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SUPPLEMENT ARTICLE |
* Brown Medical School, Infant Development Center, Women and Infants Hospital and Bradley Hospital, Providence, Rhode Island
Child Development Unit, Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
Harvard University Medical School and Children’s Hospital, Boston, Massachusetts
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ABSTRACT |
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 TOP ABSTRACT BACKGROUNDPART I: EXAMINATIONPART II: STRESS/ABSTINENCE SCALEREFERENCES |
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Key Words: NICU Network Neurobehavioral Scale • NNNS • manual • scoring criteria
Abbreviations: NNNS, Neonatal Intensive Care Unit Network Neurobehavioral Scale • CNS, central nervous system • ATNR, asymmetrical tonic neck reflex
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BACKGROUND |
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TOPABSTRACTBACKGROUNDPART I: EXAMINATIONPART II: STRESS/ABSTINENCE SCALEREFERENCES |
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Early neonatal examinations emphasized neurologic assessment of tone and primitive reflexes based on the French school under André-Thomas,7 followed by the work of Saint-Anne-Dargassies8 and Amiel-Tisson.4 The examination developed by Prechtl3 provides a comprehensive evaluation of the classic reflexes. In a departure from previous work, Brazelton1,2 developed an assessment with a behavioral orientation.
Various examinations were developed for different purposes. Prechtl3 wanted to document the condition of the nervous system. Brazelton and his colleagues2,6 wanted to document the behavioral repertoire of the term and preterm infant. The goal of the Neurobehavioral Assessment of the Preterm Infant is to describe the relative maturity of functioning in preterm infants.5 Examinations developed by Dubowitz et al9 and Ballard et al10,11 were designed as clinical assessments of the gestational age of the newborn infant.
The NNNS was developed for the National Institute of Child Health and Human Development (NICHD) Neonatal Intensive Care Unit Research Network as part of a multisite maternal lifestyle study of the effects of prenatal drug exposure on child outcome. The NNNS was designed to provide a comprehensive assessment of both neurologic integrity and behavioral function. We also wanted to document the range of withdrawal and stress behavior likely to be observed in a study of substance-exposed infants. Traditionally, scales that measure neonatal abstinence such as the Neonatal Abstinence Score12 are treated separately from neurologic and behavioral evaluation, although there is some overlap in what is assessed. We felt that a stress/abstinence scale could be incorporated into a neurobehavioral scale by recording signs of stress and withdrawal observed during a neurobehavioral examination. Thus, in addition to using the behavioral items developed by Brazelton,1 the NNNS provides a neurologic examination and a separate stress/abstinence scale.
The NNNS is applicable to term, normal healthy infants, preterm infants, and infants at risk due to factors such as prenatal substance exposure. The examination should be performed on infants who are medically stable, preferably in an open crib or Isolette. Although a precise lower gestational age limit cannot be set, the complete examination is probably not appropriate for infants <30 weeks’ gestational age. The upper age limit may also vary depending on the developmental maturation of the infant. A reasonable upper age limit is 46 to 48 weeks (corrected or conceptional age, ie, weeks’ gestational age at birth plus weeks since birth).
Key Concepts
With the development of several infant examinations, a number of key concepts emerged that enhance our understanding and assessment of the neurobehavioral organization of the newborn. Many of these concepts are included in the NNNS.
Infant State
The concept of infant state described variously by Wolff13 and Prechtl3 has become a cornerstone for the administration of reflexes3 and behavior.1 In the NNNS, an appropriate state or range of states is specified for each item, and the item can be administered only when the infant is in the predefined state. Thus, state becomes the precondition or matrix within which items are administered.
Rapport
To be sensitive to the infant, the examiner must develop a certain level of rapport with the infant. The examiner establishes an interactive relationship with the infant based on the individual qualities of the infant, and within that relationship the infant’s performance can be evaluated. This is an issue of "style" and has implications for training as well as the possibility of introduction of examiner effects in the examination.
Semistructured
In an unstructured examination, a number of problems arise. The primary problem is that different examiners may do the examination differently and elicit different behavioral qualities in the infant. The infant’s scores can be affected by these stylistic differences. Thus, the scoring reflects the examiner-infant interaction rather than the infant’s performance when faced with a standard challenge. The solution is not a rigidly standard examination, because an inflexible examination does not always elicit the infant’s full behavioral capacities. The NNNS attempts to overcome this problem in several ways. First, it carefully defines and limits when items can be administered based on the infant’s state. This state-dependent administration is inherently structured and sensitive. Second, it has a relatively invariant sequence in which items are administered. By "relatively" invariant, we mean that the specified sequence is one that is strongly preferred by experienced examiners because it can be achieved by most infants; nonetheless, it allows for modification in the service of achieving best performance if infant state requirements are not met. In addition, the order of administration and deviations from the standard sequence are recorded, and individual differences in examiner style are minimized by training and ongoing reliability assessments of administration and scoring.
