Child Development Center, 22 N. Pauline, Memphis, Tenn.
tion in 200 randomly selected infants, utilizing a standard method of examination. METHODS
AND MATERIALS
Two hundred newborn infants ranging in age from 6 hours to 5 days were examined in the newborn nursery of the University of Oklahoma Medical Center. Criteria for selection of the infants were: (1) a full-term pregnancy, (2) a birth weight of 2,500 grams or more, and (3) no evidence on routine newborn examination of systemic or neurologic disease. The infant's prenatal and perinatal histories were unknown to the examiners. Three successive maneuvers were performed on each fully awake, supine infant by each of two different examiners alternately. While one examined, the other observed and recorded. Thus, 6 separate responses were evaluated in each infant. The examination was performed while the infant was lying in a plastic bassinet. The examiner's thumbs were inserted into the ulnar side of the infant's palm and the infant was then pulled to a 45 degree angle and to a sitting position.
1 1 2 4 Jabbour and Clark
December 1965
RESULTS
This p e r m i t t e d evaluation of the ~ a s p response, e x a m i n a t i o n of the h e a d a n d back, a n d appraisal of the resistance of the infant. Patterns of response to traction were as follows: (1) d u r i n g the rise or sit the head lagged, flexed, or was in line (Fig. 1); (2) the h a n d grasp was either present or absent; (3) d u r i n g the rise the back was either inclined, 6; round, C; or flexed, / , indicating varying degrees of flexor resistance; or extended, indicating either decreased flexor or increased extensor resistance (Fig. 2). T h e arms a n d legs were either extended or flexed d u r i n g the rise and sitting positions ( T a b l e I ) . Postures in the sitting position were also recorded as indicative of the infant's resistance (Fig. 2).
I n 70 p e r cent of the infants, the h e a d lagged d u r i n g the rise a n d sit phases of the response, while in 13 p e r cent the head was in line d u r i n g the rise a n d d u r i n g the sitting phase. O t h e r h e a d responses are listed in
T a b l e I I . Description of the response to traction in 200 n e w b o r n infants
t % t No. Head Lags, rise and sit In line rise and sit Lags, rise and in line sit In line rise and sit
70 13 12 5
Back 6 Rise and sit 6 Rise and C sit C Rise and sit ) Rise and ) sit / Rise and 6 sit / Rise and / sit 6 Rise and ) sit 6 Rise and / sit / Rise and C sit ) Rise and C sit
66 132 23 46 4 8 1.5 3 1 2 0.5 1 1 2 2 4 0.5 1 1 2
Arms Flexion rise-flexion sit Extension rise-extension sit Extension rise-flexion sit Flexion rise-extension sit
36 31 30 3
72 62 60 6
Legs Flexion rise-flexion sit Extension rise-extension sit Extension rise-flexion sit Other
62 23 11 4
124 46 22 8
T a b l e I. P a t t e r n of response to t r a c t i o n in the n e w b o r n
I Head
Back
Rise
I
Sit
Lagged In line
Lagged In line Flexed
Inclined Round Flexed Extended
6 C / )
Extremities
Flexed
or
Extended
Hand grasp
Present
or
Absent
HEAD
IN
TRACTION
140 26 24 10
RESPONSE III
Head position
Logs rise
In line rise
Lags on rise
Lags sit
Lags during sit
In line sit
In line rise and sit
Number
140
26
24
10
Percent
7O
13
12 I
5 II 9
Fig. 1. Various positions of the head (lag, in line, and forward) observed in 200 newborn infants during traction.
Volume 67 Number 6
Traction in the newborn
1125
Back contour during rise and sitting positions:
& 6 ~ inclined
A C--round
/--flexed in lumbar area
)--extended
C
D
Fig. 2. Variations of contour of the back observed during traction.
