brazejton, t.b, brazelton, t.e. · differences us.ing the brazelton scale. paper presented at the...
TRANSCRIPT
BrazeJton, T.B, Effect of prenatal drugs on the behavior of neonates.
American Journal of Pswhiatrv, 1970, 126.
Brazelton, T.E. Neonatal 7.ehavioral Assessment, MenoraEh of the
National Snastic.Societv, Ncine.:nann Medical i.ioeks, Ltd., London,
1972.
Brazelton, T.B., Ereedman, D.C., Horowitz, F.D., Koslowski, B., Riccuti, H.
Robey, J.S., Sameroff, A. and Tronic, E. Neonatal Pehaviorli
Assesment Scale, Manuel, in press
Burns, L.E., flodonan, J.E., and Cass, A.B. Fetal circulatory collapse
in premature infants receiving chloramphenicol. New En3land
Journal of :.;odicine, 1059, 261, 13'8-13",
Burt, R.A.P. The fetal and maternal pharmacology of some of the drugs
used for the relief of pain in labor. British Journal of
Anestheniolo,:w, 1971, 43, 824-836,
Cohen, S.N. and Olson, W.A. Drugs that depress the newborn. Pedirtric
Clinics of North America, 1970, Vol, 17:4.
Conway, E. and Brackbill, Y. Delivery medication and infant outcome:
An empirical study. Monwzraphs of Ehe Society for Research in
Child Development, 1970, 35, 24-34,
Conway, E.F. Personal communication, October, 1972.
Corner, C.W. Exploring the placental maze. American Journal of
Obstetrics and Cynecolov, 1963, 85, 408-418,
Davis, M.E. and Rubin, R. Do Lee's Obstetrics for Nurses, W.D. Saunders
Co.: Philadelphia, Chapter 19, pp. 290-303.
Doll, E.A. Vineland Social Maturity Sca.le. The measurement of social
competence. Educational Test Bureau, Educational Publishers, 1933.
211
69
Done, A.K. Developmental pharmacology, Clinical Pbarmacology and
Therapeutics, 1964, 5, 432-479,
Emde, E.N. and Koening, K.L. Neonatal smiling and rapid eye movement
states. Journnl of Amcicnn Ar'adcmv of r5wchiatrY, 1969, 8,
57-67 (a).
Epstein, B.S. and Coakley, C.S. Passap,e of lidocaine and prilocain
across the placenta. Anesthesiology, 1967, 28, 246-247.
Fish, B., Shapiro, T., Halpern, F. and Wile, R. The predieton of
schizophrenia in infancy: III a.ten-year follow-up report of
neurological and psychological development, American Journal of
Psychiatry, 1965, 121, 768-775.
Flowers, C.E., Rudolph, A.J., and Desmond, M.N. Diazepam (Valium)
as an adjunct in obstetric analgesia. Obstetrics and Gynecology,
1969, 34, 68-80.
Foutz, J.R. The metabolism of drugs by the fetus. In J.N. Robson,
F.N. Sulivan and R.L. Smith (Eds.) Emhrvon::Ithic Activity of Druc7s,
Little nrown: Boston, 1965, 43-55.
yriedman, E.A. and Sachlleben, M.R. Dysfunctional labor: Prolonged
latent phase in the Nulliparn. Obstetrics and Gynecolor;v, 1961,
17, 135-147.
Gesell, A. and Amatruda, C.S. Develonmental diacmosis, New York:
Harper and Row, 1947.
Garcia, C.R., Waltham, R., and Lubin, S. Continuous intravenous
infusion of demerol in labor. American Journal of Obstetrics and
fynecolo7., 1953, ±!?, 312-318.
Goodman, L.S. and Oilman, A. The Pharmacological Basis of Therapeutics,
The NacNillan Company: Nc:w York, 1970.
70
212
Grahr.m, i hnvLorl diffences LQL,4,.,cn noyv!al c!Id Lraum:Li;:c..d
newborns I: The test procedurcF,. Psycholccal Monnran:-!q, 1956.
Vd. 70:20.
F.K., H.rJ., and enldwell, Bel-:avioral differences
bet:-ecn norl,al and tranmati%ed newborns Standardi.zation,
reliability and validity. P:,vcbc,leL-al i.ion,-;f:ranhc, 1956, 70.
Gustafson, S.R. and Conrsia, D.B. The Pediatric Patient, Lippincott:
Montr eal, 1965, pp. 89-95.
Hagennan, P.D. and Ville, C.A. Transport functions of the placenta.
Phvsioloical P,Iview::, 1960, 40, 313-330.
Harlow, H.F. he matern:z1 affection system. Ta B.M'. Foss, (Ed.)
Determ.inants of Trf,Int Behavior, Vol. 11, Wiley: New York,
1963, 3-340
Harper, H.A. Review of PH.,sio1w7:ica1. Chemistry. Lange Medical
Publications, Los Altos, California, 1969.
Hartman, E.L. The D-State: A review and discussion of studies on
the physiologic state concomIlitant with dreaming. International
Journal of P5:velli.atry, 1966, 2, 11-99.
Horowitz, F.D.. Al :rowiez, M., Ashton, J.L., Tims, S.N.
14cC1uskey, K., Culp, R., and Gallas, H. American and Uruguayan
infants: Reliabilities, maternal drug histories and population
differences us.ing the Brazelton Scale. Paper presented at the
Society for Research in Child Developmnt, Philadelphia, March,
1973.
James, L.S. The effect of pain relief for labor and delivery On the
fetus and the nnwbol:n. 10 97 405-630.
21371
BrazeJton, T.B, Effect of prenatal drugs on the behavior of neonates.
American Journal of Pswhiatrv, 1970, 126.
Brazelton, T.E. Neonatal 7.ehavioral Assessment, MenoraEh of the
National Snastic.Societv, Ncine.:nann 1,!cdical i.iooks, Ltd., London,
1972.
Brazolton, T.B., Ereedman, D.C., Horowitz, F.D., Koslowski, B., Riccuti, H.
Robey, J.S., Sameroff, A. and Tronic, E. Neonatal Pehaviorli
Assesment Scale, Manuel, in press
Burns, L.E., flodonan, J.E., and Cass, A.B. Fetal circulatory collapse
in premature infants receiving chloramphenicol. New En3land
Journal of :.;edicina, 1059, 261, 13'8-13",
Burt, R.A.P. The fetal and maternal pharmacology of some of the drugs
used for the relief of pain in labor. British Journal of
Anesthenioloy, 1971, 43, 824-836,
Cohen, S.N. and Olson, W.A. Drugs that depress the newborn. Pedirtric
Clinics of North America, 1970, Vol, 17:4.
Conway, E. and Brackbill, Y. Delivery medication and infant outcome:
An empirical study. Monwzraphs of Ehe Society for Research in
Child Development, 1970, 35, 24-34,
Conway, E.F. Personal communication, October, 1972.
Corner, C.W. Exploring the placental maze. American Journal of
Obstetrics and Cynecolov, 1963, 85, 408-418,
Davis, M.E. and Rubin, R. Do Lee's Obstetrics for Nurses, W.D. Saunders
Co.: Philadelphia, Chapter 19, pp. 290-303.
Doll, E.A. Vineland Social Maturity Sca.le. The measurement of social
competence. Educational Test Bureau, Educational Publishers, 1933.
211
69
Done, A.K. Developmental pharmacology, Clinical PbarrIncoloay_slnd
ThPranontics 1964 5 432-479.-
Emde, E.N. and Kooning, K.L. Neonatal smiling and rapid eye movement
states. Jourmll of Ann Agads.nv of Psygbiatrv, 1969, 8,
57-67 (a).
Epstein, B.S. and Coakley, C.S. Passage of lidocaine and prilocain
across the placenta. Anesthesiology, 1967, 28, 946-247.
Fish, B., Shapiro, T., Halpern, F. and Wile, R. The predicton of
schizophrenia in infancy: III a.ten-year follow-up report of
neurological and psychological development, American Journal of
Psychiatry, 1965, 121, 768-775.
Flowers, C.E., Rudolph, A.J., and Desmond, M.N. Diazepam (Valium)
as an adjunct in obstetric analgesia. Obstetrics and Gynecology,
1969, 34, 68-80.
Foutz, J.R. The metabolism of drugs by the fetus. In J.M. Robson,
F.. Sulivan and R.L. Smith (Eds.) Embryon::Ithic Activity of Drugs,
Little Ftown: Boston, 1965, 43-55.
ytiedman, E.A. and Sachlleben, M.R. Dysfunctional labor: Prolonged
latent phase in the Nullipara. Obstetrics and Gynecology, 1961,
17, 135-147.
Gesell, A. and Amatruda, C.S. Develonmental diagnosis, New York:
arper and Row, 1947.
Garcia, C.R., Waltham, R., and Lubin, S. Continuous intravenous
infusion of demerol in labor.. American Journal of Obstetrics and
Gynecology 1953 66) 312-318.
Gooelman, L.S. a:1d Gilman, A. The Pharmacological Basis of Therapeutics,
The I.IncNillan Company: New York, 1970.
70
212
Grahum, i hnvLor:11, diffe,Ices LQL,4,.,cn n!id Lraum:Li;:c..d
newborns I: The test procedureF,. Psycholccll -10.:Igran:-!s, 1956.
Vd. 70:20.
Grahum, F.K., Matan::zzo, H.rJ., and enldwell, h.M. Bel-:avioro.1 differences
bet:-ecn no J apd tranmnti%ed ncwhorns II: Standardi.zation,
reliability and validity. P:,vcbc,lel.-al i.ion,-;f:ranhs, 1956, 70.
Gustafson, S.R. and Coursic, D.B. The Pediatric Patient, Lippincott:
Montr eal, 1965, pp. 89-95.
Hagerman, P.D. and Ville, C.A. Transport functions of the placenta.
Phvsioloical 1960, 4U, 313-330.
Harlow, H.F. he matern:z1 affection system. In B.M'. Foss, (Ed.)
Determ.inants of Trf,Int Behavior, Vol. 11, Wiley: New York,
1963, 3-340
Harper, H.A. Review of PH,-sio1w7:ica1. Chemistry. Lange Medical
Publications, Los Altos, California, 1969.
Hartman, E.L. The D-State: A review and discussion of studies on
the physiologic state concomIlitant with dreaming. International
Journal of P5:velli.atry, 1966, 2, 11-99.
Horowitz, F.D.. Al :rowiez, M., Ashton, J.L., Tims, S.N.
14cC1uskey, K., Culp, R., and Gallas, H. American and Uruguayan
infants: Reliabilities, maternal drug histories and population
differences us.ing the Brazelton Scale. Paper presented at the
Society for Research in Child Developmnt, Philadelphia, March,
1973.
James, L.S. The effect of pain relief for labor and delivery On the
fet:us. 196,0 27. 405-630.
21371
Kennell, (;tyle, n. and Klaus, M.H. The mourming response cf
parents to the death of a neWborn. New Elrland Jolly:nal of Medicine,
1970, 283-344.
Kennell, J.H. and Klaus, M.H. Care of the mother of.the hir*,11 risk
infant. Clinical. Obtetries and Gynecology: PorinPtal Biolor,y
1971, VL1. 14:3.
Kent, S.P. and Wideman, G.L. Prophylactic antibiotic therapy in
infants born after premature rupture of membranes. Journal of
American Medical A!:sociation, 1959, 171, 119-120.
Klaus, N.H., Kennell, J.H. , Plumb, N. and Zuehlke, q. Ihmian maternal
behavior at the first contact with her young. Pediatrics 1970,
Vol. 46:2.
Kolb, L.C. Modern Clinical Psychiatry, Sounders Company: Philadelphia,
1973.
Kraemer, lUG., Korner, A.F., and Thoman, E.B. Methodological
considera::ions in evaluating the influence of drugs used during
labor and delivery on the behavior of the neborn. Develonmontal
Psycholeaw, 1972, 16, 128-134.
Kron, R.E., Stein, M., and Goddard, K.E. Newborn sucking behavior
affected by obstetric sedation. Pediatrics, 1966, 37, 1012-1016.-
Leifer, A., Leiderman, P., and Barnett, C. Mother-infant separation:
Effects on later maternal behavior. Child Development, 1971.
Levy, D.L. Obstetric analgesia - pcnazocaine and meperidine in
normal primiparous labor. Obstetrics and Gynecology, 1953, 66,
312-318.
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diffr.!rencos in attention. A1:101-!or:J, Jo:Irn:q of Dir;erlsoq
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Lorenz, K.7. M:Ir! P!./v;, Thomas Crowell Co.: New York,
1952.
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217
APPENDIX A
T. Obstetrical Medication
1. Classifiction, dese and routes of adminis:.ration of obstetric
anesthetics and inal-csi
Drugs used for the reliczf of pain arc generally cicssified nccording
to their major effect, with the understanding that some drugs produce
dfferent effects according to dose and route of administration (Bm:es,
1970; Davis and Rubin, 1966).
A. Cencral anesthetics
When given in sufficient dosages, general anesthetics will
produce a state of unconsciousness with less of sensation (i.e.,
anesthesia) that allows any surgical procedure to be carried out,
though by the-,-elvcs they are not pain killers. Anesthesia results
from the pronounced functional depression of the CNS. The most commonly
used obstetric anesthetics are the inhalation anesthetics, i.e., gases
(e.g., nitrons oxide, ethylene, cyclopropane) or volatile liquids (e.g.,
ether, halothane, methoKyfluranc, trichloroethylene). Chloroform, a
potent volatile anesthetic, is hardly ever used in obstetrics because of
its dangerous side effects. Volatile liquids can be dropped on a mask
held over the patient's face, but more frequently the inhalational
anesthetics arc administered by means of more or less elaborate breath-
ing apparatus which provides a well controlled mixture of gas (or vapor)
and o;:yeen and absorbs carbon dioxide exhaled by thc patient. Inhala-
tion anesthetics generally produce a rapid effect upon administration;
upon withdrawal, rapid recovery usually results. Recovery typically
occurs within minutes. Ne.thoxyflurane ims the longest recovery period
(30-60 minutes).
21876
General anesthesia can also be producud by high doses of sedatives.
The method canonly employed consists of intravenous injection of an
ultra-short acti.ng barbiturote (e.g., thiopental in doses from 0.12 cm.
up to 1.0 gm.). Intravenous anesthesia has the advantage of rapid,
smooth onset with few complications and side effects. On the other hand,
barbiturates do -not relievu pain, unless administered in doses causing
loss of consciousness, so that pain-relieving drugs usually have to be
added to provide fu post-operative analgesia.
General anesthetics used during the birth process arc generally
of the inhalation kind. They are nearly always administered at the end
of the second stage (i.e,, just before expulsion of fetus) though smaller
doses of inhalation anesthesia ("whiffs") arc camnonly used to relieve
pains of contractions. Intravenous barbiturate anesthesia is not often
used in obstetrics (except for cesarean section) because the recovery
. is much slower than with inhalation anesthetics.
Other depressants of.the CNS, such as alcohol are not used for
obstetric purposes. These depressants will, therefore, .not be reviewed
here.