Packages
In the NNNS, items are grouped into packages that produce a standard sequence with which to challenge the infant. The preferred sequence has the advantage that whenever the infant’s position is changed, as many items as possible are administered in that new position so as to reduce unnecessary manipulation and state changes. In the following, the terms in uppercase letters refer to the packages described in the next section (see "NNNS Procedure"). After the PREEXAMINATION OBSERVATION and HABITUATION items, the infant is unwrapped and placed in a supine position (UNWRAP AND SUPINE). LOWER EXTREMITY REFLEXES are administered, followed by reflexes of the UPPER EXTREMITIES AND FACE ending with PULL TO SIT. The UPRIGHT RESPONSES, including placing, stepping, and incurvation, are then administered, followed by putting the INFANT PRONE for crawling. The next maneuver for the examiner is to PICK UP INFANT and cuddle in arm and on shoulder. For many infants, the examination can be administered smoothly in this sequence up to this point. All of these items can be administered in or around the crib given that the infant was in a sleep state at the beginning of the examination. The examiner then places the INFANT SUPINE ON EXAMINER’S LAP for the Orientation items, followed by the INFANT SPIN responses, which include tonic deviation of head and eyes and nystagmus. Finally, the examiner places the INFANT SUPINE IN CRIB for the defensive response, the asymmetrical tonic neck reflex (ATNR), and the Moro reflex. Consolability is administered when appropriate.
Neurologic Status
The selection of neurologic items chosen for the NNNS was based on several considerations. First, items were selected to provide a valid assessment of the neurologic integrity and maturity of the infant. Second, items were selected based on their demonstrated clinical utility and empirical validation. Third, neurologic items were chosen to represent the various "schools" such as the French angles method4 and the primitive reflexes method.3 Many items were omitted because they were redundant with other items or they have shown little utility in research studies. We also limited the number of neurologic items to balance this part of the examination with the behavioral part of the examination so that the examination could be completed within 30 minutes and not cause undue fatigue or stress for the infant. The state of the infant is specified for each reflex. The optimal response, if it is applicable, is in bold type for reference. This does not mean that nonbolded responses are abnormal. For most responses there is a wide range of normal. The optimal response is only meant as a point of reference.
Muscle Tone
Muscle tone refers to the "slight constant tension of healthy muscles which contribute a slight resistance to passive displacement of a limb."14 Muscle tone exerts a continuous background influence on both passive and active movement. In the NNNS, tone is assessed under both active and passive conditions. Active tone is assessed while observing spontaneous motor activity, including efforts at self-righting. Passive tone can be assessed during the posture, scarf sign, popliteal angle, and forearm and leg recoil. Both active and passive tone may be influenced by the state of the infant, the position of the infant (ie, prone, supine, or supported upright), or the effects of postural reflex activity. When assessing muscle tone, both the distribution (proximal versus distal) and the type (extensor versus flexor) of tone should be described, because in the developing infant, proximal tone in the neck and trunk may differ from distal tone in the extremities.
Stress/Abstinence Scale
Most work documenting signs of stress in drug-exposed infants involves the use of signs of abstinence or withdrawal in infants of narcotic-addicted mothers. These are usually infants born to heroin-addicted or methadone-dependent mothers. Less-potent opiates have been identified as precipitating a neonatal opiate abstinence syndrome, and some nonopiate central nervous system (CNS) depressants have also been implicated.
In work to date with cocaine-exposed infants, neonatal abstinence symptomatology does not seem to be increased.15,16 However, abstinence may occur as a result of the depressants and narcotics that the mother may have used concomitantly with cocaine. In addition, cocaine-exposed infants may show signs of stress other than those associated with the abstinence syndrome, which may include signs of stress unique to cocaine-exposed infants or signs of stress similar to those observed in preterm and high-risk infants.
The Stress/Abstinence Scale in the NNNS is a checklist that includes traditional items that reflect neonatal abstinence described by Finnegan.12 In addition, we added other signs of stress that have been described in cocaine-exposed infants as well as signs of stress typical of other high-risk infants including preterms.6 It is scored after the examination along with the other items.
Summary
The NNNS is designed to provide a comprehensive examination of the normal and at-risk neonate. The examination includes 3 parts: 1) the more classical neurologic items that assess active and passive tone and primitive reflexes as well as items that reflect CNS integrity; 2) behavioral items including state and sensory and interactive responses; and 3) stress/abstinence items particularly appropriate for high-risk infants. The NNNS enables us to describe developmental and behavioral maturation, CNS integrity, and the kinds of stress responses that infants show when examined.
NNNS Procedure
As discussed earlier, NNNS items are administered in packages, with each package beginning with a change in position or focus of the examination. The order of administration of packages and items is meant to be relatively invariant. The following is a summary of the packages and their respective items in the preferred order of administration (Table 1; see Appendix 1, later in this issue, for the scoring form).
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Stress/Abstinence Scale
The NNNS also includes a stress/abstinence scale divided into 7 categories: physiologic, autonomic, CNS, skin, visual, gastrointestinal, and state. These items are noted if they occur, and their occurrence is noted, for the most part, regardless of the state of the infant. The following items are scored with definitions included later in the procedures (see Table 2).
