Table Of ContentClinics in Developmental Medicine No. 28
A Neurological Study
of Newborn Infants
David J. Beintema
Preface by
Heinz F. R. Prechtl
from the Department of Experimental
Neurology, University of Groningen
1968
Spastics International Medical Publications in
association with William Heinemann Medical
Books Ltd.
This book was presented as a thesis in the University of Groningen,
1968. The work was carried out in the Department of Developmental
Neurology at the University of Groningen (Head, Dr. Heinz Prechtl).
(g) Spastics International Medical Publications
Printed in England by THE LAVENHAM PRESS LTD., Lavenham, Suffolk
Acknowledgements
I wish to express my sincere gratitude to Professor Drooglever Fortuyn for his
help and warm interest, which have been a great encouragement to me in carrying out
this study.
This research was suggested by Dr. H. F. R. Prechtl. I am very grateful to him for
his stimulating guidance and cordial cooperation. His constant support and personal
involvement in the many problems were invaluable, particularly in the preparation
of the manuscript.
I am greatly indebted to Professor L. A. Joosse and Professor J. H. P. Jonxis for
their hospitality, which gave me the opportunity to study infants in the obstetrical
and paediatric departments. I am also grateful to Professor I. A. I. van de Vooren and
Dr. D. W. Smits for their permission to use the University of Groningen's digital
computers.
The Association for the Aid of Crippled Children provided the financial support
which made this research possible.
Many thanks are due to Dr. W. Schaafsma for the way in which he discussed
and solved the statistical problems. Mrs. J. H. van Dijk-van der Horst gave in-
valuable help in coding and other administrative work, but possibly helped still more
by encouraging the study from beginning to end.
I would like to address special thanks to Professor H. K. A. Visser, Dr. R. M.
van den Hoofdakker, Dr. M. Bax and Dr. Y. Akiyama for their fruitful discussions of
the text and their support while it was being written.
Many others have contributed to this study. Their assistance was indispensable
and my gratitude is extended to all of them. I should like to mention especially the
cooperation of my colleagues and the nurses in the obstetrical and paediatric de-
partments, and the members of the Mathematical Institute and the University com-
puter centre. The technical assistance of Mrs. J. Groenboom-Gerrits, Miss H. M.
Knol, Miss E. van Dijk and Miss W. van Dijk, of Mr. J. J. Hoks who made the
drawings and of the members of the University of Groningen's Central Photographic
Unit, was an essential contribution for which I am deeply indebted.
List of Tables
No. Page
1. Maternal age and parity .. .. .. .. .. 7
2. Toxaemia .. .. .. .. .. .. .. 8
3. Maternal anaemia .. .. .. .. .. .. 8
4. Placental infarction .. .. 9
5. Duration of labour .. .. .. .. .. 10
6. Drugs administered to the mother .. .. .. .. 11
7. Method of delivery .. .. .. .. .. .. 12
8. Umbilical cord loops around the neck .. .. .. .. 12
9. Foetal distress signs .. .. .. .. .. .. 12
10. Sex of the infant .. .. .. .. ,. .. 13
11. Birth weight .. .. .. .. .. .. .. 13
12. Onset of respiration .. .. .. .. .. .. 13
13. Method of scoring in evaluation of newborn infant (Apgar score) .. 15
14. Apgar scores .. .. .. .. .. .. .. 15
15. 1-minute Apgar scores per foetal distress sign .. .. .. 15
16. Gastro-intestinal signs .. .. .. .. .. .. 21
17. Jaundice .. .. .. .. .. .. .. 22
18. Dehydration signs .. .. .. .. .. .. 22
19. State of the infant during the examination .. .. .. .. 34
20. Consistency of state predominance .. .. .. .. 37
21. Consistency of state predominance .. .. .. .. 37
22. Alterability of the state by handling .. .. .. .. 38
23. Alterability of the state by handling .. .. .. .. 38
24. Alterability of the state by handling .. .. .. .. 39
25. Alterability of state and state predominance .. .. .. 40
26. Total scores for spontaneous motor activity .. .. 43
27. Total scores for spontaneous motor activity .. .. 43
28. Total scores for spontaneous motor activity .. .. .. 44
29. Motor activity and state predominance .. .. .. .. 45
30. Abdominal skin reflex .. .. .. ., 47
31. Abdominal skin reflex .. .. .. .. 48
32. Optical blink reflex .. .. .. .. .. .. 49