B. Sedatives
Calm, drowsiness, or sleep (i.e,, hypnotic effect) can be
induced by sedatives. They do not induce loss of consciousness (i.e.,
general anesthesia) when administered in usual doses, although high
--doses of some sedatives may be used to produce general anesthesia,
e.g., thiopental. Sedatives, like general anesthetics, depress the
CNS. The most canmonly used sedatives arc the barbiturates, usually
classified according to time it takes to produce the desired effect
and the duration of its effect (ultra-short, short, medium and long
77
219
acting). Barbiturates are typically administered orally. Sodium
phenobarbital, a long-acting barbiturate, can be injected intra-mulcularly,
and is often used pre-operatively in obstetrics for that purpose. (It
is also coarion.ly used in the control of convulsions,) The ultra-short
acting compounds (e.g., thiopental) are usually administered intravenous-
ly for rapid effect. Barbiturates are typically administered in doses
varying from 100 mg, to 250 ms';. Other sedatives include chloral hydrate,
a relatively non-toxic substance (0.25 gm. to 1.0 gm.), ethchlorvynol
(Placidyl) (0.1 2.1. to 0.5 gm,), and glutethimide (0.25 om. to 0.5 gm.)
(Goodman and Gilman, 1970).
C. Anals,esics and Narcotics
Analgesics (in.Auding narcotics) selectively reduce the sensa-
tion of pain while producing only minor effects on alertness, as opposed
to the action of anesthetics (inhaJation anesthetics and barbiturates).
Narcotic analgesics comprise the opium alcaloids (e.g., morphine and
codeine) and their synthetic analo,nes, (mcperidinc, methadone,
levorphanol). When these are given in heavy doses, they can also
duce drowsiness and have calring effects similar to barbiturates.
Narcotics act by depressing the functions of the CNS, although the
dnpressing influence is different from general anesthetics. Narcotics
have selective rather than general effects. For example, the principal
effects of morphine are: (a) suppression of p:_tin; (b) mild drowsiness
and euphoria; (c) depression of respiration; (d) nausea and sometimes
vomiting; (c) constipation (Goodman and Gilman, 1970). The "withdrawal
syndrome" ic characterized by irritability, tremor, increased heart
rate and bleed pressure, lacrimation, sweating, nasa discharge,
pro-
78
220
diarrhea and, occas;oo"lly, vomiting. Other narcotics produce similar
therapeutic effects and have similar withdrawal syndromes with prolonged
use.
Narcotics are most comnonly employed in early stages of labor
to relieve pain, but miy also be used in conjunction with anesthetics.
Morphine is usually administc'red by intramuscular injections of 10 mg.
to 20 mg. The most commonly used obstetric narcotic is moperidino, which
is injected intramuscular in doses of 50 mg. to 100 mg.
D. Tranquilizers
Tranquilizers arc drugs that produce a calming effect, without
affecting alertness or inducing sleep. They do not depress CMS function
when administered in typical doses. Their main effect consists of re-
ducing the intensity of emotional reactions. Numerous traneuilizers arc
on the market and they arc probably among the most widely prescribed
medications in general use. They arc divided into two main classes:
(a) -major" tranquilizers (e.g., phenothiazincs, rauwolfias, butypberones)
have profound effects and are used mainly in psychiatry; (b) "minor"
tranquilizers (e.g , benzodiazepines, meprobamnte) mainly reduce :anxiety
and have a very wide field of npplication.
There are two "major" tranquilizers that are often used in obstetrics.
The first is chlorpromazine. It is given in doses of 50 mg. to 100 mg.
intramuscularly. It is often used for its potentiating effect on
general anesthetics and analgesics that allows a smaller dose of the
other.drug to produce the desired effect. The tranqu_lizing influence
is merely a beneficial side effect. Prometazine, a related compound,
is used for the same purpose. The second major tranquilizer used
221
79
16.
obstetrics is rescrpine, an alcaloid of the rauwolfia group. It ia given
in doses of 2 mg. to 4 mg. Like other.rauwolfia preparations, it lowers
the blood pre:Isurc while also producing a tranquilizing effect.
Rauwolan is sometimes usod in latc stagos of prenaney though r,omc.
authors object to such use (Ban, 1969). It appears that some infants
are born with effects of this medication (to he discussed below).
The two minor tranquiliaers most commonly Used in obstetrics are
chlordiazepoxide (Librium) in doses of 10 mg. to 25 mg., and diazepam
(Valium) in doses of 5 mg. to 10 mg. They arc both administered to
reduce anxiety and thc latter has also a muscle-relaxing effect.
Diazepam is also used to control convulsions. Minor tranqulaizers are
used in early stages of labor, while chlorpromazine, a major tranquilizer,
and related compounds arc also used as adjuncts to general anesthesia
during expulsion of fetus.
E. Local anesthetics
Local anesthetics provide relief from pain by blocking the
transmission of impulses through the peripheral nerves (Goodman and
Gilman, 1970). Used in such a manner, they do not alter alertness of
the patient but can suprcss CNS function if administered in signifi-
cant amounts. The commonly used local anesthetics are synthetic
derivatives of cocaine (e.g., procaine, lidocaine, mcpivacaine). They
can -be divided into two major classes: the esters- and the amides3.
The former include procaine and are generally characterized by a
fairly long latent period (between administration and clinical effect)
.1d a relatively poor ability to penetrate tissues. The amides, on the
other hand, act more rapidly and longer and penetrate tissues hotter.
This group, which includes lidocaine, priletJtine and mepivacaine,
in widely used to provide obstetrical anesthesia..
80 222
In obn'tetrics, the local anesthetics are employed in three
principal ays (Divi. a Rubin, 1)66):
1. Tnfiltration anetht...:;ia is produced by injecting the drug directly
into th tissue (e,g., perinuum in preparation for cpisiotomy). This
method is simplest but not necessarily the safest, an it may
require a relatively largo quantity of drugs (up to 200 cc of a .05%
solution of procaine, or up to 40 ml. of 1% solution of mepivacaino).
2. Conduction block is produced by injecting the drug next to a nerve
trUnk (pudendal or para-eerVical block) (up to 10 ml. of 1% procaine
or up to 20 ml. of 1% mopivacaine on 'each side).
3. Massive block of spinal nerves leading to the lower part of the
body can be produced by one of the following techniques:
a. in spinal anesthesia the drug (0.5 to 2 cc of 10Z procaine or
15 to 30 cc of 1Z mcpivacaine) is injected into the subarachnoid space,
in direct contact with the spinal cord. The result is a transient
sensory and motor paralysis of the whole lower half of the body. A
variant of this technique is the "saddl.e block," in which the drug is
injected in a manner to affect only that. area of the body which would
touch a saddle (Davis and Rubin, 1966).
b. in lumbar rpidural anesthesia the drug (in amounts similar
to those used in spinal anesthesia) is injected between the dura
membrane and thu bones of the spine. If the injection is made into
the caudal cnnal (wbich is an extension of the epidural space) it in
called caudal: anesthesia.
In spinal and epidural anesthesia, relatively small amounts of the
drug pass into the general circulation. On the other hand, these
massive nerve Mocks produce cfEc.cf-s such as the pronounced F11
in the mother's bloc,: pressure (a point which will be elaborated inter on).
223
F. Other druF
Scopolamine (hyoseine) is used as an adjuvant to narcotics and
is reputed to induce amnesia of the painful experience. Succinil choline
(Anuctine) is a muscle relaxant used to facilitate surgery and delivery.
Little is known about the possible effects of these drugs on the fetus.
The classification of anesthetics, analgesics and sudatives refers
to the principal effect, when the drug is used in typical manner. One
should keep in mind, however, that all these drugs affect the function
of nervous tissue and their effects may overlap. Thus, higher doses of
morphine have a sedative effect, tranquilizers may induce sleep and
local anesthetics may cause excitation, convulsions or loss of conscious-
ness if introduced into the brain in large amounts.
In this section we have reviewed the principal anesthetics and
analgesics co=only used in obstetrics. We turn now to the utili:,:ation
processes by both the mother and the neonate.
2. vicissitudes of dru!-;s used in labor
There has been a considerable amount of research into the effects
of drugs on the mother and fetus during labor and delivery. .0ne major
factor of paramount importance is the time factor, i.e., the interval
between administration and delivery, speed of absorption, rate of
placental transfer, rate of metabolic breakdown and elimination. The
time factor plays a critical role in evaluating the effects of a drug
on the mother and the fetus. Contradictions in the data obtained by
different observers about drug effects are partially the result of the
fact that not all researchers take into account all of these variables.
ln addition, many of the original inferences were drawn from animal
22482
experiment:4 and it is now recognized that: pharmneological effects may
differ greatly from man to animal - a point which will be elaborated
further on.
When a drnz is iotroduced, by any route, into the mother's body
it will:
(a) enter, to some extent at least, into .the-maternal blood
circulation;
(b) be subjected to metabolic transformation by the maternal
organism, leading to breakdown and/or elimination;
(c) pass in variable amounts through the placenta and into the
fetus and return from fetal into maternal circulation (before severing
the cord) to he metabolized by the mother;
(d) become metabolized and/or eliminated by the fetus (and later
by the newborn).
Some general comments concerning these various stages will be
helpful.
(a) Absorption: drugs injected intravenously enter the circula-
tion instantaneously and within seconds are evenly distributed throughont
the body. Inhaled drugs are absorbed almost as rapidly. Intramuscular
injection or rectal administration requires several minutes while
ingested drugs may require an hour or more before peak blood concen-
tration is reached. Peak blood concentration is not synonymous with
maximum effect. In order to exert its effect, the drug has to enter
the tissues; in the specific case of central nervous system function,
passing the blood brain barrier is involved. The blood brain barrier
has a different permeability for different drugs (Harper, 1969).
Local anesthetics exert their effect at :ite of the injection but are
alwayf; sooner or later absorbed into genvral circulation.
.22583
(b) Metabolism; Gases and vol:Atile anesthetics are largely
eliminated throuvh the lungs. Synthetic narcotics and short-aeting
barbiturates (e.g., thiopental) are metabolized in the liver. Long
acting Imrbiturates nrc eliminated through the urinary system. Of tho
local auesthetics, esters are metabolized by hydrolysis (i.e., combining
with water and spliting into alcohol and organic aeid) and thus inacti-
vated. The amide compounds (e.g., lidocaine, mepivacaine) are metabolized
and inactivated by a liver enzyme, amidase (Cohen and Olson, 1970).
Contrary to previous opinions, it is now Idlown that many drugs
enert significant effects long after having been apparently eliminated
by metabolism and after their blood level drops to insignificant amounts
(e.g., secobarbital produces mild sedation up to 20 hours, and
chlorpromazine a tranquilizing effect up to six months, Goodman and
Gilman, 1970) . Ashton and Hibben (1967) (in Goodman and Gilman, 1970,
pp. 104) found in an animal study after-effects of barbital anesthesia
one month later.
(c) Placental trnnsfer: The old notion of the eighteenth century
that the placenta serves as a protective barrier between the fetus'
independent circulation and his mother (Corner, 1965) was shattered
te pieces in 1961, in the popular beliefs, with.the tragedy of
thalidomide in Europe, (Nehan and Lampert, 1965). A number of babies,
whoce mothers took this mild sedative in the first weeks of gestation,
were born with limb malformations and with other defects. What was
thought, early in this century, to be a semi-permeable membrane
separating the two circulations, is now knmsrn to be an extremely active
metabolic unit (Ncgerman and Ville, 1960; Marx, 1961; Moya and Smith,
1965; Watson and Lowory, 1969; Bowcn, 1970; Cohen and ()iron, 1970).
114
226
It Ls now believed that sn,.. substance found in the maternal blood will.--cross the placeitt ;o some extent unless it is altered or destroyed
during its pass:.:; :!ost drugs z2re transfured by simple diffusion, i.e.,
the molecules p:: .-etu an area of 1t i;%1: concentration to one of low
concentration wit -. little iE any metabolic energy. The rate depcnds on:
(a) lipid solubility (fat solubility); (b) molecular weight of the
drug, (drugs with molecular weight up to 600 readily cross the placenta;
(c) degree of ionization (non-ioni:ted, i.e., electrically neutral
substances cross more readily). Any change in the p11 (alkalinity-
acidity balance) that increases concentration of dissociated, ionixd
forms, will slow down transfer of drugs (Hagerman and Ville, 1960;
Cohen and Olson, 1970; Burt, 1971). Normally, the pH (the acid-alkali
balance) of the fetal blood is slightly higher, i.e., more alkaline,
than that of the mother. However, drugs such as local anesthetics may
produce acidosis in the fetus, i.e., lower the pH. In that case, an
alkaline drug, such.as mepivacaine, after having passed through the
placental barrier, may become "trapped" in the fetal circulation because
the increased acidity leads to increased ionic dissociation of the
alkaline drug and, thus, reduces its diffusibility through the placenta
back into maternal circulation (Teramo and Rajamaki, 1971). This may
be a possible explanation of why some local anesthetics have been found
at higher concentration in the fetal circulation than in the maternal
circulation (Teramo and Rajamaki, 1971).
The placenta may also play a role in metabolizing some compounds
so that they may reach the fetal circulation faster or be prevented
from ce.tering it (Cohen and Olson, 1970) . Naternal diseases such as
, 4 ,toxemLa 2 u lnocces or chronic hypertension (hiej) bleod pressure)
227
which lead to an altercd Placental vascular bed may also inhibit
passage (Cohen and Olson, 19i0).
Transfer occurs also by active transport or by special processes
such as pinozytosis (enul on t by leucocytas) or through gaps in
the placental villi pro.ieetons). The mechanisms of
active transfer arc still poorly understood (111ge7:Pan and Ville, 1960).
Drug transfer may aiso occur via the amniotic fluid to the fetus'
circulation. This route is also poorly understood but is most interest-
ing in light of the fact that the pH of amniotic fluid at term is
6.9-7.0 while both fetal and maternal blood pH is 7.35-7.4 (Cohen and
Olson, 1970). "This differ.nce in pll could result in some drugs being
concentrated in the amniotic fluid and ingested by the fetus in higher
dosage than may be suspected from maternal plasma alone." (Cohen and
Olson, 1970).
The type of administration of a drug into the maternal circulation
will affect the degree of transfer with :Lore of the drug passing to the
fetus after intravenous administration to mother than aftcr oral admin-
istration or.intramuscular injection, hold.ing dosage level constant.
(d) Metabolism by fetus and neonate: Once the umbilical cord
is severed, the neonate is on his own as far as the detmification and
elimination of drugs is concerned. The fetal and neonatal metabolism,
however, differs significantly from that of the adult. Both liver
function and the e:.:cretory function of the urinary apparatus arc not
yet fully developed (Nelson, Vaugham and McKay, 1969 a, b, c) . Compared
with older children and adults, the elimination of drugs by the neonate
is slower.
the newborn
The neonate's liver is deficient in amidase: This makes
susceptible to the Loy.ic effects of the amide group of
22886
local anesChotics ((.ohen nnd Olson, 1970). Neonates haw diff[cuivio!:
in coningating (tLo yellow piwented nob:Aimee formed by the
breakdown of bemog1ol'in fvom dey.troyed red cells). Before being
eliminated from the 1.edv, hilivehin has to he rendered writer soluble
by hilvg col,bin!:d (coujnatcd) with Oueuonlc acid. The
conjuga;:ion is aceerpli:.hod hy an erlyme, gluenvonil trnnsferase, which
is nom'ally present in liver :tissues. Thn liver of the fetus nnd new-
born has a very low level of this en%!.-me and the process of bilirubin
elimination is much slower in the newborn, especially in the premature
baby. Excess biliruhin produces jaundice and the so called "physiological
jaundice" of the neonate is thus due to the relative defficiency in the
elimination of bilirubin. Lbout 50 percent of full term babies and 80
percent of immature infants develop mild jaundice on the third or fourth
days of life, when the unconjugated hilirubin has accumulated in the
blood stream and is being deposited in the skin (McKilligin, 1970).