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Order of Examination Items in the Procedures
The examination items first described in the procedures score specific procedures in the preferred order of administration (items 1–45). The next group of items are summary scores made during the course of the examination (items 46–65). The final group of items is the Stress/Abstinence Scale, with which the examiner records the presence or absence of each condition over the entire examination (items 66–115). The NNNS scoring form is organized similarly except that the examination items are scored in "Part I: Examination," and the stress/abstinence items are scored in "Part II: Stress/Abstinence Scale." Both the procedures and scoring form specify the appropriate state(s) in which the assessment of each item can be made.
Missing Data Codes for Specific Procedures Items
Codes 95 to 99 are used to identify reasons why an item cannot be scored. Each item contains only those codes that are logical outcomes of the specific manipulation or observation. Code 95 indicates that the item was started but discontinued because the infant’s response lasted too long (eg, Habituation items). Code 96 indicates that the item was not administered because the infant did not respond after gentle prodding (eg, Habituation items). Code 97 indicates that the item was started but discontinued because the infant changed to an inappropriate state. Code 98 indicates that the item was not administered because the infant was in an inappropriate state. Code 99 indicates that the item was inadvertently skipped by the examiner (eg, items 1–45). To accommodate the special format of the skin-texture item (item 7), missing data due to examiner error should be indicated by using an error/edit code for permanently missing data.
Scoring of Asymmetries During Reflexes
For many reflexes, the left and right sides of the infant are evaluated separately. The scoring system is designed to reveal systematic asymmetries across items. Whenever possible, the optimal response is in bold type for reference. When an asymmetric response occurs, the examiner should score both sides separately.
Summary Scores
Summary scores include Habituation, Orientation, Amount of Handling, State, Self-Regulation, Hypotonia, Hypertonia, Quality of Movement, Number of Stress/Abstinence Signs (which also can be computed by system), and Number of Nonoptimal Reflexes. Summary score definitions and calculations are shown in Appendix 2 (later in this issue).
Preparation Before the Examination
If the infant is asleep, he or she should not be undressed. The Preexamination Observation and Habituation packages should be administered before undressing the infant. If the infant is in a state 6, the infant should be consoled before starting the examination. If the infant cannot attain a lower state than 6, the examination cannot be administered. If the infant is not in a sleep state and Habituation items cannot be administered first, the examination should begin with item 5, posture. A postural adjustment can be elicited by turning the head to the side and repositioning in midline.
State
Because an infant’s reactions are state-related, it is extremely important that observations of state be considered as a starting point from which all other observations are made. Before starting the examination, a careful assessment must be made of the state of the infant. The infant should start off in a sleep state that has been maintained for at least 45 minutes if at all possible. The examination should never be started just after the infant has fallen asleep. The ideal time to administer the examination is when the infant is asleep and midway between feeding cycles. A configuration of behavioral and physiologic characteristics must last at least 15 seconds to be considered a state.
Scores
Sleep States
1. State 1: Sleep with regular breathing, eyes closed, no spontaneous activity except startles or jerky movements at quite regular intervals; external stimuli produce startles with some delay; suppression of startles is rapid; state changes are less likely than from other states; no eye movements.
2. State 2: Sleep with eyes closed; rapid eye movements can often be observed under closed lids; low activity level, with random movements and startles or startle equivalents; movements are likely to be smoother and more monitored than in state 1; responds to internal and external stimuli with startle equivalents, often with a resulting change of state; respiration is irregular; sucking movements occur on and off; eye opening may occur briefly at intervals.
Awake States
3. State 3: Drowsy or semidozing; eyes may be open but dull and heavy-lidded, or closed, eyelids fluttering; activity level minimal, may be reactive to sensory stimuli, but response often delayed; movements are usually smooth, although there may be startles; infant has a dazed appearance and is minimally reactive even when eyes are open. This state is considered to be "transitional" and is sometimes difficult to score. Some infants may also show fuss/cry vocalizations in this state. When this happens, state 3 may be difficult to distinguish from state 5 (below). What distinguishes state 3 from state 5 when both are accompanied by fuss/cry vocalizations is the minimal movement in state 3 and considerable movement in state 5.
4. State 4: Alert, eyes open with bright look and appropriate changes in facial expression as stimulation is varied; focuses attention on source of stimulation or a visual or auditory stimulus; motor activity is minimal; there can be a glazed look that is easily changed into a brighter look with appropriate stimulation.
5. State 5: Eyes likely to be open; considerable motor activity, with thrusting movements of the extremities, and even a few spontaneous startles; reactive to external stimulation with increase in startles or motor activity, but discrete reactions are difficult to distinguish because of general activity level. Brief fussy vocalizations can occur in this state. Some infants may transition directly from lower states (1, 2, or 3) directly to state 5. These are often the cases described above in which fuss/cry vocalizations occur and states 5 and 3 are difficult to distinguish unless the differences in motor activity are taken into account.
6. State 6: Crying; characterized by intense, loud, rhythmic, and sustained cry vocalizations that are difficult to break through with stimulation; motor activity is high. It is important to distinguish between crying as a state from the fuss/cry vocalizations that can occur in state 5 and even state 3. Some infants show repeated episodes of fuss/cry vocalizations in state 5 but may not reach state 6. This may also be a maturational issue, because some preterm infants may not have the energy reserves to sustain state 6. In general, state 6 can be distinguished from state 5 by the intensity and sustained quality of the crying (at least 15 seconds) and unavailability of the infant in state 6. Repeated brief episodes of fuss/cry in state 5 do not mean that the infant has moved into state 6. Examiners need to give the infant the opportunity to show state 6. Premature administration of consolability and cuddling maneuvers may prevent the infant from reaching state 6 and provide an inaccurate assessment of the infant.