33. Acoustic blink reflex .. .. .. .. 50
34. Acoustic blink reflex .. .. .. .. .. .. 51
35. Acoustic blink reflex .. .. .. .. .. .. 51
36. Total scores for resistance against passive movements .. .. 53
37. Total scores for resistance against passive movements .. .. 54
38. Total scores for resistance against passive movements .. .. 54
39. Resistance against passive movements: total scores on the first day .. 56
40. Relationship between resistance against passive movements and jaundice 59
41. Resistance against passive movements of neck and trunk .. .. 60
42. Resistance in neck and trunk muscles .. .. 61
43. Resistance in neck and trunk muscles .. .. 61
44. Resistance against passive movements of neck and trunk on the first day
and respiratory effort on the 1-minute Apgar score .. .. .. 62
45. Total scores for power of active movements .. .. .. 64
46. Total scores for power of active movements .. .. .. 65
47. Total scores for power of active movements 65
48. Recoil of the forearm at the elbow 66
49. Recoil of the forearm at the elbow 67
50. Recoil of the forearm at the elbow 68
51. Intensity of tendon reflexes 71
52. Intensity of tendon reflexes 71
53. Intensity of tendon reflexes 71
54. Tendon reflexes - threshold 72
55. Tendon reflexes - threshold 72
56. Palmar grasp 74
57. Palmar grasp 75
58. Palmar grasp 75
59. Plantar grasp 77
60. Plantar grasp 77
61. Plantar grasp 77
62. Babinski reflex 79
63. Magnet response 82
64. Magnet response 82
65. Magnet response 82
66. Crossed extensor reflex 85
67. Crossed extensor reflex 85
68. Crossed extensor reflex 85
69. Withdrawal reflex 88
70. Withdrawal reflex 88
71. Withdrawal reflex 88
72. Rooting response 91
73. Rooting response 91
74. Rooting response 92
75. Sucking response 93
76. Sucking response 94
77. Sucking response 94
78. Head control in the sitting position 97
79. Head control in the sitting position 98
80. Head control in the sitting position 98
81. Moro response : total scores for abduction and extension 103
82. Moro response : total scores for adduction and flexion 103
83. Moro response: abduction and extension movements 103
84. Moro response : abduction and extension movements 104
85. Moro response: adduction and flexion movements 104
86. Moro response : adduction and flexion movements 104
87. Moro response: threshold 105
Moro response : threshold 106
Moro response : threshold 106
90. Low-frequency, high-amplitude tremor 110
91. Low-frequency, high-amplitude tremor 110
92. Low-frequency, high amplitude tremor 110
93. Head-lifting in the prone position 112
94. Head-lifting in the prone position 112
95. Head-lifting in the prone position 113
96. Side-to-side movements of the head 114
97. Side-to-side movements of the head 114
98. Side-to-side movements of the head 114
99. Crawling 118
100. Crawling 118
101. Crawling .. .. .. .. .. .. . . 1 18
102. Incurvation of the trunk .. .. .. .. .. 121
103. Incurvation of the trunk .. .. .. 122
104. Incurvation of the trunk .. .. .. .. 122
105. Head posture in prone suspension .. .. .. 124
106. Head posture in prone suspension .. .. .. 125
107. Head posture in prone suspension .. .. .. .. 125
108. Placing response .. .. .. .. .. 127
109. Placing response .. .. .. .. 128
110. Placing response .. .. .. .. .. 128
111. Stepping movements .. .. .. .. .. . . 1 31
112. Stepping movements .. .. .. .. . . 1 31
113. Stepping movements .. .. . . 1 31
114. Rotation test with the head free . . 1 35
115. Rotation test with the head free .. .. .. .. 135
116. Rotation test with the head free .. .. .. 135
117. Correlations between total scores for spontaneous motor activity and
other neurological signs .. .. .. .. 138
118. Correlations between total scores for resistance against passive move-
ments and other neurological signs .. .. .. 139
119. Correlations between intensity of tendon reflexes and other neurological
signs .. .. .. .. .. .. 141
120. Correlations between threshold of tendon reflexes and other neurological
signs .. .. .. .. .. .. 141
121. Correlations between magnet response and other neurological signs .. 143
122. Correlations between rooting response and other neurological signs .. 144
123. Correlations between sucking response and other neurological signs .. 145
124. Correlations between total scores for abduction and extension movements