Any marked increase in the rod cell destruction, such as happens in
Rh incompatibility, results in severe jaundice which may lead to death
or to brain damage in the form of kernicterus (yellow coloration of
basal ganglia of the brain by bilirubin). Conjugation with glucuronic
acid is a dcto-.7.ifying mechanism used for the elimination of a wide
variety of foreign substcnces including such common drugs as salicilates
(aspirin), sulfonamide, chloremphenicol, morphine and others. Thus,
bilirubin and many drugs conpetc for the same detoxifying mechanism in
the neonate's liver with the result that jaundice may delay elimination
of many drugs and many drugs may aggravate jaundice. (Kent, 1959; Lncey
and Dolan, 1959; Burns, Hodgman and Cass, 1959; Zuelzer, 1961; Done, 1964;
Oustrifsott, 1965; Nylinn end L;m1pert, 1065; Adons and Joelsson, 1966;
Watson and Lowery, 1969; i;elson, et a,h, 1069; Burt, 1971).
87
229
In order CO stimulate the production of the drug-metaboliming
onzym, glucuronil transfernse, physicians sometime,: advocate the
administration of barbiturates (Foutz, 1965; Young and Yu, 1971) , such
as phenobarbitone, or of bon::)pirene. This, however, does not solve
the oholo probl(:m because the neonate's glom,,rular filtration (passof:e
of the fluids frum the blood into the kidney glomeruli and formation
of fluid which oventually becomes urine) is low (Nelson, et al., 1969 b).
Thus some conjugated bilirubin
neonate's body.
The elimination of drugs
processes aro deranged,
and/or drug continues to circulate in tIle
may be further
by acidosis or
Since a number of drugs may produce acidosis
slowed r.lown if the metabolic
lowered body tmperature.
(e.g., local anesthetics)
or interfere with feeding (i.e., reduce caloric intake) and hence inter-
fere with heat regulation, a vicious circle may start. The fall in tem-
perature is even more pronouoced in the immature and malnourished
infant (Adamsons and Joelsson, 1966).
From the point of administration of the drug to its elimination
by the mother and/or leonate is a long and complex process. It is
not yet a fully understood process, but what is already %nown suggests
that the introduction of analgesics and anesthetics into the mother's
body during labor and delivery starts n chain of. effects that invariably
add to the demands of the birth process on the system functions in
the neonate.
1. Effects on methe-: ond newborn
There have been a number of studies on the effect of obstetrical
4110rugs. The can be divided into two groups: the effect on the mother
and thc effect on the infants.
23088
1. Pffects on maternll nhv!Itolo,, and labor
When considering relations between a drug and ffnlIsi metabolit-da,
much more than a. wir,Tio pharmacological effect of the drug itself may
be involvv'l. lt i.!; true that in many instnnees the drug crosses the
placenta unchanged and affccts the fetw; in a f;shion similar to that
in which it affects adult:I. Nost of the volatile anesthetics, the
barbiturates and many narcotic analgesics probably affect the fetus
in this manner (ns will be described below). But a drug may influonce
the fetus also by altering the maternal physiology in such a way that the
intrauterine environment is changed. It has recently become apparent that
spinal anesthesia may have far-reaching consequences oven in the cases
where drugs themselves do not cross tho placenta in significant qunn-
tities. At the time of cesarean section, a patient who lies in a
supine position and then is given a spinal anesthesia, may experience
an alarming hypotension (Ucland, Gills, and Hansen, 1968) which can be
reflected in the reduction of fetal oxygenation and increased acidosis
(Stenger, Andersen, de Panda, Eitzman, Gessner, Preptousky, 1964).
Anything that alters placental transfer of respiratory gases (exygon,
carbon dioxide) electrolytes, water or metabolic end products (urea)
will jeopardize the fetus to a certain extent. Consequently, a drug
must be considered not only for its direct effect upon the fetus but
also for its indirect and no less important effect on maternal physiology.
Friedman and Snchlleben (1961) have warned against dysfunctional
labor due to a prolonged latent stage (predilatation stage of the
contractions). Both local and seller:al anesthesia may have adverse
effects on the fetus since they may unnecessarily prolong the latent
23189
stage (above 10 honer) to the point or dynfunctioral lakor (contractions
which do not produce OilatoiJon and expulsion of the fetus). Dysfunc-
tional labor may lead to asph.xia (vuffoeation). Luecy, Nihbard,
nehrmna, Esquivol do CnliwIdo Windle (10(4) have found n significnnt
correlation ht:twoon asphylJa and bernicterus in nhosus monkeys, and
they hnvo concluded that tile more imature the newborn Cho greater
the dangers of birth asphyxia, intrauterine insults and drug effects.
2. Direct effects on newborn
The newborn's transition from intrauterine to extrauterine life
imposes upon him the need to activate a number or functions that have
been dormant or incoplot,...ly activated (Snyder, 1949). Some of them,
such as respiratory activity and maintenance of body temperature, must
be established immediately at some minimal level of acceptable function-
ing.
The birth process itself with the sudden, often catastrophic, alter-
ation in physiology may be a hazardous experience for the fetus. James .
(1960) at Columbia University studied a. large number of babies illtmediate-.
ly after birth and found that all the infants were subjected to varying
degrees of oxygen deprivation and carbon dioxide retention during the
course of labor and delivery. Under normal circumstances most infants
tolerate this brief "asphyNia" without difficulties and within a short
time slmw little evidence of the biochemical storm they have recently
survived. Failure of the oxygen supply during labor, however, results
in depression or absence of fetal respiratory movement at birth,5 as
well as iu vascular injuries giving rise to edema and hemorrhages of the
lungs and other o/Tans. These, in turn, aggravate the lack of o:;yen
thus crNltfl1 a Vic:ion:1 cycle Onmc!:, 1960).
90
232
In premature infants, oxygen deprivation is clo!,ely linked with
-perinatal mortality. Thus, the fetal respiratory system is the site
of greatest vulnerability to injury in labor and delivery and that is
why for years the majoritV ef the research has been concerned with the
relation of obstetric m.edientiens and neonatn1 depression(' (Snyder, 1q49).
Even in 1933, Shut and Davis observed that morphine could incrcase U.
chances of asphyxia in utero as indicated by change of rhythm of fetal
heart. Asphyxiated infants were, in turn, more susceptible to morphine
and showed severe symncoms of narcosis. Sny:ler (1949) summed it up:
"All drugs commonly given for the relief of pain tend to alter the
functioning of respiration thus striking the fetus at the point whicll
has been found to be of maximum susceptibility to injury during labor."
Many observers disagree with the statement and the research on whether
narcotics (o.g., meperidine) cause depression in the newborn, rang.ls from
s.tudies that claim zero percent depression to studies that attribute
327, of their ne-Aporn depression to mcperidine (Shnider and Moya, 1964).
.Garcia, Waltham and Lubin (1953) even recoomiended the administration of
meperidine in quantities of up to 100 r:ag., but they also reported that
some of the babies in their study had to be resuscitated by artificial
respiration lasting up to 90 seconds before onset of respiration.
However, they did not attribute such depression to meperidine. Others,
such as Znru, Espcsito and %aril (1967),.have advocated continuous
infusion of meperidine (average per hour 40.3 mg.) since "obstetric
and subjective evaluation of pain relief was excellent and newborn
depression was not significant." In contrast, Flowers, Rudolph and
Desmond (1969, who us,.'d diazepam (Valium) which is classified as a
23391
"minor" tranquilizer and a mild analgusic, found that a significant
percentae of neonates suHered moderate depression and some showed
severe depression in comparison with a control group that did not have
any drags. Flowers, et nl. attribued the depression to a hyPotonie
effect of diazepam and not to any direct effect of the respiratory cen-
ter in the CNS. This drug has lately been used in the mntmgCment of
neonatal narcotic withdrawal syndrome (Nathenson, Golden and Litt, 1971),
since it produces temporary hyponctivity and hypotonicity in neonates.
The concentration of barbiturates, e,g., amyloharbitone, in the fetal
liver is already relatively high 7: to 2 hours after injection and de-
creases very slowly. This accumulation might indicate an exhaustion of
the detoxicating capacity of fetal liver (Ploman and Persson, 1957).
Floman and Persson (1957) also studied the concentration of barbiturates
in fetal brains. They found a much higher amount of barbiturates
concentration in the region of the fourth ventricle as compared to the
cortex. 'This s5.gnMeant since the medullar respiratory center lies
in the vicinity of the fourth ventricle.
Despite these findings, Bran and Montalvo in 1971, advocate the
use of barbiturates in labor, claiming (on the basis of animal experi-
ments) that barbiturates protect the neonates against the effects of
prolonged ano-:ia (oxygen deprivation). Epstein and Coacley (1967)
reported that local anesthetics (lidocainc and prilocaine) had little
depressing effect on the neonate. However, Levy (1953) and.Morisima,
Daniel, Finster, Popper and James (1966) found that a relatively high
percentage of neonates were depressed even with local anesthetics such
as mapivacaine. Those drugs, which were not supposed to reach the fetus,
23492'
did pass througk the so called placental barrier into the fetal blood
stream in significant amounts.
Drugs may affect the neonate's respiration in other ways too. For
example, resernine i.n relatively mild trnnquili:i.er; for this reason
it has been employed to ease the course oE labor. The adverse effects
in the adult do not appear to be disturbing. S_tuffiness of the nose
is the major frequent complaint. A stuffy nose in the newborn may, on
the Other hand, produce mild to severe respiratory difficulty because
of the relative inability of the infant to breathe through the mouth
(iyhan and Lampert, 1965).
The confusing and contradictory data on depression of neonates
produced by different drugs may be due to two reasons. Firstly, many
of the basic experimentc have been conducted on animals. Animals differ
in their reaction to drugs and are certainly different from humans
(Done, 1964). For example, thalidomide did not produce any teratogeuic
effect (maldevelopment) in rats and in monkeys it proJuced only
sterility (Nyhan and Lampert, 1965). Secondly, the importance of the
time interval between administration and delivery has often been over-
looked, even though there has been important evidence about this factor
since 1933. That year Shute and Davis pointed out that Morphine has the
maximum effect on the neonate when administered to the mother in labor
anywhere between oneand six.hours before delivery. This was true even
if mothers had received only 50 mg, of meperidine. Shnider and Moya
(1964) sutdied the.effects of meperidinc on newborn infants and found
that there was no statistically significant effect if the drUgs were
administered within one hour before birth (confirming Shute and Davis'
conclusions). However, there was a significant increa.se in
235
the percentage of depressed babies if the drug vas administered more
than one hour before delivery. This was true even if mothers had
received only 50 mg. of meperidine. Peak effect of drugs occurred if
the drug had been administered somewhere between hours prior to
delivery. These conclusions are quoted by many writers. Shnider and
noya and other investiF,ators have based their conclusions on the Apgar7
Score taken at 1 and 5 minutes ixonediately after birth. Shnider nd
Moya's results could be explainted by suggesting that if the drug is
administered less than one hour before :iirth, 'the newborn will receive
a significant3y smaller amount.of drugs. However, as mentioned before,
the drugs that pass through the placenta do so within seconds after the
injection or inhalation and thus the explanation can be questioned.
A more likely.possibility is that the observations of Shnider and noya
and others can be explained by t:lic fact that the babiesin-their
studies were examined for depression in the first. minutes after delivery
znd none of the studies concerned mentions the search for drug effacts
after two, three, or more hours after delivery. Thus, one may suspect
that babies whose mothers' were given medications during the last hour
preceding delivery are not necessarily free from effects of the drug
but that the peak effect has yet to maeifest itself.
It is the pediatrician who sees the newborn two, three or more
hours after delivery. Brazelton (1970) noted: "...(Some) neonates
had excellent Apgar Scores in the delivery room and remained clinically
responsive for half an hour - long enough to be sent to the nursery
downstairs. After this initial period of responsiveness, (which I
now postulate is large] y due to the neonate's ability to mobilize his
resources to respond o the stimulation of labor, delivery and 01:!
23694
onslaught of new environmental stimuli), these habics shiacd rapidl.y
into a frightening state of relative unresponsiveness and they became
unresponsive to any but very disturbing stimuli, with little spontaneous
motor activity; they nlr, ha.d very slow heart and re:Tiratory rates.
Diffuse acrocy7nosis (bluish extn:neties) demonstrated their poor
circulatory response to the hypexia that was present, and their ability
to clear mucus from their airways became impaired. This depressed
behavior lasted for a period of a few hours to a day and then tapered
off not-so-gradually; subclinical behavior maaifestations could be
demonstrated for as long as a week in many infants." (Brazelton and
Robey, 1965).
Drug effects arc not limited to the functions measurable by the
Apgar Scale, which is clinically useful but a rather crude es.timate of
infantile physiology. There have been a few attempts to investigate
other aspects of infant's behavior and functioning using EEC, suckingJ--
behavior, sleep and smiling, attention and mother-child interactions.
In some of these areas there is only the briefest of literature;.in
others, it is a bit more extensive; in none of them is there a
definitive literature.
Neuroloic ination and EEG
Borgstedt and Rosen (1963), in a controlled study of 52 infants,
found that "behavioral impairment" (as measured by infant's alertness
and reactivity) as well as .EEC alterations were highly correlated with
obstetric medication (meperidine, prometazine, phenobarbital). The
behavioral .changes disappeared in most cases within three days, but-
EEC changes persisted in ten infants.
23795
Suckinc'.
Both Bra3e1ton (196i II) and Kri'm (1966) independently studied
sucking beha,Jior. In Brav.etton's study, two groups of neonates were
evaluated. One had relatively little premedication, i.e., hariturat
not exceedin 60 mg. ith or without anesthetic, general or local; and
the other group, 150 Ir:g. or more with general or local anesthesia. The
less medicated group started to suck well on the second day. The neo-
nates in the heavy premedication group showed a lag of 48 hours duration
in their specific ability to adapt to breast feeding. Weight gain
was also (lc:laved 24 hours in the heavily medicated group. Kron's (1966)
results confirmed those findings. His control group had no medications
and he used a more refined measure of sucking. The bottle was attached
to instruments which measured the rate of feeding, pressure of suction
and z%mounts. By studying only bottle fed babie.s, the possibly confound-
ing factor of drug effects on the nursing mother was excluded.
The implications of these studies are related to the fact that body
temperature control may be affected by inadequate caloric intake.
REM and Smilin
Emde and Koening (1969 a, b) found that neonatal smiling occurred
durine states of REM sleep',,and drowsy REM and had a significant
tendency to occur in bursts. Smiling was also found to have a
characteristic distribution within each REM period and to be evenly
distributed across successive REM periods. Amount of smiling was found
to be influenced by depressant medications given to the mother within
8 hours before delivery. Infants of these mothers smiled significantly
less both in number of smiler; and smiles weighed for intensity. Medica-
Lions did not seem to affect the length of 7ZEM st:ates.