Table I I and Fig. 1. The back contour was inclined in 66 per cent of the infants during the rise and sit, while in 23 per cent the back contour was inclined during the rise and round during the sit phase of the response. Other positions of the back are recorded in Figs. 2 and 3. T h e limb positions are recorded in Table
II. One third of the infants demonstrated flexion; a third, extension; and a third, a mixture of flexion and extension of the upper limbs during the rise and sitting phases of the response. In contrast to this, the lower limbs were flexed in 62 per cent of the infants, extended in 23 per cent, and a small number were both extended and flexed dur-
1126
Jabbour and Clark
BACK
Back position
December 1965
IN
6 - - rise
TRACTION
6--rise
RESPONSE
C--sit
C--rise and sit
Others rise and sit
46
8
14
23
4
7
and sit Number
132
Percent
66 I
I
I
I
Fig. 3. Type of back contour during traction in 200 newborn infants.
ing the rise and sitting phases of the response (Table I I ) . All but one infant had a hand grasp response. No effort was made to measure the degree of response. Table I I I illustrates the influence of age on the response to traction. Increased resistance was evident during the first 24 hours of life and then gradually decreased,
DISCUSSION Previous studies of infant's response to traction. Recent interest in the neurologic evaluation of the newborn as a means to detect cerebral dysfunction has encouraged study of many reflexes and responses of the infant, a-6 The variation of response to traction has been evaluated in several previous studies (Table IV).1-~ In the original motion pictures of postural development studied by McGraw, 1,717 observations of traction in 82 infants ranging in age from a few minutes to 2~2 years demonstrated three separate phases of the response? Phase A. The newborn or passive phase (birth to 4 months) was manifest when no resistance to gravitational force was present. When the infant was pulled by his hands from the supine to the sitting position, the head dropped backward to the intrascapular spine. In the sitting position, the head fell
forward and the chin rested on the chest. The extremities, both upper and lower, did not assist in the maneuver. The head dropped backward and the spine assumed a position of extension. Phase B. The orthotonic phase characterized the 2 to 6 month infant, who was less passive when pulled by his hands to the sitting position. The cervical region exhibited better control and the head was in line with the body. In younger infants, as the body assumed a vertical position, the head occasionally dropped backward. The infant made no effort to aid in pulling himself up. The lower extremities remained flexed, abducted and inactive. Phase C. Voluntary flexion occurred during further development of the infant (4 to 9 months). As the infant was pulled up, the head stayed in line with the body. Flexion of the head, trunk, and upper and lower extremities was observed. This series of observations established the sequence of response to traction. A study similar to the present investigation was performed by Knop, 2 who utilized a different method of evaluating newborn resistance. She examined 698 newborns at 24 hours and again at 8 days of age for a specific reaction to an applied force which was termed "the dynamics of newly born infants." The infant was placed on his back on the examination table with the lower
Volume 67
Number 6
Traction in the newborn
1127
T a b l e I I I . T h e i n f l u e n c e o f a g e ( h o u r s ) o n t h e r e s p o n s e to t r a c t i o n i n t h e n e w b o r n
Age (hr.)
6.12 % Head Lags, rise and sit In line rise and lags sit Lags, rise and in line sit In line rise and sit
56 28 I1 5
Total
t
13.24
25-48
No.
%
I No.