of the Moro response and other neurological signs .. .. .. 147
125. Correlations between threshold of the Moro response and other neuro-
logical signs .. .. .. .. .. .. .. 147
126. Correlations between head control in sitting position and other neuro-
logical signs .. .. .. .. .. .. .. 148
127. Correlations between side-to-side movements of the head and other neuro-
logical signs .. .. .. .. .. .. .. 149
128. Correlations between stepping movements and other neurological signs .. 150
129. Correlations between the low-frequency, high-amplitude tremor and other
neurological signs .. .. .. .. .. . . 1 51
130. Hyperexcitability syndrome: incidence 155
131. Hyperexcitability syndrome and age .. . . 1 55
132. Hyperexcitability syndrome: consistency .. .. .. 156
Preface
Research on respiratory, circulatory, genetical and biochemical features of the
neonate has made tremendous progress in recent years, but knowledge of the function
of C.N.S. at this time is still scanty. The brain of the young infant has been the neglec-
ted organ par excellence. There are now indications that this situation is changing.
Research on brain mechanisms of the young infant has often been limited to
studies of single responses or reflexes. This has led to a detailed description of the
repertoire of brain mechanisms. These findings in the infant were related to neurologi-
cal mechanisms found in pathological conditions of the adult brain. Recently, however,
the developmental processes of the infant brain have been studied in their own right.
Specific methods for the clinical assessment of the infant's brain functions even
in the first week of life have been designed. Standardization of the technique (of
determining the state of the infant and of the testing procedure) allows us to quantify
the responses examined, and makes descriptions of optimal as well as non-optimal
and abnormal neurological patterns possible. The latter were found to be related to
complications in the pre- and perinatal history of the baby.
Ample evidence is available that many response patterns undergo at least quanti-
tative changes throughout the neonatal period. However, what role the nervoussys tern
plays in the postnatal adaptation to extra-uterine life is unknown. Furthermore, the
nervous system itself must be influenced by this adaptation process. Detailed knowledge
of these phenomena is clinically highly significant and most pressingly needed.
Beintema's systematic study of the neurology of infants in their first nine days of life
attempts to fill this gap.
A comprehensive approach to developmental processes must be inter-disciplinary.
Borders between traditional disciplines become increasingly artificial. This is particu-
larly true of the neurological, neurophysiological and behavioural methods of studying
developing systems. It also holds true, however, for modern biochemical and physio-
logical techniques recently applied in obstetrics and paediatrics, which are highly
relevant for developmental neurological studies. Beintema's work is only a beginning
in that direction, but it shows clearly the way future research has to go.
Heinz F. R. Prechtl
CHAPTER I
Introduction
The possibility of a relationship between pre- and perinatal complications of
pregnancy and later cerebral dysfunction has led to an increasing interest in the
early detection of these defects in the newborn infant. There are, too, ample reasons
for studying the brain mechanisms of the normal child; apart from their intrinsic
interest they may reveal something of the future life of that particular individual.
Attempts to assess the neurological condition of the newborn infant have proved,
however, difficult, owing to various problems of which the most striking is the neonate's
variability. Signs which are present at one moment can often not be found at another.
This is one of the reasons why Saint-Anne Dargassies (1962) stipulated that 'one
single neurological examination of the newborn infant is insufficient.'
The purpose of the present study was to study the consistencies and incon-
sistencies of neonatal neurological signs. The problem could be broken down into
three essential questions :
1. What standardization procedures should the examiner introduce in order
to get reliable information from the neurological examination?