96
2 38
'Attention
Stechler (1964) Found that visual attentiveness in 2 to 4 day
old infant, vas affected if the mother had received analgesics and
hypnotic drugs duriug labor. There vas neg;Ltive correlation between
the dosage of the depressing drtTs and nepnatcs' attention to.vicual
stimuli. In a study that is.not directly related to our discussion,
Lewis, Bartels, Campbell and Colderg (1967) used the Apgar Scale
as a measure of condition at birth against which they compared the
visLal attentive behavior of infants at 3, 9 and 13 months. Their
data indicated that infants who rated between 7 to 9 on the pgar Scale
at birth were significantly less attentive than infants who rated 10.
This difference, in general, held over the first year of life and
according to Lewis et al., indicate that individual differences in
infant attention within the first year of life are a function, in part,
of birth condition. Lewis, et al. also found that habituation at the
age of three months in high Apgar score infants was much more rapid
than in the low score infants. There was no difference in habituation
rate at 9 and 13 months. Lewis, et al., however, do not relate their
observations to maternal medication of their subjects, but instead
discussed the birth condition as a global concept. Conway end Brackbill
(1970) found that neonates who have been subjected to grca:ter amounts
of obstetrical medication (analgesics and anesthetics) lagged signifi-
cantly in their ability to inhibit responding to an auditory stimulus.
These findings may have important implications concerning the
welfare of the infant since "habituation is the efficient response to
stimulation that is no longer providing the organism with useful
239
97
information" (Lewis, Et al.). Neonates just cnnuot get up and lalk
away from the stimulus which by then may become aversive for them.
Conway and Brackbill (1970), who studied the infants on their second
and fifth days and at nne month, also found that "the medicated neonates
performed significantly pcorer on standard behavioral tests than infants
whose mothers have not been medicated durincr. labor." The differences
persisted even at the age of one month -- as measured by the Bayley
Motor Scale (1969), which at the one month age level consists largely
of postural adjustment items. No 'significant diff_c=nces were noticed
for the Bayley Mental Scale, in which the age appropriate items concen-
trate more heavily on testing visual regard, that is, eye coordination
and following in horizontal, vertical, and circular direction. Visual
differences were also found at 5 days of age, but no differences were
found on the second day, probably because of the swelling of the'
eyelids and consequent visual impairment caused by the silver nitrate
given to all infants shortly after delivery. Significant differences
were found at 2 and 5 days in performance on the Graham Muscle Tension
Subscale (Grahem,.1956). The babies with history of obstetrical
medication performed less ell. Conway and Brackbill followed some babies
till the age of 5 months. At this age there were no significant
differences on the Bayley Scale nor in habituation scores although the
latter showed a tendency toward quicker habituation with less
medication (Conway, 1972).
24098
Footnotes
1. Tha reader rill fLLA Go,-5=n & GEU.an (1970colny1ete reference
on drllg troant and ::;nycloa, (1949) gcoft rc:fcr=co on obstctric
aliesthcia Rna
2. An cstc::: iz an c.717nic cri:-.pound fon-.Ld by cobining an .alcohol
with an acid 1969, p. 5:113)
3. Amides aro co:q:eurds containing tha croup -co(m)) or its
substitutes (117.77.Ntr, 1969:
Tc;:cmia i3 a toxic st:Lto associatea with pregnr.:.ncy zsid its main
cyl...pto:as aro: cl:Tc-tod'Dlooti prsuro, v=itinr; ch...nGe
in kidn,zy function.
5. aTe-_, fctus rc-s Sx;tc:ry never,ents a1rea6y in utoro ana thcy
whc:n. tcrn
6. "I:sono.tca d.o y.r,:ssion" 12.can:i a :7c6ur:tion or slmring do..m of a
number of physiologicu1 funations: rc!spiration, heart rata,
mobility, etc.
7. The Ap3.ar Scel-e is bnzrd upon tha conbinod *Zating of five inaicors:
heart rate, rcspiratory offvrt, muscle tone, roflcx irratibility and
color az jual. at 1 minuto and 5 ilnute intcrvals after clo2ivory.
Ea.ch is -rated (..:1 sco.la of 0 to 2, with :cro indicatinG no function;
1, function rrn.nit bnt poor; and 2, function perfect. Thus, azi
infant in 7::rfu;cJ.: c1itIc1L would r:Ictlive a score of 10. This
Scale is hCW Ty mnst aztotriclans ana rece.rchre in order
to dctornizie cp.veagion (Arf;=,
24199
'1 1953).
8. la.:7; or flv.piCi r.ye Yow.lmont olocT thcl plY%so of clooD 11:7,117.11y
a2soci1 tth rjnr cllso c7.11d "activo fskop." Thc,.
tino 17=-c:cno of acv 1zcp (co;17....ccd to total s1c.-,p timo)
dooroa.7 ftc7.1 8W; in pure nowborno to 13;;;
in tr.1.111t% adativ(:s (knrctzu Pi:: in adult:: (1:ant 1966).
242
100
APPENDIX B
243
APPENDIX B
'MANUAL FOP. SCORINC TUE ERAZELTO:J. SCAL
Recommended Sc:-ile Order (See discussion above)
1. Observe infant for 2 minutes - note state2. Flashlight (3-10x) through closed lids3. Re.ttle (3-10x)
4. Bell.(3-10x)
-5. Uncover nfant6. Li4;ht (4x)
7. Ankle elor.us8. Plantar grasp9. Babinski
10. Undress infant11. Palmer grasp12. Passive movet,ents and gen,!ral tone
13. Orientation inanimate: visual, auditory
14. Pull to sit15. Standing16. Walking17. Placing.18. Incurvation19. Body tone across hand20. Cra'A.in - prone responses
21. Pick up and holdClabella reflex
23. Spin - tonic deviction and nystagmus24. Orientation animate: visual, auditory, visual and auditory
25. Cloth on face26. TNR27. Moro
States
"State of consciousness" or "state" is one of the mo§t important
variables in any observation period. Reactions to stimuli must be inter-
preted within the context of the presenting state of consciousness. Thase
reactions vary markedly from state to state in each infant. State depends
on physiological variables such as hunger, nutrition, deree of hydration,
time within the wake-sleep cycle of the infant, etc. The patterns of states
as well the movu:nost fro::: one state to anothr appcar to be imnorzant
244101
characteristi,...s of infants in the neonatal period, and this kind of evalua-
tion may be the *hest predictor of the infant's receptivity and ability to
respond to s imuli in a cognitive sense. Our criteria f r determining
states are based on our experiences and on those of others, and are
comparable to the descriptions of Prechtl, et al. (16).
Sleep '0.itos
(1) Deep sleep with no spontaneous activity except startles orstartle equivalents at quite regular intervals; externalstimuli produce startles with some delay; suppression ofstartles is rapid, and state changes are less likely.
(2)
Awake States
(3)
Light sleep with nyes closed. low activity level withrandom movements and startles or startle equivalents;responsf.ve to inteenal and external stimuli with startleequivalents, often ith a resulting change of state.
Eyes may be open or closed, eyelids fluttering, drowsy,or semi-dozing; activity level variable with interspersedmild startles from time to time; reactive to sensorystimuli, but delay in response often seen; state changeafter stimulation frequently noted.
(4). Alert, bright lc.ok; seems to focus attentin on source ofstimulatin such as an object to be sucked, v_:Njuai OLauditory stimulus; impingiiu:, stimuli may break: through,but with some delay. Motor activity is at a minimum.
(5) Eyes open, considerable motor activity with thrustingmovements of extremities, even a few spontaneous startles;reactive to external stimulatiaiwith increase in startlesor motor activity, but discrete reactions difficult todistinguish because of general high activity level. Inter-mittent fussing does not result in a change of state.
(6) Cryin. Characterized by intense crying which is difficultto break through with stimulation.
We have suggested in parentheses appropriate states in which the assessment
can be made for eneh state. Since state behavior is an integral part of any
observation of the newborn, it is vital that this reflect the starting point
102
245.
from which all tbe rest of the observations are made. The reactions arc
state-related, and on infant's use of states as a framework for his re-
actions to the observer may be most important as part of the observation.
Initial State
In the two minutes before stimulation is begun, an assessment of
the infant is made by observing the infant's spoutaneous behavior, respira-
tions (as observed by the movement of the gown or covering sheet) , eye
movements, startles, and responses to concurrent spontaneous events in
the environment. States are scored according to the criteria given above.
Predominant States
At the end of the observation period, E should record the two or,
at most, three states within which the infant performed. Since the most
important influence on his scores will be his available states, it is
important to have an idea of the range, as well as the kinds of states
used by the infant in this period, their importance to him in controlling
himself, and the amount of time spent in them.
IX. Scale Items and Xanual Description
1. Response Decrement to Lit:ht (),3)
One of the most impressive mechanisms in the neoaate is his capacityto decrease responses to repeated, disturbing stimuli. This shouldmeasure the decrement which occurs in a quiet state (2,3) afterthe infant has responded with an aversive reaetian to the flash-light shined briefly into his eyes (closeti or (1.:'en). Since somebabies alert as C:c l!gilt is used, there is ne ol:servable aversivereaction. Viten this happens, wait until he is alert, and afterhe begins to react with an aversive reaction (tii.ht blinking,general motor a.r.tivity, and change in respiratic.u) habituation ismeasured by a real decrement in the etent of t'ae above.
Up to 10 stimuli can be used. Criterion for shut-2own equals twotrials past. Score the mast obstrved decrement. Stimuli presented
24610'3
every five secends after th e end of each previous responr:c. Thinthe o':)crtr.-"s ability to jud;.:u tlie end of each reaction.
Thl.s tent Ihould be done with a standard L:" flashlic:ht with twonoz:iun siso batter!os in rcoi wrd..nr cond.ition. Flashes :tust bediserote and aniont noinc level should he accounted for and ruledout as nuch as T:ossible. Cf course, a baby in a semi-darkencquiet roon will renT:onr1 difrerently than one in a brichtly lit noiTynurner.71 and t'le Adeel of the quiot, darkened roon cannot al-:.-aynbc achieve,d. ::eactions -;:hich a.' rid in te-ns of the neDn,te'sability to control over- tine are: a) all or none st:Irtle ofentire bo:iy, delycd and ::raded loo:.11inod 2;t:-Lrtic, c) res-piratory chan7c7, d) blin::s or oyraids. andshutting out on7 rc,::ctions ari_t er;recc of the n:In.e ;-zild of ha'uitu-ation. E%-alu:-ttc nin at the end of 10 -ror scorn7 unlosshas successfully roachd crite,-ion before teat. If baby is toosleepy to show a response, he can bc rouser.: slightly by shakin teebed or uneoverinc hi:1. If there ' s never any response, score hin rA.
1 - ro dution in 1.1ir-h resPonse over the 10 stinuli..2 - Daayod startles and rest of responses are still :-,resent,
. e. , body novment, eye bln, respiratory chances cen-tiime ovr,r 10 t--;:,1s.
3 - starticz; no lon::cr 1:ro:::,-nt but rest are iJJ. r)resent, in-clue:111c body move:lent in 10 triZis.
4 - Uo startles, ooz novent delayed, resrAratory and b:linssane in 10 trials.
5 - shutdoI:n of bo,dy novenents, sonn dicf,nution 4 n blinl:s andrestpirator:r chanes in 9-10
6 - in 7-8 ctir-214.7 - ... in 5-6 stinua.8 - ... in 3-4 strIraLL.
9 in 1-2 stimuli.
2. Re:;nonse 7s,ec-r-nt to RnttleSee below..
R.-snonse Decrent to "r?ell (23)
These a,-.e a nr%asure of the monatc's ability to shut out a disturbingauc:4 to17 7:Lav.s . icace (as in 'nab; tu:Ltion to lint) the st47-ulusmust be able to break throuch his anbient state and create a st.artleresponse. The bell nay be nore success-1'a' in prod=inr: a startleresponse, especially in a noisy nursery. Often the rattle nay brin:;-him out of His r7,no,-el1y shut-down state, and the test should thenbe conpletol with the ball. A bell is that used in a ...:tandardGesell test. is scorz1:1 (as above) for an averr:ive reaction(concral -tartlo. tir;ht and re!:;-:iratory ch7nr,r,,$). AS :lc,
habituates, he tends to daay those reactions and .1'-'nally shutsthen out. Often the shut-out 21s a tenTorar:: one, but this reflectshis capacity to do so. If the baby is tcxs ic(2.ry to shor a rr--sponse, he can bc roused n11:ly by aha:-.in-: bod o- u:=0ver4:-.7him. If there's never any rc::r.onsP, score H4-1
Stinuli are brief, discrete and presorted air, seconds aftor
10/1
247
end of the previous response while tho baby is in state 2 or 3.Present. the i.,1mulus until you have had no responso for thre,.!consecutive times or until 10 stimuli have beer presented.After the rattle,reest the procedure with the bell.
1 - No diminution in ..e.; 10 stft.rnai..roe-1 -o2 Delayed .Ldit1Ct, and rest of .responses nre still
presont, i.e., body movement, eye blinks, respiratory -changes continue ever 111 trials.
3 - Startles 'no Jen.,:er pre!lent but:. rest arc still present,ineludini; body movement in 10 trials.
4 -.No stnrcles, body movement. delayed, respiratory nodblinks r.nne in 20 trials.
5 - Shutdown ta.f body movements, some diminution in blinksand respii-atory changes in 9-10 stimuli.
6 in 7-8 stimuli.7 - in '5-6 stimuli.8 - in 3-4 stimuli.9 - ... in 1-2 stimuli.
4. Response Decrement to Pinrrick (1,2,3)
As a test of rc.wonse decrement to tactile stimulation the diaperpin may be used to prick ti.e heel of the infant's feet when he isquiet. This may c epeated several times. The eaminor watchesfor hew totally' and how rapidly the whole body responds to thisTinprick, ln an immature or CS-damagd infant, the oppositefoot withdraw and the whole bodv responds as euickly as thestimulated foot (a demonstration of the all-or-none aspect of animmature or,n:sm). det:.ree, rapidity, ahd reoetition ef this"spread" of stimulus te the rest of the body is measured hetc.The other aspect is the infant'.s capacity co shut dev,m thisspread of a generalized response. *,:hen he continues to respondin an obligatory, repetitive way, he rates a low score. As hedemonstrates a sunpression of responses to the stimulus -and changeshis state to a more alert, receptive one, he deserves a high score.Many infants demonstrate some hut not all of this behavior, aneit may be evidence of excellent CNS functiOn, Xiddle scores aresaved for infants who demonstrate some habituation but not anaccompanying state ehange of alertness.
The foot should be pricked at least four timos. If no responsedecrement oc'..:urs, the stimulation should be steprod. If decrementoccurs, a fifth stimulus aad mere can be applied to test the extentof the,decremen:-. (For the squeamish, an pprpriate stimulis isa pin pushed torough a cork to extend 1/16th cf an inch beyond thecork.)
1 - Response generali;:ed to whole body. Both feet with-draw together. No dcerement'in responr!e.
105
248
2 - Response limited to stImulatud foot. No decrementof response.
3 - Variable response to stimulus. Response decrementbtri; return of response.
4 - Response decrement after five trials. Localized tostimtiated Jec. No rhange to alert state.