Initial State
In the 2 minutes before stimulation is begun, an assessment of the infant’s state is made by observing spontaneous behavior, respiration, eye movements, startles, and activity. When the examiner begins administration of the items, the last state that the infant was in for at least 15 seconds is recorded as the "initial state." If the infant is changing states within the 2-minute observation period, the examiner should try to begin the Habituation items when the infant is in state 2. Observation of the infant’s activity during these 2 minutes also serves as the baseline for observing the infant’s reactivity to the Habituation items.
Predominant States
At the end of the examination period, the examiner records the predominant state and second-most predominant state that the infant has been in over the course of the examination (excluding the Habituation items in both cases). Because the most important influence on the infant’s scores will be the state in which the infant is observed, it is important to have an idea of the range and variety of states in this period and the amount of time spent in each one. The duration of each state is an important component to consider when scoring.
Postexamination-State Observation
After the last item of the examination (Moro reflex), the examiner places the infant in the crib and records the infant’s state.
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PART I: EXAMINATION |
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TOPABSTRACTBACKGROUNDPART I: EXAMINATIONPART II: STRESS/ABSTINENCE SCALEREFERENCES |
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1. Initial-State Observation
Scores:
B. Habituation
Habituation or response decrement is assessed on the basis of the infant’s ability to shutdown, suppress, diminish, or delay responses to the repeated presentation of a stimulus. A response involves a movement of the limb or whole body, eye blinks with a full facial grimace, writhing movement, or other gross or discrete limb movements. There may be startles, and diminution and delay should be considered in scoring. However, do not count eye blinks, changes in respiration, or small and slow finger or hand movements as responses.
Evaluate the infant’s performance after 10 presentations unless the response has been successfully shutdown before that. The scores of 5 to 9 are reserved for infants who shutout their responses successfully. Score according to the last presentation to which there was a response. For scores of 
4, there is no complete response decrement. Use scores 95 through 99 to describe why the item was not administered or discontinued.
For each trial, allow 5 seconds from the cessation of the response to the presentation of the next stimulus. Up to 10 presentations are given if no response decrement occurs. The criterion for shutdown is 2 trials without a response for 5 seconds. If the infant reaches criterion for shutdown, discontinue the stimuli and move onto the next item.
If the infant shows no response to the first stimulus, gently loosen wraps, and try again. If the infant responds to the next presentation, count it as the initial presentation. If there is still no response to the stimulus, gently shake the infant and present the stimulus again. If there is still no response, go on to the next Habituation item. If the infant wakes up (changes to state 3, 4, 5, or 6), discontinue administration of the Habituation item.
If the infant’s response to a stimulus continues for >45 seconds, go on to the next Habituation item. Make sure that the infant has stopped moving for 5 seconds before administering the next Habituation item. If the infant continues to respond for >1 minute, do not present the next Habituation item, and code it as 98.
2. Response Decrement to Light (States 1 and 2)
This item measures the response decrement that occurs when a flashlight is repeatedly shined on the infant’s eyes. Hold a standard 8-inch flashlight 12 inches from the infant, shine the light directly into his or her eyes for 2 seconds (a 2-count), and observe the response.
Scores:
95. Item started but discontinued because the infant responds for >45 seconds to a stimulus.
96. Item not administered because the infant does not respond after loosening wraps and gentle shaking.
97. Item started but discontinued because the infant changes to a state 3 or higher.
98. Item not administered because the infant is not in state 1 or 2.
99. Item not administered due to examiner error.
3. Response Decrement to Rattle (States 1 and 2)
The next 2 items are designed to measure the infant’s ability to shutout a disturbing auditory stimulus. Hold the rattle 12 inches from the infant and shake it briskly 2 times in succession as in a 2-count.
Scores:
95. Item started but discontinued because the infant responds for >45 seconds to a stimulus.
96. Item not administered because the infant does not respond after loosening wraps and gentle shaking.
97. Item started but discontinued because the infant changes to a state 3 or higher.
98. Item not administered because the infant is not in state 1 or 2.
99. Item not administered due to examiner error.
4. Response Decrement to Bell (States 1 and 2)
Hold the bell 12 inches from the infant. Ring it briskly twice in succession for a 2-count.
Scores:
95. Item started but discontinued because the infant responds for >45 seconds to a stimulus.
96. Item not administered because the infant does not respond after loosening wraps and gentle shaking.
97. Item started but discontinued because the infant changes to a state 3 or higher.
98. Item not administered because the infant is not in state 1 or 2.
99. Item not administered due to examiner error.
C. Unwrap and Supine
5. Posture (States 1–5)
The infant’s preferred posture at rest reflects total body muscle tone. Unwrap and undress the infant and place in the supine position with head in midline. Allow the infant up to 1 minute to settle into a relaxed or preferred position. If the infant is already supine and undressed, turn the head to the side and back to midline and then wait for the infant to return to a relaxed or preferred position. Even a brief postural adjustment in an infant who is moving can be scored. If the infant is too active or crying, it may not be possible for the infant to find a position of comfort. When the infant settles, score as shown in Fig 1.