2. What is the developmental course of neurological signs during the first days
of life?
3. Do obstetrical and postnatal conditions affect the developmental course
and the consistency of neurological signs throughout the neonatal period?
1. Standard Procedure
Already many conditions are known to affect the neurological status of the
newborn infant; examples are the environmental temperature and the timing of the
last feed. Both these conditions are related to the quality and the quantity of various
responses. It is also known that in different 'states'* an infant often shows signs of
different nature.
Where particular conditions influence the findings of the neurological examination
(or are indicators of such an influence) one should try to control them as much as
possible; for example by examining a baby only at a constant environmental tem-
perature and at a definite time in relation to the last feed. The relationship between
neurological signs and the 'state' of the infant requires that certain tests are only
administered when the infant is in a previously defined 'optimal state'.
A description of such a rigorously standardized examination procedure has
been given in 'The Neurological Examination of the Full Term Newborn Infant'
(Prechtl and Beintema 1964). Using this technique it was found that the 'state' of
the infant during the examination fluctuates considerably in the first days of life (Prechtl
1960) and therefore the neonatal age of an infant on which a neurological examin-
ation is carried out should also be controlled. Neurological examination on the
first two or three days of life is contraindicated in the interest of a valid result, but
♦The concept of the state of the infant is extensively discussed in Chapter V.
1
in many countries the examination cannot be postponed for practical reasons because
infants leave the hospital. One of the purposes of the present study was, therefore,
to find out to what extent and for how long the instability of the 'state' during the
early days of life is a significant impediment to the neurological examination of the
infant.
2. Developmental Course
For many neurological signs a 'normal' developmental course during the early
days of life has been assumed. This developmental course in general has been regarded
as a consequence of the on-going maturation of the infant's central nervous system
as well as of its adaptation to extra-uterine life.
The course of neurological signs during the neonatal period has rarely been
investigated. Bryan (1930) was probably the only investigator who examined the
same responses in the same infants on each of the first ten days of life. Escardo and
de Coriat (1960) investigated the development of postural and tonic patterns in
newborn infants, who were examined daily during the first four days of life.
Other investigators who re-examined the same infants on different days of life
were Stirnimann (1938), who studied crawling and stepping movement on the first
day as well as between the 9th and 14th day, Knop (1946), who tested the 'muscular
energy' of infants on the first day and on the 8th day, and Yang (1962), who examined
many neurological items in newborn infants on the first day and on the 3rd day of
life.
Most other investigators who assessed the dependency of neurological signs
on the postnatal age of the infant did not re-examine the same infants.
3. The Role of Obstetrical and Postnatal Conditions
Many conditions with a known relationship to the neurological signs can be
controlled during the examination, and therefore eliminated as variables. This
standardization procedure is frequently impossible, however, because it is not known
in what way such conditions are related to particular neurological signs. In such
cases one can only try to recognize these conditions and to find out to what degree
they are responsible for the inconsistencies of neurological signs from day to day.
Examples of these conditions are :
(a) obstetrical complications or the effects of drugs given to the mother during
labour, by which the adaptation of the newborn infant can be hampered
during the days after delivery. For this reason abnormal neurological signs
may be transitory and disappear after some days ;
(b) transitory postnatal complications (for example gastro-intestinal upsets,
physiological jaundice or slight dehydration).
In the present study these conditions have been introduced as variables in order
to investigate their possible influence on the developmental course and the consis-
tency of neurological signs throughout the neonatal period.
To sum up, the purpose of the present study was to obtain more data about
the changes in neurological signs during the early days of life. More specifically,
attempts were made to answer the following questions :
2
1. What is the developmental course of neurological signs during the neonatal
period ?
2. How consistent are single neurological signs in individual babies from day
today?
3. How consistent are the intercorrelations of neurological signs in individual
babies from day to day ?
4. To what extent and for how many days are neurological signs related to :
(a) prenatal and perinatal factors (such as obstetrical complications) ?
(b) postnatal factors (such as gastro-intestinal symptoms, physiological
jaundice and signs of dehydration) ?
3