5 Response derrement after five trials. Localized tostimulated foot. No change to alert state.
6 - Response limited to stimulnted foot after 3-4 trials.No ch:xl.:',0 to altl-t state.
7 - Response limited to stimulated foot after 1-2 trials.No change to alert state.
8 - Respense locali;:ed and minimal. Change to alertstate (4).
9 Complete response decrement. Chanv to alert state (4).
5. Orientation Rosnonso - Inanimate Visual (4 only)
Since most neonates will demonstrate some abiliry to fix on avisual ohjoet (a contrnsting bright or shiny cmect, :e.g., abell, red ball, white mask) and follow it horixontally for briefexcursions, this is a measure of that lbility. It is highlystate-related, and may not be demonstrated in any one exam, but,under optimal conditions (a quiet, semi-dark room), it is
repeatable; following with the eyes is also accompanied by head-turning to 'follow. Vertical followinc SeCT:s of an even hi;therorder, and many babies will stretch their necks to follow up anddown. This is a summary score.
The infant may respond with (1) alerting (decrease in randemactivity, focus on examiner's face when it is in his line ofvision, slow regular respirntions, and follows face when it movesin arcs) ,and (2) bri:;htening (change in facial expression, wideningof eyes and brighter look, jaEg'ed respirations, with an associateddecrease in random activity).
When the infant will not attend or follow in the bassinet, he m3ybe held on the E's lap, slightly propped up. This facilitateshis doll's eye reflex; his eyes open, and he attends to the object.Obviously, the act of holding him restrains interfering movementand helps alert him. But he may also be distracted by the examiner'sface. Held at the E's shoulder, his following responses can bedetermined by another examiner.
1 Does net focus on or follow stimulus.2 - Stills with stimulus but no focus.3 - Stills, focuses on stimulus when presented, little
spontaneous interest, no felluwing.4 - Stills, fecuses on stimulus, brief following.5 Focuses end follows with eye:A .horizontally andlor
verticolly for at least a 30' arc. jerky movement,
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249
loses stimulus but finds it again. No following with
head, some spontaneous interest.
6 .1! Follows for 30° arcs, not with head. Eye movements
are smooth.7 - ie. I with eyns and head at lenst 60" horizontally,
briefly vertic;.Illy, partinlly nontinuens movement,
c:ccasionally, head turz,7 io follow.
8 Follow!. with eyes and head 60' horizontally and 30'
vertically.9 - Focusc's ():)
::timulus and fellows with :.t-.00th, continuous
head mevement horizontally, vertically,and in ,a circle.
Follows for at least a 120° arc.
6. Ci,intation Resnonse Tnanimate Auditory (4,3 states)
This is a measure of his response to the rattle or a soft bell
(non-social) as a stiulus when he is in an alert state. The
auditory stimuli shculd be presented to one side and out of
sight (at least 6" way and no more than 121) o that onu can
observe the infant' J.:yes and head as they red to the
lateralined stimulus. This scores his best performance in one of
the awake states to the stimulus. Latency alc:ring deiiree of c'v
shift and had turning to the stimulus are scrod. Brii;hteniag
of face and eyes can be seen, and they are eviHences of his
attention to the stimulus.
1 - No reaction.2 - Rer,iratory chanse or blink only.
3 General quieting as well as blink
changs.4 - Stills, brightens, nu attempt to locate
and respiratory
5 - Shiftini; of eyes to sound, as well
brightens.
6 - Alerting a'ild shifting of eyes and
7 - Alerting, head turns to stimulus,
8 - Alertingprolonzed, head and eyes
repeatedly.9 - Turning and alerting to stimulus pres:-,rced
sides on every presentation of stimulus.
source.
as stills and
head turn to source.ant:. Fearch eyes.
turn to stimulus
7.Orientation - Animate Visual (4 only)
on 1-eth
The three items score the a:tention whizh. is called .up by
the cwminr:r's social cues--voice, face, cutldiing, holding, rock-
ing, etc. The infant may respond with a1ertin.7.,and
settling li::to the arms. He may turn his head to seek :he voice
or face. Hn...ing caw:hc the examinr, he may rivet his :ittention.
and "'o'er:" on for 1,.!ng prieils. No interest is unusual. Hr.!w he
iS held m7ly strongly influence this, and the F should att.-mpt to
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250
reproduce two maneuvers commonly w.ed by mothers: (l) hold theinfant dn a cuddled position in the arms up ;,gainst the chest,and (2) upright on the shoulder in a bubbling position.
For the "visual only" item the examiner places his face in theline of visio then mOees it slowly in lateral and vertical
arcs until the :; !!tops following.
1 - Does not focus on or follow stimulus.2 - Stills with stimulus but no focus.3 - Stills, focuses on stimulus when presented, little
spontaneous interest, no followins,.4 Stills, focuses on stimulus, brief following.5 Focuses and follows with eyes horizontally and/or
vertically for at least a 30° arc. jerky movement,loses stimulus but finds it ae,ain. No followingwith head, some spontaneous interest.
6 - Follows for 1.0° arcs, not with head. Eye movementsare smooth.
7 - Fellows with eyes and head at least 60° horizontally,briefly vertically, partially continuous movement,.3esasstimulus occasionally, head turns to follow..
8 - Follows with eyes and head 60° horizontally and 30°vertically.
9 Focuses en stimulus and follows with smooth, continuoushead movement horizontally, vertically, and in a circle.Follows for at least a 120° are.
8. Orientation Ani7ato Auditory (4,5)
The examiner removes his face from infant's line of sistht and talksto him from one side (6 to 12 .inches from ear).
1 - No reaction.2 - Respiratory chance or blink only.3 - General quieting as well as blink and respiratory
changes.4 - Stills, brightens, no attempt to locate source.5 - Shifting cf eyes to sound, as well as stills and
brightens.6 - Alerting and shifting of eyes and head turn to source.7 - Alerting, head turns to stimulus, and search with eyes.8 - Alerting prolonged,- Lead and eyes turn to stimulus
repeatedly.9 - Turning and alertinl; to stimulus presented on beth
sides on every presentation of stimulus.
251. 108
9. Orientation Animnte - Visual and Auditory (4 only)
The same criteria for scoring are used as in Items 5 And 7. Thesame condjtions pertain except that the examiner's voice is usedto reinforce face, both on the bed and when infant is held.Voice is continuous while face is moving.
1 - Does not focus on or follow stimulus.2 - Stills with stimulus but no focus.3 Stills, focuses on stimulus when presented, little
spontant.ous interest, no following.4 -'Stills, focuses on stimulus, brief following.5 - Focuses and follows with eyes horizontally and/or
vertically for at least a 300 arc. Jerky movement,loses stimulus but finds it again. No followin,-;
with head, some spontaneous interest.6 - Follows for 30° arcs, not with head. Eve movements are
smooth.7 Follows with eyes and head at least 60' horizontally,
briefly vertically, partially continuous movement,lost'!s stimul.ss occasionally, head ttlrns co follow.
8 Follows ith eyes and head 600 horizontally and 30°vertically:
9 - Focuses on stimulus and follows with smooth, continuoushead movement horizontally, vertically, and in a circle.Follows for at least a 120° arc.
10. Alertness (4 only)
This is an assessment of the frequency of the hes:: nerir.'.:!s ofPerformance in 4. Often this is elicited while the E i.s theinfant. Since newborns arc as variable as they.are, and arealert for such a shert period, one must assume that any periodof alertness in a 30 minute exam may be taken as an index ofthe infant's "caacit for responsiveness." In a less randomlyselected time sample than this, or when one can wait fcr aspontaneous 7ericd of alertness, this measure mi.;:.ht be a hotterindex of his availability, but T have found thnt most infantsshow small periods of alert behavior during r.n exam. Theseshould be assessed. Alerting is defined as bri;:htening andwidening of eyos, while orenting is used for tne response ofturning toward the direction of stimulation.
1 - inattentiverarely or never responsive to directstimulation.
2 - W1,1 alert res-sivity brief and Tone:any quitedelayed--alertiog and orientation very brief andgeneral.
3 When alert responsivity brief and somewhat _layed--quality of alertness variable.
109
252
4 - When alert,responsivity somewhat brief hut not.generally delayed though variable.
5 - When plertIresponsivity of moderate duration andresponse generally not delayed and less variable.
6 - When alertiresponuivity moderatoly sustained and notdelaykA. May usu stimulation to come Le alert_ staLe.
7 - When oluvt,cpisodus are of gonerall> sustained dura-tion, etc.
- Always has tmstained periods of alertness in bestperiods. Alerting and orientation freqw.sit and re-liable. Stimulation brings infant to alert state andquiets infant.
9 - Always alert in best periods. Stimulation alwayselicits alerting, oriuntinA. Infant reliably usesstimulation to quiot self or maintain quiet state.
1l. Oenern1 Tonus - Predominant Tone (4,5)
This scores'the tone of the bnby in his most eharnet.eristic statesof responsiveness. Since this must be a summary assossrzellt,should include the overall use of tone as he responds Cc boinhandled. This should be asses!.ed in state 4--unless there is noopportunity to produce such an asscssment. This should nat.: beassessed in 6.
Tone is assesFed in such maneuvers as spontaneous activity, pullto sit, holdini; him over hand horizontally, prone placement, etc.,and should be an overall assessment of his body Lone as he reactsto all of these.
1 - Flaccid, limp like a ragdoll, no resistance when limbsarc moved, complete head lar., in pull to sit.
2 - Little response felt as he is moved, but less than about25Z of the time.
3 Flaccid, limp most of the time, but is responsive about25% of the Lime with some tone.
4 Some tone half the time, responds to being handled withsome tone loss than half the time.
5 Tone vhen handled, lies in fairly flaccid state inbetween handling.
6 - Variable tone in resting, responsive with );ood tone ashe is handlod apnroximately 75% of the time.
7 - Is on the hypertonic side approximately 50:; of the time.8 When handled he is responsive with hype:tonicity about
75% of tho time.
9 - Hypertonic at rest (in flexion) and hypertonic all thetime (abnormal).
Sunplerentprv F,roro After most of the shaped summary scores,there will be n (Tportunity to score a second 1:ind of obl-xrvcilion.
253110
This need not hc utilined. it is used, it will mean thatthe first score repreL:ehts the score for the major part of theobservation, since using a summary score for two very divergenttypos of behavior negates the importance of ench. This secondscore gives an opportunity to assess body tone of a secondarykind and, alo, sc.;..e idea of the range of tone which the babymay prenent. hni.e, this can be used to denote ;: minority value,which may or may not have significance for the long run. Forexample, this ;(-)re could predict future heLavior, or it maypresent evidence to contradict complete reliance on the su.:,maryscore.
12. Motor Mnturitv (4,5)
This is a measure of motor responsesspontaneous and elicited--assessed throughout the exam in the alert states. The arm move-ments become the ealiesc to score. The assessment is of(1) smoothness vorsns jerkiness which reflects the balancedflexor and extensors versus the unbalanced cog.Alool mnvent: ofthe premature or CNS irritation with flexors and extensors com-peting, and (2) freedom of arcs of movement (90')(arms on bed)versus restricted arcs (45° ete )(arms and legs in flexion).The premnture hes unlimited freedom of movement (floppy) inlateral, sagittal, and eephalad nrens, but the movements are jerkyand cog-like, overshooting their marks. The very mature infanthas both freaziom of movement in all directions associated with asmooth, balancud performance (not floppy). The average newborn issomewhat limited in arcs of movementespecially those abovethehead, and somewhat in the lateral plane.
1 - Cogwheel-like jerkiness, overshooting of legs and armsin all directions.
2 Jerky movements and/or nlad overs:looting.3 Jerky movements, no overshooting.4 - Only occasional jerky movements predominatin: arcs to 45°.5 Smooth mov.emeats predominate, arcs predominately 60°
half the time.6 Smooth movements, arcs predominately 60°.7 - Smooth mevements and arcs of 90° less than half of
the time.8 - Smooth movements and unrestricted arms laterally 90°
most of the time.9 Smoothness, unrestricted (90°) all of the time.
13. Pull-to-sit (3,5)
The examiner ploces a forefinger in each of the infant's palms.With the arms extended, the infant's automatic grasp is used topull h2m to sit. Thc shoulder muscleF, should resp!-.5nd with
111
254
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Actually resists hoinr, hold, continuously pushin away,thrashing ur stiffening.
2 1:esists being held most but not all of the time.
3 Doesn't resist but doesn't participate either, liespassively iv arm:4 aud orainst ohoulder (like a sack ofmonl).
4 - Eventv:.ily molds into arms, but after a lot ofnestling and euidling by :e,tr.Ancr.
5 - Usualjy molds nad reloxL:. h.hen tirst i.e nestleshead in cruok of neck ond of elbow of examiner. Turnstoward body vhen heJd herixontally, on shoulder heseems to lean forward.
6 - Always molds initially with above acti.vity,7 - Always molds initially with nestling, and turning toward
body, and leaning forward.8 - In addition to molding and relaxing, he nestles ovd turns
head, Jeans forward on shoulder, fits feet into cavityof other arm, all ofbody Tarticipates.
9 - All of the -ab,:ve, and 1:aby grass head of t.lieoxaLt_nor to oiinj,.
35. Defensive 1.1ovements (4)
A small cloth Is placed with examiner's fingers asserting 1:, .cv3.0over the uppr p;Irt of the face which would partially occlude ti;enose, and is kept in place for one minote, or until the iofntresponds with a ,..eries of responses: (1) i.uneral quieting(b) mouthing (c) ad turainp, and rooting from side to siee(d) head turnint; lateral as well as neck streten up and -down(e) general uirected increase in activity (f) directed swip,-:sin general area of, cloth (p) dir'uctee swipes in specific areaof cloth which removes the cloth. Infant's hands should not beunder cloth.
I - No respenae.2 - General quieting.
3 - Nonspecific activir.y increase with long latency.4 - Same with short latency.5 - Rooting and lateral head turning.6 - Neck st:..etching.
7 - Nondireeted swipes ofartls.8 - Directed swives of arms.9 - Successful removal of cloth with swipes.
2 5 6
113
: 7 :
7 :
with this haby to t.,) asintc. iafants will quiet only when they are dre--ed andleft alone. A;:v !-Jimultis :rom tho environment disturbs them.Others will when they ni. h.Id and activv roctsed. Asteady hand hcld on a crying bnhy's holly will act. ns eothini..,stimulus. (..'ter he:.d cr ic,1d in additioa :e Cau
. rfc.:es za;disturbing stnrtle hi:h gets trir,..d off by try;n:ior fussing. A ILw babies may quiet to the E's voice or face.They should be graded in the reverse order, and best performanceis scored.
3 - Dresnia, bolding in ;:.ms and rocing.4 - Holding and rocking.5 - Picking up and holding.
Hand en bell and restraining both arms.7 Hand on belly steadily.8 - Examiner's voice and face alone.9 - Examine:-'s face alone.
17. Peak of Excitc7ent (6)
This is a measnre of hey much motor .nnd crying nctivity theinfant gives eff to the observer at his neaks ef excitement, nndresponsiveness pulls him toward the mean. The kind of fntonsereactions which scme infants demonstrate when they reach their
. Leak of oxcitemeat shows an unavailability to the outside world,and must he scored Others aro hardly allie to he joFed torespond at all, and their peak is very low. An average andoptimal respease would full in the moderate, reachable range, inwhich the infant could be brought to respond to stimuli in spiteof a high degree of upset or excitement, but then return to moremoderate states.