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98. Item not scored because the infant is not in an appropriate state or is continuously moving.
99. Item not administered due to examiner error.
6. Skin Color (States 1–5)
This is a baseline description of the infant’s general skin color. Skin color is more difficult to assess in some infants of dark color; however, even in these infants extreme deviations can be observed by paying particular attention to the mouth and eye regions, hands, and feet.
Scores:
98. Item not scored because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
7. Skin Texture (States 1–5)
The textural composition of the skin can reveal signs of intrauterine or postnatal stress. Desquamation (flaky, peeling, parchment-like skin) can be a sign of postmaturity; excoriations (abrasions or sections of the skin that are irritated and red) can result from rubbing or excessive movement related to neonatal abstinence. Loose skin is a sign of weight loss suggestive of intrauterine growth retardation. Deep creases around the eyes and nose are signs of oligohydramnios (insufficient amniotic fluid).
Is infant in state 1, 2, 3, 4 or 5? [yes] [no]
If yes, record the presence or absence of any of the following skin conditions. Mark all that apply, and leave blank if the item was not administered due to examiner error.
Scores:
7a. Desquamation: shedding or peeling.
7b. Excoriations: abrasions.
7c. Loose skin.
7d. Deep creases around eyes and nose: marked and substantial.
8. Movement (States 1–4)
This is a description of the amount of baseline motor activity, not a judgment of the quality of movement. The item is meant to capture excessive movement even during sleep. Eye movements are not included.
Scores:
98. Item not scored because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
9. Response Decrement to Tactile Stimulation of the Foot (States 1–3)
Place the infant’s head in midline by using head supports. With 1 hand, hold the infant’s leg just above the ankle between your thumb and index finger and flex the leg at the knee and hip until the inside knee angle is 90°. Avoid holding the back of the leg. Press the heel of the foot gently but firmly with the sterile plastic stick. Hold the leg loosely and allow the infant to move. Five seconds after the movement has ceased, press the same heel again. Stop the item if the response is localized to the foot. The infant gets credit for decrement at the trial on which successful localization of response occurs. A maximum of 5 trials is administered. This item is not repeated with the other foot.
In some infants, the opposite foot withdraws and the whole body responds as quickly as the stimulated foot (a demonstration of the all-or-none aspect of an immature organism). The degree, rapidity, and repetition of this "spread" of stimulus to the rest of the body is measured here. The other aspect scored is the infant’s capacity to shutdown this spread of a generalized response. When responses continue in an obligatory, repetitive, or increasingly active manner, the infant rates a low score. When responses to the stimulus are suppressed and the state changes to a more-alert, receptive one, the infant deserves a high score. Many infants demonstrate some but not all of this behavior. Scores 95 through 99 describe reasons why the item was not administered or discontinued.
Scores:
95. Item started but discontinued because the infant responds for >45 seconds to a stimulus.
96. Item not administered because the infant does not respond after loosening wraps and gentle shaking.
97. Item started but discontinued because the infant changes to a state higher than 3.
98. Item not administered because the infant is in a state higher than 3.
99. Item not administered due to examiner error.
D. Lower Extremity Reflexes (States 3–5)
Position head at midline by using head supports. Administer the reflexes in the sequence listed below with the infant supine. Once a package has been started, attempt to administer all the items in the package. The reflexes should be administered gently but firmly and in a smooth, even flow, disturbing the infant as little as possible. Administer most of the reflexes separately on the left and right side to look for asymmetries. Unless otherwise indicated, if a normal reflex response is observed, reflexes do not have to be administered more than once. Score both sides, which effectively tracks any asymmetries. Avoid getting "bogged down" in this part of the examination.
If the infant is in a sleep state, these items can serve to rouse the infant to achieve the appropriate state. If the infant is in a state 6, use consolability maneuvers including a pacifier to bring the infant to an appropriate state. However, the pacifier must be removed when the reflexes are administered, because the presence of the pacifier will alter the reflex response. Items not administered in the appropriate state have to be readministered with the scores based only on performance in the appropriate state.
10. Plantar Grasp
Press thumb against the ball of the infant’s foot. Do each foot separately. The infant should respond with plantar flexion of all toes.
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
11. Babinski Reflex
Start from the toes and scratch the lateral side of the infant’s foot toward the heel with a thumbnail. Pressure on the foot rather than a scratch may elicit the plantar grasp and not the Babinski reflex. Do each foot separately. Look for extension of the big toe and spreading of the smaller toes.
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
12. Ankle Clonus
Hold the infant’s leg just below the knee with the leg relaxed. Using 2 or 3 fingers placed on the ball of the foot, dorsiflex the foot with a rapid, brisk, pulsating movement. Repeat with the other foot. Clonus is seen as a quick dorsiflexion of the foot or it is felt as "beats." The maneuver is somewhat like "bobbing" a ball in the water (ie, trying to keep the ball submerged each time it breaks the surface). It is normal for clonus not to be present in the newborn; therefore, an optimal score is not provided.