I0 5 2 1
55 14 24 7
16 4 7 2
18
%
.I
I N~
78 12 5 5
t
59 9 4 4
29
5o-154 %
I U~
72 12 13 3
55 9 10 3
76
77
Back 6 Rise and sit 6 Rise and C sit C Rise and sit Other
39 50 -I1
7 9 -2
69 21 I0 --
20 6 3 --
62 25 1 12
47 I9 1 9
75 16 4 5
58 t2 3 4
Arms Flexion rise-flexion sit Extension rise-flexion sit Extension rise-extension sit Flexion rise-extension sit
44 28 22 6
8 5 4 1
45 31 17 7
13 9 5 2
29 38 20 3
30 29 15 2
27 23 48 2
12 18 37 1
Legs Flexion rise-flexion sit Extension rise-extension sit Extension rise-flexion sit Other
89 11 ---
16 2 ---
48 28 I7 7
14 8 5 2
66 13 14 7
50 I0 11 5
56 35 8 1
43 27 6 1
T a b l e I V . F e a t u r e s of t h e r e s p o n s e to t r a c t i o n ~-5
Investigator
McGraw I No. of infants Observations Head (Rise and sit) Newborn (0-4 months) Orthotonic (2-6 months) Voluntary (4-9 months) Back Newborn (0-4 months) Orthotonic (2-6 months) Voluntary (4-9 months) Extremities Newborn ( 0-4 months) ( 2-6 months)
Knop ~
]abbour and Clark
82
698
200
1,717
1,396
1,200
Dropped back- Dropped ward, flopped backward forward held up In line
Lagged or in line flexed
In line
Inclined
Inclined or round
IThomas A,,ar~I and Dargassiess
lltingworth 4
Lagged
Lagged
In line
Lifted
Assist
Raised spontaneously Round
Straight Straight
Straight or flexed
Straight
Flexed or straight
Paine 5
Lagged then fell forward
1 1 2 8 ]abbour and Clark
limbs apart and his buttocks braced against a small upholstered support. The examiner then held the infant by his hands and gently pulled him to the sitting position. In the next procedure, the infant was returned to the supine position and the examiner slowly pulled on the feet to straighten the infant's lower limbs. The infant's responses to the two procedures were rated according to their activity. At one extreme, the child's body was limp, the head fell back by its own weight, the upper limbs were straightened without noticeable resistance from the baby, and the lower limbs followed the pull of the examiner's hand. At the other extreme, the child resisted, his body exhibited strong muscular tension, and he actively lifted and held up his head. The upper limbs were flexed at the elbow and the pull on the lower limbs produced intense flexor contraction at the knee. Of the 698 infants examined by Knop, 25 were classified as Grade 1 or as least active; 465 as Grade 2; 192 as Grade 3; and 6 as Grade 4 or most active. Toxemia, diabetes mellitus, or syphilis in the mother, or heart murmur, CNS disease, mongolism, atelectasis, or respiratory difficulty in the child were related to the infant's "dynamics." The accumulation of these abnormalities in the children in Grade 1 (the limp child) and their absence in those in Grade 4 (the tense or hypertonic infant) was noted. There was a greater prevalence of males in the higher grades. No definite correlation could be established between the baby's weight and the dynamics. The relation of the mother's labor and the method of delivery to the grading of the dynamics was inconclusive. Only 13 per cent changed from one grade to the next between the first and second examination. Two babies made a change of two grades. Knop 2 concluded that dynamics was an inherent quality not decisively aItered by outside factors. The passive and spontaneous sitting responses of the infant were described by Andr6-Thomas and Dargassies. 3 For the first few weeks, the head lagged, in about 3 months the head was kept in line with the trunk, but the infant displayed little par-
December 1965
ticipation appreciated by the examiner. At 6 months of age, the infant raised himself by pulling against the examiner's fingers. A descriptive sequence of the response was reported by Illingworth 4 in 1960. His analysis of the newborn response, although similar to that of Andr6-Thomas, Dargassies and McGraw, revealed that when the infant was pulled to the sitting position, complete head lag was noted, although the sitting infant lifted the chin momentarily. In the sitting position the back was round. By 12 weeks of age, minimal head lag was described; this disappeared by 20 weeks of age. When the 24-week-old infant was pulled off a couch, he lifted the head, while at 28 weeks he raised it spontaneously. By 24 weeks of age, the back was straightening and the head and back were erect and in line. There was no description of the extremities in this study. According to Paine, 5 the response to traction was accompanied by assistance of the infant's shoulder muscles. The newborn infant's head lagged behind, then fell forward suddenly when the upright posture was reached. In some instances during the neonatal period, head control sufficient to bring it back upright was observed. With increased age, greater control of the head, back, and extremities occurred in the infant. S I G N I F I C A N C E OF T R A C T I O N IN T H E N E W B O R N
The variation of the newborn responses to traction seem dependent upon increased or decreased pull of the infant, which may be termed flexor tone. It would seem, as pointed out by Knop 2 and later by Donovan, Coues, and Paine, 6 that hypotonia (decreased flexion) probably occurs more often than suspected and represents CNS dysfunction. In the neonatal period, conventional neurologic signs either singly or in combination have a limited predictive value of latent central nervous system abnormality. In the evaluation of the response, therefore, hypotonia appears to be of prognostic significance and may indicate an unfavorable future for the infant. 2-6 The significance of hypertonia has not as yet been evaluated.