I Low level of arousal to all stimnli. Never abovestate 2,.does not awaken fully.
2 Some arousal to stimulationcan he awakened to state 3.3 - Infant reaches state 4 briefly, but predominantly is
in lower :itates.4 - Infant is in.:;tate 5 after stimulation.5 - Infant reaches :..trIte t; after stimulation once or twice,
but.predomin.,"tly is ia state 5 or lewer.
114
257
6 - Infant roaches state 6 after stimulation,'but returns to ?ower status rpontaneonsly,
7 - infant reaches state 6 in myense to stimuli, butwith consoling is easily brought back lo lower states.
8 - Infant. screams (stale 6) in response to stimulation,althongh ,:eme quieting can oceur with conholing, withdifficviLy.
- Infant achi:...ves insulated crying state. Unable to hequieted or soothed.
18. Rapidity of Buildun (from 1,2 to 6)
This is a measure of use of states from quiet to agitated state.It measures the timing and the number of stimuli which are usedbefore he changes trem his initially quiet state to a moreagitated one. Since this inpiik.'s that we start with an initialtyquiet baby, it measures the period of "control" which he canmaintain in the face of increasingly aversive stimuli as wall as theadditive effect of t!.ose stimuli in ebangin7, his initially qniotstate. The first pre'..crence is when one can chervu the infantas he changes frem.a sleep slate or a quiet awake one (5) to anagitated crying state (6).
1 - No upset at all.9 - :oro, prone placemer .id defensive
reactions.3 - Not untIl 1NR, Yoro, prone placemenL r defensive
reactions4 - Not uail Ilulled to sit.5 - Not ustil6 - Not until plaprich.7 Not until uil-verino him.8 At first z.u,Litory and light stimuli.9 Never was quit-.t enough to score this.
19. Irritabilit-:
This measures the number of times he gets upset as well ns thekind of stimuli which make him cry. Since the presentation ofthe stimuli is fairly set but some may bring ni:.out cryiag, otherseven more aversive may not, we have tried to mrIke th:2 scoresflexible by counts of number of aversive stimuli.
115
258
AverOve Stimuli
uncover pinprickundress TNRpull to sit Moroproue defensive reaction
3 - Nd irritable crying2 - Irritable crying to
3 - Irritable cryini!, to
4 - irritable crying to5 - Irritable crying to6 - irritable crying to
7 - Irritable crying to8 - Irritable crying to
9 - To all of them.
20. Activity (alert states)_
to any of the nbove.one of the stimuli.two of the stimuli.three of the stimuli.four of the stimuli.five of the stimuli.six of the stimuli.seven of the stimuli.
This is a summary of the activity seen during the entire observa-tion especially during the alert states. The activity consists oftwo kinds - (1) spontaneous, and (2) in response to the stimulationof handling and the stimuli used by the observer. A further dimen-sion is reflected in the inaccessibility of the activity in ahyperactive child--vig. the activity is not interfered with by theobserver's maneuvers. Amount of activity is graded: much = 75:or more of the tir., moderate refers to 5M of the time =
of the time. After stimulation which trip.,,.ers activity, the amountof activity which nrri can be assessed; much, builds up first,perpetuates itself for a period after activity is initiated;averae, no buildup, and at least 3 cycles of dctivity which isdecreasing all the time; little, 2.or 3 cycles of activity whichdie out quickly.
SPONTANEOUS ELICITED
1 none none2 none brief3 slight little4 moderate little5 moderate moderate6 moderate much7 much much
8 continuous consolable9 continuous unconsolable
Mere may be a nre. marked difference between spontaneous andelicited than this scale reflects. Then, he should be scoredtiidwav be'.-ween them, and the examiner should be alert to thefact tat this rc.flcts n, kind of discoordinntion, such as inseen in metabolic imbdlance or t.S irritation.
259116
21, Ti emul utisa(n;s (al 1 states)
Since this may be a measure of CNS irritation or depression, aodmay occur for mozabelic reasons, or since it may he a sign ofimmaturity, it becomos one more way of assessing nil of those.Tremulow,ness is demonstrated at the end of a startle, and as ababY comes from leeping le awake f:I.;1te8. There is C.M0 tremorof the chin and ex!remivies which can be expected in the neonate'sfirst week. A2 the infant is dehydrated normally in tho secondand third day, me:nholic imbalaaces cause tremulousness. la
light sleep or as he startles in deep sleep, trel,ur! of the ex-tvomi:ies Jle noted. As be becomes alert and active, the tremulous-ne-ls should be overcome with smooth, voluntary behavior of thelimbs. Aversive stimuli set off a startle which is followed by aretuni of tremulousness of the chin and extremities. Mildlyaversive stimuli should not cause observable tremors in their re-actions (.:.:ee intredurtion for lists of aversive stimuli). Quiver-ing and tremors are synonymous.
1 - No tremors or tremulousness noted.2 - Chin quivering only during sleep.3 - Chin quivering and brief tremors of extremities
only during sleep.4 - Chin and extremities quiver in response to one aversive
stimulus.5 Quivering with first presentation of aversive stimulus
and/or %,-irh crying.6 - Quivering with some aversive stimuli and/or with state
changes.7 - Quivering with most aversive stimuli, some mildly
aversive stiuli and/or with state chanz-,e.8 - Tremors with some state changes and/or with all
aversive and mildly aversive stimuli.9 - Tremulousnes with all stimuli and also with all
self-initiated activity..
22. Amount of Startle durine Exam (3-6)
Both spontaneous startles and those which have been elicited inthe course of stimulation are included in this. Some infantsnever startle durino an exam, except when a MIro is elicited.Abnormally sensitive infants overreact to any disturbing; stimuluswith a startle, and have observable startles for no observablereasonhence they must be considered "spontaneous" or due tointernal stimuli.
1 - No startles noted.2 Startle as a response to the Examiner's attempts to
set oil: a Moro reflexonly.3 Startles to two avorsiv,, stimuli (including Moro).
117
260
4 - One spontaneous startle and at least one aversive.stimulus besi,ic a
5 - St;:rtles to (3) aversive stimuli at the fir5-,tpresentation.
6 One spontaneous startle and/or startic responses tonv:rsive stimuli:
7 - Scver:.1 spontaneous startles and/or startling La allaversivt. stimuli.
8 - Start:en te all stimuli which Examiner presents(avorsive nnJ mildly aversive).
9 - Startles to tolf-initinted stimuli hndior to all ofExaminer's presented stimuli.
23. Lability of Skin Celor (as infant moves from 1 to 5)
This measures the chan,.os of 'color and'vascularity which takeplace in a period of e.g., the acretiosis of peripheralmild cyanosis when-the extremity is left uneovered, the chan.,...,efrom pink te :,ale or ournle when the baby is en:ressed--m.:ttling:and a web-...ike appeance may occur in an (ffort t.obody heat. A nom..o) n,born is likely to demanstrate r,ila color,changes several tiMes in an enam during which he: !ins been undre:ised,disturbed, and upset. This should he assessed in particular ns theinfant comes from a sleep state 1 to 5. Tile leat:th of time alterundressinF before he bei;ins to chanp,e color is a good way to de-termine this. Additionally, the frequency-deree of chani;ebe scored. ::(1 C:!:_1717 in color may be the result of depressed oroverstressed :::tto:lc;nie and vascular system, as seen in dopeY, PaLL:,or cyanotic iniantF. :.;arked chanes which vary from minute tominute would ke seen in promatures er babies who were no: yetadjusted to extrauerine temperature chaw:es, or in infants whosecentral and autenomic nervous systems were unable to master thechanges durins: an exam.
Acrocvane,,.is ,4hould be indicated when there is more than mild,localied cyanosis of the extremities er around the mouth, andespecially when the infant is not In enough str: s to accountfor such mild changes.
Panne, should be checked when paleness is unusual or excessive.
Reedeninc,. mieht be the result of unusual vascular changes, dehydra-tion, or skin irritation.
Any other skin .v::normality should be recorded as it might reflectmk!tabolic or variations, which-could influence thebehavioral outcome of the
1 Pale, cyanotic not chans:e durinq exam.- Good color which does n^t change during entire exam.
261118
3 - Healthy shin color, no change except chanze to bluearound month, or extremities when uncovered or redwhen crying, recovery is rapid.
4 Acrocyauosis around mouth and extremities when un-dressed, slight change in chest or abdomen but rapidrecoverY..
5 Healthy color 1:ut changes celer all over when uncoveredor crying; face, lips, extremities may pale or redden,mottling may appear on race, chest, limbs;. oricinalcolor returns quicHy.
6 - Change 5n color during exam, but color returns withcrying or covering.
7 Healthy color at outset, changes color to very red orblue when uncovered or crying; recovers slowly ifcovered ur soothed.
8 Good color which rapidly changes with uncovering; recoveryis slow but does finally recover, when dressed.
9 - Marked, rapid chang.es to very red or blue, no recoveryto good color during rest of exam.
24. Lability of Sti.ltos (all states)
This measures the infant's state perfo--lance over the exam period.Frequency of state changes over a recognizable, wide swing arecounted. (Slee7 to ay:.,ke, crying to alert, sleep to crying,crying to sleal).) Counting should include changes upward anddownward over the exam period of 30 minutes, ln the event an examdoes not take 30 minutes, prorate it to half an hour by thefornulao
Score = state change, X 30, divided by the length ofexam in minutes.
The score corresponds to the frequency of swings:
1 = 1-2 swings as prorated2 - 3-53 = 6-84 = 9-105 = 11-136 = 34-157 = 16-1F,8.= 19-229 - 23 on up.
262
119
25 . Sol f OuietinP, Activity (6,5 to 4,3,2,1)
This is a measure of netivity which the baby initiates in afussing state an ohservable effort to quiet himself. Thenumber of activities which cah he observed is counted. Theirsuccess is measured by an observable r:t;A-0 change which persistsfor at least 5 sevonds. Most United States baies cry or fussvigorously at some time durin2, ihe exam (sta(e 6). For thosewho never do cry, the supplementary score C.AM be used, measuringthe same number o:" efforts. if none, Ciffi be.used. Theactivities which can he counted are: (1) hand to mouth efforts(2) sucking on fist or tongue (3) using visual or auditorystimulus from the environment to quiet himself (more than a simpleresponse is necessary to determine this).
1 Cannot quiet self, makes no attempt, and interventionis always necessary.
2 - Brief attempts to achieve hand to mouth ns if to quietself, but no success.
3 Attempts to bring hand to mouth, and/ or quiets briefly.4 - Brings hand to mouth, attempts to seek on fist but:
without success, quiets for a short time perceptibly.5 - Makes at least two attempts to suck on hand or fist and/or
has two successful brief quieting periods.6 Two attempts to quiet self result in observable successful
quint:in; for perlocis.
7 - Repeats hand to mouth, sucking and/or uses visual orauditory stimuli to quiet self for three successes, butall are brief.
8 - Uses maneuvers to quiet self three times for shortsustained periods.
9 - Consistently quiets self for sustained Teriods.
26. Hand to mouth facilitv (all states)
This is measured in all states. A hand to mouth reflem is inborn,and seems to he a response to trokin the cheek or the palm ofthe infant's hand. It can 1:e triggered off by mucous and gaggingin the neonate, by discomfort, by placing him in prone. It isseen spontaneously as the neonate attempts to control himself orcomfort hi:::self when upse.t. This is a measure of his ability tobring his hands to his mouth in supine as well as his success ininsertion. Soz%e infants bring their hands to. their mouths re-peatedly, insert a part of the fist or fingers, and suck activelyon the inserted part.
1 No attempt to bring hands to mouth.2 - Brief swipes at mouth area, no real contact.3 - Hand bri.ught to E:out.h contact, but no insertion,
once only.
263120
Hand breue,ht ne.xt t.o mouth area twice, noinsertion:'5 - Hand breuf nent to mouth area at :east 3 times,
but no real in,,ertion, abercive attf:mpt's to suckon fist.
6 One insertion which is brief, unable to bo maintained.7 Several actual insertions which'are brief, not
maintained, abortive sucking attempts, more than threetimes next to mouth.
8 Several hriyr insertions in rapid succession in anattempt tc prelon,.. period, sucking at this time.
9 - Fist and/..:r fingers actually inserted and suckingon them for 15 seconds or more for several 'briefinsertions.
27. Smiles (all states)
Smiles are seen in the neonate. They nurely can be of reflexivegrimacing in nature, and they also occur "appropriately"--orin response to soft auditory and/or visual cues. Occasionally,when the baby is h.:-.ndled and restrained in a cuddling position,a smile comes :.er:,ss his face as he relaxes. 1 have seen closereplicas of "soc.fal smiles" in the newborn period--when anexaminer leans over his crib and talks softly to him. They aredifficult to be suro of, may consist primarily of a softening andbrightening of the infant's face with a reflex grimace thrown in,and they may certainly bc difficult to reproduce. Hence, onehesitates to call thcY:e. social_"smiles," but they surely are t-hefacial precursors of such smiline behavior. A mother reinforcesthem as such.
1 21
264
El c Led .11e flexes
Those are described in Prechtl and Beintema's monograph (11) andneed not be described hcrn. Their procedure is followod foreliciting the 16 refle::es listed. Since this is not desined tobe a neurelugiel assessment, these will serve ns baseline datafor more foTmal neurological where it is 2 ndic6ted. Thismanual scores':
X = omitted.0 = reflex not able to be elicited despite several
attcn:pts.L = hypoactive response.M = normal respor:se as determined by Prechtl's manual (11).Ii = hyperactive response.A = asymmetrical response, either in terms or laterolination
or segments of body (arms vs. legs; etc.). Since LiSmay be of importance in a:.:1;essing neurulegical dama;:e,real, repeated asymmetry should be carefully assessedand not.ed, tu be followed by a formal nentclogicalassessment.
Examples of our use of these reflexes aro:
Crayl.i.na nclucies n31 of the prone responses: head-liftin andhead-turning, crawling, hand-to-mouth in prone.
Tonic_devia_t_ion_o;'head_and ee is an 8th nerve response to boisrrotated in froh of t.bc ce-,-:iner. He is held under both arms;then, examiner and infant rotate slowly in a circle. Eyeshead go ahead of examinor, then nus of the eyes beFins tooccur, both in response to an 8th nerve compensatory reactionand as the eyes catch the passing light while they rotate.
Passive Movemen.s nf Arms and Lees (4,5)
As defined in Andre Thomas, Chesni and D'Argassies, The Neurolos.:ealExam of the Infant (10), this becomes a measure of consistency and
extensibility el muscle tone, in reaction to passive stretehin::of the limbs as well as the amount and degree of recoil of thelimb after exce!,sion. As a summary of these in ail the limbs andthe trunk, it represents the muscle tone of the body plus itsreaction to stimulation. A big, floppy baby may have no resistanceto stretchin of his limbs. A very tense, jittery infant will be'very resistant to being msved, and limbs Will snap back intoflexion after beinF, stretched. Infants normally show some resistanceto havini; their e:-:tr c-ni t I ox stretched, and a little snapback is
265
122
normal. The deroe to which I -t' (np to fullo:.:ten.ii.01) in order to ::1c,C resistanc.:, as well thoof sh.-Ipl-,ac 11.L....:r05 Cho overreaction or rlo:.:or musc1:ois scored. Lgs are -o.t..tially more resi,:tant to u:.:ccnsionarms, o7...! vers.. lew infants do not attempt Co mnintnin tone.ofthei,. lops af%ainst stretching. Ineguniity of tho to sidesa very important. pa;t ot i-issesmont. (e Prochtl (M.)