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
13. Leg Resistance
Hold both feet of infant’s legs near the ankles with 1 hand, with your index finger between the feet. Fully flex hips and knees with thighs and legs together. Extend thighs and legs and release. Observe amount of resistance to passive extension and the speed and amount of thigh and lower leg recoil at hips and knees. This maneuver is used to score both leg resistance and the next item, leg recoil.
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
14. Leg Recoil
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
15. Power of Active Leg Movements
Assess the power of active leg movements by providing gentle resistance to lower extremities when the infant is moving. Grasp moving foot above the ankle between index and middle fingers and apply gentle resistance. This item can be assessed during the infant’s movements immediately after the leg resistance or popliteal angle.
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
16. Popliteal Angle
This is an assessment of passive flexor tone of the knee joint, assessed by resistance to extension of the lower extremity. With the infant supine, unstrap 1 side of diaper. With the pelvis flat on the examining table, the thigh is held on the infant’s abdomen in the knee-chest position with the knee fully flexed. Wait for the infant to relax into this position, and then grasp the foot at the sides with 1 hand. Use the other hand to support the side of the thigh without exerting pressure on the hamstrings. Extend the leg until a definite resistance to extension is felt. The angle formed at the knee by the upper and lower leg is measured by using Fig 2.
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98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
E. Upper Extremities and Face (States 3–5)
17. Scarf Sign
This is a test of passive tone of the shoulder-girdle musculature. Place the infant’s arm just above the chest with 1 hand. Place your other hand on infant’s trunk to prevent trunk rotation, your thumb on the infant’s elbow. Gently push the elbow across the chest so that the arm comes across the neck like a scarf. Look for resistance to extension of the shoulder-girdle flexor muscles. Use Fig 3 to identify and score the point on the chest to which the elbow moves easily before significant resistance. Please note that higher scores indicate smaller angles.
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98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
18. Forearm Resistance
With both hands, hold the infant’s arms at the wrist and fully flex the arms at the elbow. Extend forearms and release 1 arm within 1 second and the other arm 1 second later. Observe the amount of forearm resistance and speed and amount of recoil. Use this maneuver to code both forearm resistance and the next item, forearm recoil.
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
19. Forearm Recoil
Scores:
120° but slow (after 1/2 second). 98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
20. Power Of Active Arm Movements
The power of active arm movements is assessed by offering gentle resistance to active movements of upper extremities. Grasp the wrist of the moving hand between your index and middle fingers, and apply gentle resistance to the infant’s movement. This can be performed during the movement immediately after the administration of scarf sign or forearm resistance.
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
21. Rooting
Stroke the perioral skin at the corners of the mouth. With your other hand, hold the infant’s hands against his or her chest, because arm position can influence the rooting reflex. The infant should turn his or her head toward the stimulated side and try to suck. If there is no initial response, you may stroke the upper and lower lips to elicit the response. Stimulation of the upper lip may be followed by opening of the mouth and retroflexion of the head. After stimulation of the lower lip, the mouth may open and the jaw drop.
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
22. Sucking
Place your glove-covered finger 3 or 4 cm into infant’s mouth with the nail toward the tongue. You should feel rhythmical sucking movements that include stripping action of the tongue forcing upward and back with suction (negative pressure). Sucking typically occurs as groups of 8 to 12 sucks per 10 seconds with pauses: the "burst-pause" pattern.
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
23. Grasp of Hands
Place 1 finger (index finger or thumb) in the infant’s hand and press the palmar surface without touching the back of the hand. The infant’s fingers should flex and close around your finger. Do this for both hands but not at the same time, because pressing both palms at the same time can elicit the palmer mental reflex (infant’s mouth opens).
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
24. Truncal Tone
Place 1 hand under infant’s buttocks and hold the back of the infant’s head at the neck with the other hand. Lift the infant above the surface of the crib such that his or her buttocks do not touch the surface during the maneuver. Gently flex the infant’s trunk by bringing his or her head forward. You should be able to bring the infant to a sitting position. Score only the tone of the trunk, not the tonicity of the arms and legs (see Fig 4).
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98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
25. Pull to Sit (States 4 and 5)
Place a thumb in both of the infant’s palms and also hold the infants wrists/forearms with your fingers. With the arms extended, use the infant’s automatic grasp to pull the infant to sit. As the infant is pulled to sit, the score is based on the extent to which: the shoulder-girdle muscles respond with increased tone; there is muscular resistance to stretching the neck and lower musculature; and the infant attempts to right his or her head into a position that is in midline of the trunk and parallel to the body. When in a seated position, the infant’s attempts to right his or her head can be felt via the shoulder muscles as you maintain a grasp on the infant’s arms.
Scoring is based on the extent to which the infant attempts to maintain his or her head upright and the length of time the infant is able to do it. Some infants can get their heads up only to have it pivot forward through the midline. This pivoting may be because of the infant being pulled forward, not because of the infants’ effort. For other infants, the head is heavy and out of proportion to the rest of his or her body mass, so the head falls backward. You may talk to the infant during this maneuver to help keep the infant calm and encourage the infant to lift his or her head.