Volume 67 Number 6
The response to traction permits the physician to evaluate the infant's head control, facial symmetry, grasp response, and the tone of the extremities and trunk muscles. The relationship of a normal newborn response to rnyelinization of the posterior columns, cerebellum, or other brain stem and cerebral structures is unknown. The precise localization of the systems influencing the variation of the response to traction in normal and abnormal infants has not been defined. The responses of newborn as well as older infants described by K n o p 2 and McGraw 1 were similar to the variation of the response observed in the present study. While it is worthy of notice that the newborn infant may manifest responses similar to those of infants up to 6 months of age, the significance of the variations are not known. The response to traction in the infant from 12 hours to 5 days of age demonstrates that the head lagged during the rise and sit, the back contour was inclined or round, and the extremities were extended or flexed in over 66 per cent of newborns evaluated during the first 5 days of life. The response was related, as seen in Table II, to the age of the infant. Infants 2 to 5 days of age exhibited less flexor tone than infants from 6 to 24 hours of age. The transitory phase of increased resistance was probably related to the infant's adaptation during the first 24 hours of life. 7 Other variations of control of head, back, and extremities occur less frequently and may be influenced by disturbances of pregnancy, labor, delivery, or by underlying disease in the infant. The previous studies by McGraw and K n o p suggest a similar pattern of response to traction and the present standard method of evaluation supports these observations. The fact that the response permits the physician to detect infants with neuro-
Traction in the newborn
1129
logic dysfunction will probably establish traction as a worthwhile part of the examination of the newborn and infant. 6 SUMMARY Standardized traction studies of 200 newborn infants were made in order to describe the variation in response during the first 5 days of life. The predominant response included head lag, inclined or round back, and flexed extremities in almost all infants examined during the newborn period. Infants under 1 day of age exhibited greater flexor tone whim infants from 2 to 5 days of age exhibited less flexor tone. The relation of the variations of the response to underlying cerebral dysfunction is reviewed. Further studies utilizing a standard method of traction in infants relating such factors as type of delivery, anesthesia, and birth weight, correlated with neurologic development, may establish the predictive value of the response. REFERENCES
1. McGraw, M. B.: The neuromuscular maturation of the human infant, New York, 1943, Columbia Press. 2. Knop, C.: The dynamics of newly born babies, J. PEDIAT.29: 721, 1946. 3. Andr6-Thomas, Chesni Yves, and Dargassles, S. Saint-Anne: Neurological examination of the infant, London, 1960, Little Club Clinic No. 1, National Spastic Society. 4. Illingworth, R. S.: The development of the infant and young child, London, 1960, E. & S. Livingstone, Ltd. 5. Paine, R. S.: Neurologlc examination of infants and children, Pediat. Clin. North America 7: 471, 1960. 6. Donovan, D. E., Coues, P., and Paine, R. S.: The prognostic implication of neurologlc abnormalities in the neonatal period, Neurology 19: 910, 1962. 7. Dotson, E., and Desmond, M.: The evaluation of muscle tonus in the newborn, Neurology 14: 464, 1964.