Descri:,tive Pararaph (optional)
Descrilqive Scores ice,tion-1)
This is a summnry of all the F:ubjective impressions which havebeen amassed in t.!:e pet.iod. They include the style with chinhthe infant reacts, the eNaminer's major impressions about thf::
infant, his feelinc.. abeut the auflarhuce and hehhvior ofinfant, his reL:i.cflear. about th- of responses Liv.se illcal] up in his :nctl:cr, :is veil as predictions about their ultImaceoutcome as the.child ,,-ows. This win be tlie para:.traph whinh wilihelp tho to re..*mher th;: child lat.or, nhd may b.:. ah im-portant way of catc-,..,nriing infants, or unciers1;7,n;.'lnl; the scoresin the different catc:..erios, and of underst,IndiTI;; meaninl:ful con-stellutions of thesc! catc4lories. This is not c:e.p':.ued to he subjectto interscorer reliaility.
The subject:Ivo of the E is subsumud under "0.Ltr:IyLifin an aLl.c:1;lt- to obj,2ctify this.
Interferinc N.Y,rinbles such as noise, too many observurs,should be scord und listed.
Need for stimula..-ion scores the result. of the infr:nt.'s observableresponses. t-,cs!e ln:ants seem to nued stimulation f.rom outsidehimself in order to function smoothly and well. Thesewould score hi11 on this measure. Others seem to pay littlo
Lo outside stimulation, respond 'auto;,:atically. Theya low score.
The kind of activity w-hich the infant uses chnraccoristicallv toquiet_hir::seif has been of some interest to many observers. :hiscan be checked and/or scored on a 3 point scale.
Comments: te a descriptive prirrarnph al.,ont the baby whichincludes the particular characteristics ..ehich are cf interest inyour study. This 1...nra::raph scrvc as a reminder of the u:ligeecharacteristics of the baby which are m.):: recordable elsewnere.
266
23
APPENDIX C
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APPENDIX D
270
earent:
THE UNIVT,RSTTY 01' KAN:3A:3LAV/RE;.-TGE, KANSA:3 66044
DepIrtment of Human Development
APPENDIX D
-.a Infant Research PrograM is part of the Kansas Cener for P.escrch in Early Childhoodcation at the University of WC are ultimately inter,:..ntc,-.: in understanding what
:e the best experiences for diitdrn co th::It each child e:In be hcAped to ,.'njoydevolop:nont. As p,..irt of .-:ifort.we arc engzlaej in vior::ing on the development
:a behaviord scale for n.:v.;bern .
:ministering the scale invol.ve2: ta:nc7 the..infant in his own ba:::inel.`,-e to a quit rc:cm whoreis examined by experiencc,d per-ronne). Hospital procedures of scrubbing end gowningfollowed prior to each infant exem:nation. The examination prcigedurs have been re-
2wed and approved by your doctoi-. A description of thoso procedures is provided for)ur information.
are now testing a number of behies born in this hospital. If you are willing to havebaby examined in the hospital, please sign at the bottom. Your cooperation in this
.,tter will be gre.1.1., approciaty:::. ;_;re hopeful 'Lhit our research and the of:lars around the country will lead us to a better understandin,.: of how children grow andam. We shall then be able to hel,,-) cil children rech their full potential.. The willingnessparents to have their babies participate in a program such as this vili bring us neeirer
. that goal.
Tharz: you very much,
Frances Dr..,ccn -Torowitz, PhProfessor in Human Development ancl
-Psychology
): Stormont-Vail Hospital
lave read the above letter and the rlecription of the examination 7.,recedures contained on2 reverse side, and I consent :r.) the examination of my baby by'authorized persons from:a University of Kansas Infant :'.,J7eerch Program.
,mderstand that v.tile the hospial is cooperating with the Department of Human F.Vvnlopment,liversity of Kansas, by alleviing the use of hospital facilities, the examination is not done.,..hospital employees, nor is the i-:ospital responsible thev.efor.
'.c.rther understand that certzlin in fo.rmation concerning my Cnild will ::::e. obtairvy:i .from the,.spi'al .:.records, and I authoriz Sterr..,cni-Vall Hospital to rclease the requested information...)-.,. medical record and my *:>:aby':; medical record.
'!te2Ci
271126
Signature
APrENDIX
272
The 117!.mbers fre.n ono ::.%) tic.nty-seven in the fol1o7:in fiures
represent the Scale Items:
1 - Respon dec:!:::-!nt to lif-;ht2 - Respone rattle3 - Responoe decret to 110114 - Response docr,nt to pinprick5 - Orienttion visuz:16 - 0ricntz,.tic7-. at!ditory7 - Oriel,tation3 - Orientation ar,Th:te nudl.tory
9 - Orientation analLIte - visual and auditory10 - Alertness11 - General Tonus12 - Motor :qaturity13 - Pull to sit14 - Cuddliness15 - Defensive mov=ont16 - Consclabilitv17 - Peak of ey.citeal.7,nt
18 - Rapidity of builc: up19 - Irritiiitv20 - Activity21 - Tremulousness22 - Startle23 - Lability cf s:dn color24 - Lability of state25 - Self quietin activity26 - Hand-mouth facility27 - Smiling
273127
ES
19
1 2 3 3 ci 3 9
10 11 1 9 f. 5
1 fe 17 18 19 20 3I
9 7
23 25 2C)
APP
EN
DX
. E-
TA
BL
E1.
DA
Y 0
::F.
BR
AZ
EL
TO
N I
T M
S C
OR
PJ:L
AiE
D 1
.:1T
II D
AY
S 2,
3,
4,
5,
7,
10 A
iM 2
8
34
56
78
910
n12
13
7 45. 3
5*
32*
.
DAY ONE (continued)
ITEMS
14
15
16
.17
13
19
90
21
22
23
24
26
'77
9 3 1. , '5
.6 7 -
.8 '6
17
13
19
20
21
22
24
26
27
-.34*
.31*
53**
*
37*
.37*
DAY ONE
ANn STA'::PAPD
11:174
1
STAN1Vn
9.227.682 7.05 2 2.233 7.93 3 2.10
5.07 4 2.245 4.07 5 2.696 4.59 6 2.077 5.23 7 2.508 5.52 8 1.699 5.30 9 3.32
10 4. 7 IC 10 3.(i4
:11 4.59 11 1.2212 3.03 12 1.2813 4.18 13 1.811 4 5.20 14 1.4715 4.50 15 ').46
16 7.0" 16 9.5917 5.&O 17 1.3618 4.48 18 1.8119 3.50 19 1.7320 4.09 20 1.3491 3.39 91 2.3622 9.9": 22 1.6123 5.20 23 1.8424 4.32 24 2.2225 5.61 25 3.1926 4.43 26 9.6427 0.57 27 0.85
ITEMS
1 3 5 6 7 9
4110
,4
Ii
11
15
23
24
25
APPENDIX E
TABLE 2
DAY TWO
BRAZELTONS CORRELATED
WITH DAYS I, 3, 4,
5,
7, 10 AND 28
19
34
56
78
910
1 1
12
.40**
.73***
.43**
.38*
DAY TWO (continued)
ITEMS
14
15
16
17
18
19
20
71
22
23
1 2 3 4 5 6 7
1C
11
00
13 i. 15
16
17 18
19
20
21
22 3
25
96
27
.34*,
25
26
27
-.30*
.31*
-.36*
.42**
-.33*
.36*
.50***
-.42**
.54***
.34*
.41**
.40**
.33*
-.36*
-.55***
-.38*
.31*
.34*
.43**
3
DAY TWO
i',?7D STANDARD DEVTATI(VS
TTEM TTEN STANA
1 7.09 1 2.80
7.59 2.163 7.68 3 2.36
4 4.27 1.965 4.556 4.50 6 1.81
7 5.20 7 2.158 5.34 8 1.439 5.39 9 ?.76
10 4.23 10 2.1211 4.84 11 0.9112 3.68 12 1.1213. 4.02 13 1.6514 4.66 14 1.4015 5.05 15 2.3316 6,41 16 2.4317 5.95 17 1.70
18 5.30 18 1.5819 4.61 19 1.7120 4.27 20 .42
21 4.09 21 2.3122 3.32 22 1.5823 4.91 23 1.90
24 5.16 24 2.11
25 4.86 25 2.81
26 4.25 26 2.5727 0.50 27 0.84
279
133
DVV7ATTO::
APP
EN
D I
X E
TA
BL
E 3
DA
Y T
HR
EE
BR
AZ
E L
T O
N I
TE
MS
CO
RR
EL
AT
ED
ITH
DA
YS
1,
2, 4
, 5, 7
, 10
AN
D 2
8
ITE
MS
19
34
56
78
910
3 4 5 7 9
1 0
1 1
12 13 17 is '21
25 27
4 5
. 32*
1 1
7 9
L3
7 . 35*
.
_16*
47:.!
:.4
9**
31.*
DAY Min (dontinued)
2 3 4 5 6
10
11 12
13
1 4
15
16
17
13
19
20
21 2
23
24
25
26
27
14
15
16
17
18
19
20
21
99
93
24
95
26
.37*
.31*
33*
30*
42**
47**
.44**
.45.::*
.33*
.31*
-.70***
-.61***
it8***
.60***
.35*
.33*
.40*
.36*
..37*
-.37*
.48**
39**
.33*
.40**
31*
-.33*
5 5
.30*
-.30;:
.33*
97
1TM
12
3
4
5
6
7
8
9
10
11
12
1314
15
16
17lA19
20
21922324
25
26
27
DAY '1l1nEE
STA:MARD DEVIATIO17
743 1
7,617.30 3
4.62 4
5
6.45 6
5.34 7
5.39 8
5.64 9
4.57 104.2 Ll
377 19L 7"3 13
13
3,57 166.36 174.50 184.97 194.52 201.02 21
3.27 99
4.50 93
94
4.4 256.89 960.43 27
STADA",11
2.22
1.772.132.573.939.57
1.84
1.17
1.DE
2.731.56
1.771.682.181.531.)51.762.5?2.090.82
282
136
TABLE 4
DAY FOUR
BRAZELTON ITEMS CORRELATED WITH DAYS
1, 2, 3, 5, 7, 10 AND 2,$
ITENS
12
34
56
78
910
11
19
13
14
2 3 5 6 7 9
10
11
b0 12
CO 13
lA
13
16 17
IS
19
25
26
.31*
.47**
ITES
15
16
17
18
19
DAY FOUR (continued)
*90
21
9923
94
95
26
27
1 2 3.33*
.31*
4.33*
.39*
5-.37*
3 1
6-.14*
-.33*
.34*
3 9
10
-.49**
-.40**
.34*
11
.33*
.33*
o12
13
.1?*
66
15
CO
16
..3G*
14u
17
18
19
.68***
.37*
47*
70
-
-.41**
21
.34*
23
24
25
-.35*
-.4C**
96
27
-.36*
MEANS A7:7fl
I.ITEM
7.502 7.593 7.864 5.005 3.776 4.487 5.438 5.579 5.43
10 4.3911 4.9812 3.8913 4.4014 5.2715 6.1816 5.7517 6.0518 4.5719 4.2520 4.9821 3.5022 3.2223 4.9824 4.7725 5.3226 5.0D27 0.03
nAY rouR
ZDATID rINLAT:ONS
1 2.402 2.213 2.1/4 2.495 2.536 2.097 2.408 1.769 2.9.7
10 9.1.)
11 1.0512 1.7713 1.8614 1.2115 1.7816 2.4017 1.6318 1.9819 1.75)0 1.3721 2.15
1.6723 1.6194 2.0595 2.5826 2.6027 1.68
285
1 19
TT
E:1
31
1 2 3 5 6 7
19 20 21 ? 23 94 25 27
9
txTABLE 5
411
DA
Y F
IVE
DR
AZ
EL
TO
N I
TE
S C
OR
RE
LV
IDD
AY
S 1
,2
,3
,4
,7
,10
23
34
56
78
9
. 73
1 0
123
33c
TTENS
1 4 6 7 9
10
11 ")
13
14'
15
IND 16
00 17 18
19
20
21
2-7)
--
24
1-
26
27,
DAY FIVE (continued)
15
16
17
18
19
20
21 ;
22
23
24
It -.33*
11
-.35*
-.37*
13
26
27
-.38*
.33*
,31*
.31*
-.65***
.32*
.33*
.42**
.57***
.33*
,37-:'
.39,-:*
.39
56*.:.r..:
.32*
.30*
.34*
.32*
-.5'5***
.74***
.51***
.11*
.33*
34*
.37,
.33-::
.Tj.....*
.35*
.35*
33*
1
2
3
4
5
6
7
8
9
10
11
12
13
1415
16
17
18
19
20
21
22
23
24
25
26
27
DAY FIVE
A!,7) STL:DARD DEVIATIONS
8.00 1
7.95 2
8.02 3
5.93 4
4.81 5
6
5. 7
5. 3
9
104. 11
12
13, 14
15.75 16
6.03 174.2 133.80 194.84 20
212.58 224.50 231,.60 244.86 254.57 26
0.70 27
2.352.01
9.03
2.2A2.3';
1.S52.39
1.171.671.971.622.672.531.859.051.961.462.031.511.902.272.862.591.93
288
1 4 2
ITEMS
12
3
1 2 3 4 5 6 7 a 9
10
zs.
11
12
13
Cr.)
13
QD
16
17
13
19
20
91
23
9'4
25
26
27
-TABLE 6
DAY SEVEN
BRAZELTON ITEMS CORRELATED WITH DAYS
1, 2,
.6:3***
..75***
45
67
8
.38*
3, 4, 9
5, 10 AND 28
10
L1
12
13
J.',
. 67
.
..;
.37*
.33*
.45e
:
ITEMS
9 3 4 6 7 9
10
I 19 13
14
15
16 17
is
19
20
21
?2
23
24
25
26
27
15
16
17
18
19
DAY SEVEN (continued)
20
71
22
93
24
25
96
97Flz7 .31*
.39**
-.45**
35*
.35*
.49*
.42*
33*
.35*
34*
40**
.70***
.31*
.32*
.34*
.33*
371::
.64***
.41**
.42**
.37*
.43**
.41**
43**
43**
.33**.
-.32*
.33*
.30*
33*
.33*
.34*
-.43**
.40**
/
-.31*
.30*
.44**
.36*
.30*
.33*
.36*
.33* -
.35*
.44**
34*
.42**
.46**
.36*
-.37*
-.33*
35*
-.33*
-.35*
.3'3*
vEN
DEVIATIOS
1 7.=,0 1 9.537 7.5 2.373 7.61 3 2.544 4.90 2.465 5.02 5 2.206 5.01) 6 1.787 5. 7 2.078 5.82 8 1.339 3.95 9 2.21
10 5.3 10 2.9711 4.82 11 1.1312 4.12 19 1.3413 4.84 13 1.8914 4.90 1.7015 5.57 15 9.4216 5.73 10 2.5317 5.84 17 1.5718 3.77 18 1.9319 3.39 9 1.6020 4.70 20 1.4921 3.07 21 2.0829 9.64 29 1.2423 4.49 93 1.7424 4.32 94 2.0725 5.70 25 2.8926 3.86 26 2.3027 1.09 97 1.80
291
145
ITL
.::s
1
1 9 3 L. 7 0
1.0
3
.