Some infants resist flexion and head righting by arching backward. If this occurs, the item must be scored 11. If the infant becomes completely hypertonic, assign a score of 10. The average infant makes 1 or 2 attempts to maintain the head in an upright position after seating and can participate as he or she is brought to sit. If the infant’s head remains back after being pulled to sit, score no higher than a 2. If there is no head lag (or forward head drop) as the infant is pulled to sit, score 8 or 9.
In some infants, Pull to Sit can be administered only when you provide support to the upper trunk. If Pull to Sit can be elicited only with additional support from you, such as extending the arms to the side after being placed in seated position, assign a score of 2 regardless of the quality of the response that is elicited.
Scores:
2 seconds. 98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
F. Upright Responses (States 3–5)
26. Placing
Hold the infant upright or slightly leaning forward with both hands under the arms and around the chest. Use your thumb(s) to limit or support movement of the infant’s head. Do not hold the infant against your chest. Lift the infant so that the top of the infant’s foot is stroked and gently pressed downward against a protruding corner or edge on the crib or a table top. The infant should lift his or her foot by flexing the knee and hip and then extend the leg as if taking a step. Repeat with the other foot.
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
27. Stepping
Hold the infant upright and slightly tilted forward, with both hands under the arms and around the chest. Let the soles of the feet touch the surface and move the infant forward as stepping occurs. Slight rotation of the infant’s body may help elicit the response. Alternating stepping movements with both legs are scored.
Scores:
3 steps. 98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
28. Ventral Suspension
Suspend the infant in the air in a prone position by placing a hand under the infant’s chest and abdomen. Keep the infant horizontal and make sure the limbs are hanging free. Observe the final position of the infant’s head, limbs, and trunk. If a final position (consistent tone) is not observed, score 6 (see Fig 5).
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98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
29. Incurvation
Slowly tap/poke or scratch a line with your thumbnail a few centimeters from the vertebrae, downward from the shoulder to the buttocks. Repeat on the other side. The trunk should flex laterally in a concave curve on the stimulated side.
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
G. Infant Prone (States 3–5)
30. Crawling
Both Crawling and Head Raise in Prone (next item) are scored from the following maneuver. With infant prone, place head in midline (without supports) and arms near the head, palms down. Observe for 30 seconds. If the infant does not crawl spontaneously, stimulate the response by gently pressing your palms on the soles of the feet. Score the response, and then score whether stimulation of the feet was necessary to elicit the response.
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
31. Stimulation Needed
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
32. Head Raise in Prone
Scores:
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
H. Pick up Infant (States 4 and 5)
Cuddliness
This item is a summary measure of the infant’s response to being held in alert states. There are several components that are scored in response to the infant being held in a cuddled position both horizontally against your chest and vertically on your shoulder. The infant’s resistance to cuddling should be assessed as well as the ability to relax or mold, nestle, and cling to you. Give the infant a chance to initiate cuddling (
10 seconds). Facilitate cuddling only if there is no active participation on the part of the infant or if the infant is unable to relax or mold. If the infant initiates cuddling, score 5 and above. Cuddliness should not be administered with the infant swaddled. Also, refrain from talking to the infant during the administration of this maneuver. Assign separate scores for Cuddle in Arm (horizontal) and Cuddle on Shoulder (vertical).
33. Cuddle in Arm
Scores:
97. Item discontinued because infant changes to state 1, 2, or 3 or reaches state 6.
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
34. Cuddle on Shoulder
Scores:
97. Item discontinued because infant changes to state 1, 2, or 3 or reaches state 6.
98. Item not administered because the infant is not in an appropriate state.
99. Item not administered due to examiner error.
I. Infant Supine on Examiner’s Lap (States 4 and 5)
The Orientation package examines the infant’s ability to orient to animate and inanimate visual and auditory stimuli. The order of administration of the Orientation items is not predetermined. The auditory inanimate (ie, rattle) and animate visual and auditory (ie, face and voice) stimuli are generally thought to be the most arousing and attention-getting, and the visual alone (ie, face or ball) and animate auditory (ie, voice) the least arousing and attention-getting. For more-fragile infants who may be hypersensitive, starting the orientation sequence with less-intense stimuli may be preferable. Other infants may need more-intense stimuli to maintain a state 4 or 5.
Administer the Orientation items while sitting on a chair with the infant resting on your lap. You should have the infant at a slight upward angle. (It may help to place your feet on a footrest.) When administering the Orientation items, it is recommended to try each Orientation item at least once before going on to the next one. However, do not spend too much time administering individual items (ie, 15 seconds with each stimulus [eg, a duration of 15 seconds for the rattle on 1 side of the head]).
Give the infant the opportunity to maintain a state 4 or 5 on his or her own. The preferred focus is on the infant’s ability to maintain a state 4 or 5 and show orientation abilities within a self-maintained state rather than on how well an infant can orient when you manipulate his or her state (eg, when swaddling). It is generally believed that infants will show better orienting abilities when swaddled, but the infant’s capacity to deal with environmental demands are better reflected in the ability to 1) maintain a state 4 or 5 and 2) orient while in a self-maintained state. Nonetheless, you can use techniques such as swaddling if the infant cannot maintain a state 4 or 5.