411
BRAZELTON ITEMS CORRELATED WITH
DAYS 1,
2,
3, 4, 5,
7 AND 28
45
67
89
10
11
12
.46**
.43**
.37';
.37*
._;.
,
/TC
rD
GN
I
9-6
SZ
CZ
IZ
o81
LI
91
CI
S21.11
(ponulluoD) Nu :kw
TEN
1.:EANS AN!) DLVIMS
1
3
4
5
6
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
2697
0, 11 1
8.047.93 3
6.09 4
5.75 5
5.07 6
6.14 7
5.57 3
6.23 0
5.57 104.804.09 124.55 134.77 146.34 136.43 16
5.60 17
4.16 183.30 194.57 902.89 212.504.43 234.09 945.57 253.60 261.00 27
2.35
2.24
9.432.442.111.552.141.501.909.41
1.111.511.741.509.409.971.949.372.141.262.01
1.151.692.363.192.23
1.56
294
148
ITENS
1
1.
2 3 A 5 6 7 9
10
11
13
b0
11.'t
CID
13
cn
16
7.7
18
19
26
27
9
DAY TWE!.:TY EIGHT
BRAZELTON ITEUS CORRELATED WITH DAYS
1, 2, 3, 4,
5, 7 AND 10
34
56
.7
39
10
1117
1
9,.35*
.34*
.35*
.33*
rrE.Is
1I I
91 1
3 41
5I
6 9
10
r.-..
11
019 :-
..1
Q,
CrO
-4
1
,
13
1
--7
- ..
.. - .
.
DAY TWENTY EIGHT
(continued)
15
.16
17
18
19
70
21
22
93
.36*
.36*
40**
A2,..-*
.48***
.55***
.32*
.37*
.47**
.30*
.43**
. 40**
.35-:'
.51***
.41**
40**
40**
53***
.31*
.5*
.33*
.30*
.43**
.44**
5
:27
-.34*
.36*
.37*
.41**
.32*
.34*
.33*
1 nU. b;
3 9.00I. 5.615 6.346 5.617 7.278 6.259 7.90
10 6.4311 5.4019 5.7S13 5.5914 4.7315 6.5916 5.5317 5.9318 4.4319 3.0020 5.2521 2.5522 7.1893 4.3724 / rr
25 4.7726 2.5227 1.23
)7 11 T0;1'1:
])17,1,PLVI'fONS
1 1.7r,23 1. Sq4 2.965 2.286 1.947 1.82
2.159 1.93
10 2.13ii 1-3012 1,7513 9.3714 1.9515 9.2416 3.301718 9.4919 2.0620 1.5391 1.8692 1.0523 1.5694 2.6795 3.4596 2.5527 1..40
297
151
Grout) 0 _
APPENDIX E
TABLE 9
SCALE RELIABILITY BY SUBJECT AND BY USING
AFOF.21ULA TUO SCORES ADJACE::T
1-2
2-3
3-4
4-5
5-7
7-10
10-28
1-3
1-4
46.-28
7 -?8
1 n:.! iv Lt1::-..-21
80
63
70
33
63
77
61
75
40
56
57
57
61
83
63
69
64
76
61
77
73
81
68
'35
77
70
85
74
67
87
83
33
f;..)
23
93
73
79
CO
60
-rd
"29
f:i.
f.--)
50
79
89
73
71
.,
78
;.-
...,
.71
70
75
'' 1-1.
i6
59
72
77,
66
_;..)
, 12,1
(-
Group I
63
67
73
.63
70
74
75 03
74
73
74
'74
59
70
71
83
78
63
85
67
54
79
33
70
59
35
64
63
74
67
75
74
96
74
63
78
74
63
52
65
50
59
67
85
46
65
83
33
83
63
58
77
73
379
68
72
92
83
71
88
64
64
81
85
73
59
74
85
83
74
63
54
58
92
71
78
91
92
41
59
71
59
44
44
63
67
-p
Of.
.
68
-/ /4
78
74
63
79
63
74
71
56
67
71
-67
63
67
58
67
.-....%
65
-70
78
63
96
57
61
77
7'
89
59
:9
72
73
83
91
99
71
73
92
70
67
7:3
68
67
96
65
20
63
-.'.7
65
72
78
77
-0
i .
74
42
ric,
63
62
38
70
78
977
56
33
74
35
01
o -
36
63
Q ....O
%,
63
43
77
71
33
58
63
59
:16
32
63
51
;,-
96
S7
87
!:.(-,
75
9?
73
:-.!3
77
67
71
75
77
79
92
77
Vi
62
:=M
33
73
5)7
96
69
36
52
'.)=:
92
f-,':7
=2
73
61
59
71
71
61
70
C7
77
7J
78
74
62
cr -
Ju
74
74
30
65
73
65
74
77
31
7Zz.
68
'--1
63
83
71
71
50
63
53
..3
100
74
96
52
87
:0
67
65
77
50
75
Neaps
72
72
73
73
72
73
73
69
72
71
7C/
Gro
un I
I1-
22-
33-
44-
55-
7
Till
iLE
9
7-10
(con
tinue
d)
10-2
31-
31-
44-
74-
?$7-
28Ir
nliv
idu-
-.1
67 81 73 9L
63
81
61 69 77 86
81 59
91 54 61 88
74
70
81 96 69.
79
74
75
92 85 70
SI
75
79 71 65
67
58
63 71 54 74
67
82
70 75 70 I,/
04
48 39
71 79 73
74
73
70
78 88 67
74
67
_-6
67 79
61
-,,=)
Y.
67 33
52
71
64
JI
73 14
70
-,
r,,9
Moan
:LT"
Mea
n
Crc
up I
V
76 75 78 70 69
72
73
79
80
68
69
68
73
75
`.35 53 ? L
67
60 60 ri:i
91
71 74 79 81
71 59 S t
81 7 I
:-. 3 79
:,,r,
76 64 6 L
73 :: 7
43 77
67 76 67
,
69
.-..,
,
if
7372
7673
7379
/ --,
-71
7277
88 99 78 75.
76 69 54 99 6(!
33 83 71 67 48 53 63 81 u-4
0,
81 100 63 81 78 74 69 8-',
83
81 77 33 82 69 59 6510
0 70
54 93 77 57 91 54 78 87 ,/_ _
79 81 63 79 83 83 71 74 . 61
61 64 58 79 58 63 75 36 61.
63 48 65 79 56 63 55 58 59
63 54 3f3
70 56 70 75 34 70
99 31 - /4 65 33 85 53 73 -9
-_,T
i
64 63 57 5!,
73 :1,i
75 e- ..,/ 71 81 69 65 41 74
67 73 73 6;3.
6":.: .; - q
Nea
n77
463n
-71
7275
67
,--,,!:.
-.,.'
_L._
_ _
!.!./
1-:i
70
300
LI
7,,F-1:__Ii
1 C :-
1
11---
i-t
t1I
i/ z
s il T 1.:!s.,
1.!..
11
1----
i
Ci'
--r-
1
rI
,t,,.
C ''
..:(.;;-,
-:;
,....2.
::,:,:".;
-*,t ,."1
a c) i cv.1zi
......,;.:,.., i ''.1
i
[II.;
-
IG
C
.
CC
-..
- L1(.--.cr
-... ..
.,., ./1-)
1 4.1-.-....,:,,;.I
4.
0::.1 I.
7,. ::..v.- ,-. .
tI
2261
2 I.":.1]L
esI
91i -f3c '
S1cr.1) [ 0,
-,.:',-,-.::., '
i
r-; IL
I
I' c,[
1
I--tic
s;./I. T
:it: oz:111- r):,: a..--.:
lir.
t91
1,..;.:..1.)43 ti
c_, 1A
or.tI. . i)
[...;.,)I
e'it
7.II
i1'
L 1 ..
.-1:II::
rii.r1
, ,;----,
."--::. --!----
i::'
-1
(,.1
1/Q
.1
I...
:F.....,...1 i) 2,
...4:
--oj
11...).!,).)
-.5
f.
,'
:!ii
....
-_l_I
1------j'
J
-i
I
1
-
1_.1
Li
; q6R.
11
(1L
_ ___
p',-.. ,..- -..,;.:1 .,.
- i-;:-)-.;
'.;
: (..)
:', i-.;;;
ir .- il___ _..... ____.
........- );-,..4.
1....- :iv . !3;-.)
IF:9
C)
*pili." i:;',..iI-.);!.)1::(_)
tI
1It
()L '
.-c,
:-..1 A.
.0........1. 71 1: ,ri 3 0
Ii !.. r
...
1
i
r,I1
co. _f.
Tloct -)I
LS'
/I
./. f?
-
1
(.101 11ti..2
'17.q;:ii1...;11
11.`11 a, v:11
%
S110.1.W.-1
3NO
AV
G
Ia mian-aaav
STE!:S
ITEMS
II
APPENDIX F
TABLE 2
DAY TWO 7
FACTORS
H:thit. light
I-.
.-. -
....
-.53
L
I..a
..a.
V /I
IIA
IAn
iL
1c2
:!:hi.t. raLtle
9-.89
!i
.
____I
:f"..
Hnbit. boll
3-.90
iL
F1nrIck
4-.83
i-
__t__.....:__
..
1 1.90
-1.s2
0..-!...,'nt,_
!..r_ln_._...,,i_s.
Or!.,..r.t.
1n:n!.
.ard.
v1!:.
d.
5 6 7 8
_2,83
f-.83
-.50
T
-.,A
-
1
'
-
. 1
_1 -
_
1 i 1
-1
Orici:t. an. vis.
::::1
anti.
_____
9-.93
.A1.- r t2t1,s.s
10
-.75
C.
..1*/
7.n.
11
-.8n
I1 .
:-.-:It_or :-int.
12
.57
T1,!:LI sit
13
.76
i
('-' ';
....._.,,:,...
14
-.)
1!
7 7
.,
-.40 1
.':,7:i
15I
Con:ol
16
.40
I___
__!
I. 7
471:::11.. oNcint
i 7 ..,
- .7
1,
1. %
..;_
.hldun
18
-.76
i
--
__
-1--
-_-_1_:
-
i
Ir:i.t.
'
19
-.70
1
Activ.
20
-.75
ir
4 ,..
1
.53
1.78
1,:'
:i .
.:.,,
21
-.57
r1
1
:1.
' r :-
..1.
.1._
1. :;)._:-i..:1;1 colIr
.._
:.e.
q 9
r_ z
..._"
1 ;2:3
2!/.
-.90
i1
1 I----
1
..);
-.53
26
-.79
I.79
1.,-,-.
27
-.58
/
!1.7)
STE
MS
rrnq
TT
ri
APP
EN
DIX
'. F
TA
BL
E 3
DA
I T
IME
..
FAC
TO
RS
9
i..!h
i.t.
lip-.
,ht
1__
_..
.-v
sr L
i.V
..t.
L 1
il
I11
.t. r
an le
9
nr__
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DIX
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APPENDIX F
TABLE 8
-
DAY TWENTY EIGHT
STEMS
ITEMS
FACTORS
IV
VV
IV
'ET
sl9
Habit. lic_tht
1-.SO
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3....94
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4.70
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10
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11
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12
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1
AITENDIX G
309
kirrANiilA
TABLE 1.
DRUG CODE
1. Local and Regional Anesthetics (Classified according to route ofadministration):
1.0 unknoum or others (i.e., not listed)1.1 perineal (local)1.2 pudendal or paracervicai block
rec-ional1.3 spinal, saddle block, caudal, epidurafT
2. Tranquilizers
2.0 unknown and not listed2.1 Chlorpromazine (Thorazine), Base dose: 50 mg2.2 Diazepam (Valium), Base dose: 3 mg2.3 Chlordiazepoxide (Librium), Base dose: 10 mg9.4 Hydroxizine (Atarax), Base dose: 95 mg2,5 .Promethazine (Phenergan), Base dose: 25 mg
3. Narcotic Analgesics
3.0 not.listed or unknown3.1 Meperidine (Demerol), Base dose: 50 mg3.2 Alphaprodine (Nisentil), Base dose: 30 mg3.3 Pentanyl citrat2, Base dose: 0.1 mg (given only in combina-
tion with Drcperi.:Ial (Innovar), Base dose: 5 mg3.4 Morphine, Base dose: 10 mg
4. Barbiturates
4.0 other or unknown4.1 Thiopental (Na Penthotal), I.V. (dose not usually recorded)4.2 Secobarbital (Seconal)i P.O., Base does: gr. 1/2 (or rectal)
5. Inhalation General Anesthetics
5.0 other and unknown5.1 Nitrous oxide5.2 Cyclopropane.5.3 Methoxyflurane (penthrane)5.4 Fluothane
6. Scopolamine (hyoscine), Base dose: 1/2 amp.
7. Muscle Relaxant Succinil choline(Anectine)
310
162
;i1!)10. 4
Intercorre1ation Detween Drug Grouped According to Typo
(Usi';g Pearson r.)
-;"),
Ii 5 7 6 7
1
2 .23
< 3
4
-.18
-.20 -.10
-5 -.56- -.22 1 .37' 27
6 .3f'
7 -.04 ., 1i .17
.18
4
All -.29 ! ./: .P0-- .60' .47'''!
= all local ancstheia
= all tranquili.4ers
S.3 = all narcotics
= all barbiturates
= all general ancst:IL:ti:::;
. .6 = Scopolamine'
7 = muscle relaxant
311
163
1A1
ArPEND IX H.
312
9-
7-
6-
5.1
3-
2-
Day
t u Dect C.'nc:1: to
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1
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Drug Grou',.Y.;
cf,o
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313
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7
6
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Drug Groups
0 c .3 El -o
it.........
r
Day : 1 2 3 4 5 7 10
165 3 4
9
a /
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Drug Groups
-r c
Day: 1 2 3 4 10 Vt'
166 315
4..
,
2-
1
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/ N.
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. ./,.....-- 0 ..,....,... .... . I/ r, . \ a' ,. ............"-- . 0 ".,........0_,_________. -.
. ..... ... \ %. / ...... . 7. I
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4 4
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Drug Groups
0-:17
Day: 1 2 5 7 10
167
316
3
7
0
0.
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/
Drug Groups
0 a.- 17I 0J 7.7_
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,
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r ; i
Day: 1 2 3 4 5 7 10 4.;./k...;
317lr,....;
7-
6-1
3
2
:
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.... ...', ;.... ..". ..
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1 .S. a .6 ! )ci. ,, .// ., -": ....\ 0; s'
Drug Groups
o o o--
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1 r-2 3 4 7 10
169
318
7.
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Drug Groupe.;
a ---0T
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Day: 1 2 4
1703 1 9
5''!
7 10
9.7
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9
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0 -..-o El t3.11
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Day:. 1 2 4 t;
3 2 1
172
7 10
6-
4 -
3
2-
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Drug Groups
o. o n--:LT
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0 Tr T i
Day: 1 2 3 4
322.173
5 7 10 4 v,1Ic z;
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s
3-
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1 0 fe 3
APPENDIX I
340
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