There are several techniques you can use to elicit a state 4 or 5 from a lower state. These techniques include gently rocking the infant up and down and presenting auditory stimulation (rattle/voice). If the infant cannot maintain a state 4 or 5 or the infant’s activity interferes with his or her performance, hold the infant’s arms and/or legs to restrain interfering movement, swaddle, and give the infant a pacifier to suckle. If used, score these items in the summary items as techniques used to maintain alertness (item 46, Orientation Handling Procedures). Additionally, if the rattle is used to rouse the infant during orientation, the rattle should be counted as a technique used to maintain alertness.
Some infants, such as small prematures, may have more difficulty with stress and temperature regulation. In these cases, it may be necessary to wrap or swaddle for the infant’s safety. You should attempt to administer these items without swaddling, but if the infant appears stressed, it is appropriate to swaddle.
35. Orientation: Inanimate Visual
This is a measure of the infant’s ability to fixate on and follow the red ball. Jiggle the ball and change its distance from the infant slightly to find the infant’s focal range, generally 10 to 12 inches from the eyes. Then slowly move the ball horizontally from 1 side to the other. If the infant’s head becomes "stuck" on 1 side, gently position it back to the midline and repeat visual stimulation with the ball to the other side. If the eyes and head follow to at least 1 side, move the ball vertically and in an arc to see whether the infant will continue to follow.
Avoid talking to the infant or letting the infant be distracted by your face during this maneuver.
The score is based on the infant’s ability to alert (decrease in random activity, focusing on the object when it is in his or her line of vision, slow regular respiration, and following in smooth arcs when it moves), brighten (change in facial expression, widening of eyes and brighter look, and irregular respiration, with an associated decrease in random activity), and fixate on the stimulus, following it horizontally or vertically, and coordinate head and eye movements. If the infant’s eyes and head follow the stimulus concurrently, score 6 to 9. Chin movement can be used as the criterion for assessing a 30° and 60° vertical following.
Scores:
98. Item not administered because the infant is not in a sustained state 4 or 5.
99. Item not administered due to examiner error.
36. Orientation: Inanimate Auditory
This is a measure of the infant’s response to the rattle stimulus. Shake the rattle twice (a 2-count), 6 to 12 inches from the infant’s ear and out of sight. Repeat the procedure so there are 2 "trials" on each side. Gently position the infant’s head back in midline after each presentation. The response may include brightening of the face and eyes, turning, and searching and looking toward the stimulus. The sound may be varied in intensity and rhythm to determine the level of stimulation appropriate for the infant.
If the infant turns his or her eyes and head toward the stimulus, score 6 to 9. A search is defined as looking for the stimulus. If the infant responds with a head turn but the eyes are closed, the maximum score is 6.
Scores:
98. Item not administered because the infant is not in a sustained state 4 or 5.
99. Item not administered due to examiner error.
37. Orientation: Inanimate Visual and Auditory
Gently shake the red rattle 10 to 12 inches from the infant’s eyes. Slowly move the rattle horizontally from 1 side to the other in front of the infant’s face. If the infant’s head becomes "stuck" on 1 side, gently position it back to the midline and repeat the stimulation with the rattle to the other side. If the eyes and head follow to at least 1 side, move the rattle vertically and in an arc to see whether the infant will continue to follow.
Avoid talking to the infant or letting the infant be distracted by your face during this maneuver.
The score is based on the infant’s ability to alert (decrease in random activity, focusing on the object when it is in his or her line of vision, slow regular respiration, and following in smooth arcs when it moves), brighten (change in facial expression, widening of eyes and brighter look, and irregular respiration, with an associated decrease in random activity), and fixate on the stimulus, following it horizontally or vertically, and coordinate head and eye movements.
Scores:
98. Item not administered because the infant is not in a sustained state 4 or 5.
99. Item not administered due to examiner error.
38. Orientation: Animate Visual
The next 3 items score the infant’s response to your social cues: voice and/or face. This item measures the infant’s response to your face. Place your face 12 to 18 inches in front of the infant’s face. Then, slowly move from 1 side to the other. If the infant’s head becomes "stuck" on 1 side, gently position it back to the midline and repeat visual stimulation to the other side. If the eyes and head follow to at least 1 side, move your face vertically and in an arc to see whether the infant will continue to follow. Do not talk to the infant during this item.
Scores:
98. Item not administered because the infant is not in a sustained state 4 or 5.
99. Item not administered due to examiner error.
39. Orientation: Animate Auditory
This is a measure of the infant’s response to your voice. Speak softly into 1 of the infant’s ears with your face out of the infant’s line of vision, 6 to 12 inches away. Present the stimulus twice on each side. Gently position the infant’s head back in midline and repeat the stimulation with the voice to the other side. The sound of the voice may be varied in intensity and rhythm. A soft, slightly higher-pitched voice can be the most-potent stimulus.
A response may include brightening of the face and eyes, turning, and searching and looking toward the stimulus. If the infant turns his or her eyes and head toward the stimulus, score 6 to 9. A search is defined as looking for the stimulus.
Scores:
