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by Docteur Alain Caron, Pediatrician, Brussels, Belgium
Mrs. D. called me for an appointment, and introduced herself by reminding me that her first child, Charline, had been born prematurely, two and half years years earlier. Charline had been examined on the NBAS in the NICU follow-up clinic, and her mother had learned a great deal about her daughter as a result. This mother was now requesting that her second daughter, Lou, be examined on the NBAS. Mrs. D. revealed to me that at 31 weeks gestational age she had been infected with the cytomegalic virus (an infection of the bowel). Her gynecologist had informed her that the infection could potentially increase the infant’s risk for future sensory problems, mood disorders, psychomotor instability and cognitive difficulties, such as, dyslexia, dysorthography and dyscalculia. At Mrs. D’s request, the NBAS was scheduled in my office when was Lou was two weeks old.
The fetal echocardiogram performed at 35 weeks and 1 day gestational age revealed normal fetal growth, no morphological abnormality, and no evidence of a cytomegalovirus infection. An echocardiogram made 15 days later, at 37 weeks and 1 day gestational age, revealed estimated fetal growth ranging between the 70th and 90th percentile and still no sign of fetal infection . At the time of the Brazelton evaluation, we had the results of some of the specialized tests that Lou had undergone. Everything seemed normal, but her mother was still concerned.
Lou was born at 39 weeks gestational age by Cesarean section and an epidural anesthesia. Her birthweight was 3,340 gms., her height 51.5 cm, her head circumference was 35 cm, while her ponderal index was of 2.45. The Apgar score at the birth was 10 after one, five and ten minutes of life, and the macroscopic aspect of the placenta was also normal.
Lou was 42 weeks gestational age, when Mrs. D. came to my office for her appointment at 10:30 a.m. She had breastfed Lou at 09:15 a.m. and Lou was asleep in her seat, covered with an eiderdown, when they arrived. Before the NBAS session, I disconnected the telephones. The room was in semi-darkness and the room temperature was at 23°C, which was ideal for the evaluation. At 10:41 a.m., we began the Brazelton evaluation. Lou’s mother was on my left, about one meter away, and she was looking at her baby all the time. Lou was in a sleep state. We observed eye movements under the closed eyelids and from time to time Lou opened her eyes. At the end of the required two minutes observation, I evaluated the initial state as a light sleep state.
Because Lou was asleep, I started with the habituation items. For the habituation to the light, at the second presentation, there was a decrease in Lou’s body movements and a reduction in the blinking of the eyelids and in her respiration. After the third presentation, there was no response. The score was 9. The habituation to the noise, the rattle, was also excellent. After the second presentation, there were no body movements, and eye-blinks and respirations also decreased. The score again was 9, the highest possible score. In response to the sound of the small bell, Lou opened her eyes from time to time and was given a score of 5. Nevertheless, she managed to stay asleep and it was only when I uncovered her that she began to wake up and move into a drowsy state, state 3, with heavy – lidded eyes. The level of her activity increased, and I proceeded to the administration of the motor-oral package items.
The foot reflexes, the Plantar grasp and the Babinski, were normal, and no beats were observed in the ankle-clonus. The passive movements of the lower and upper extremities were symmetrical and showed moderate resistance to the extension and good recoil, thus receiving a score of 2 (normal). I then gently carried Lou towards the changing table for the rest of the examination. When I began to undress her, her state changed. She moved into an alert state 4, with a bright-eyed look. She seemed to have a well-focused alertness. I chose to continue with the evaluation of the motor-oral items and those of the truncal package. The Palmar grasp was firm and symmetrical. With the Pull-to-Sit maneuver, Lou brought her head up and she was able to hold it in an upright position. She was able to maintain it at midline for two seconds, before she lost control. She received a score of 5. Throughout this time, Mrs. D., was less than one meter away and could see her baby clearly. She was very impressed with Lou’s response to the placing, standing and automatic walking reflexes, all of which were in the normal range. The Gallant and the Crawling reflexes were also excellent.
I was struck by the stability of Lou’s alert state, which was well-focused and robust. . For short periods she was in state 5, accompanied by brief fussing, but otherwise Lou was able to maintain her alert state without any intervention from me, the examiner. The only apparent evidence of stress during this 32 minute-long examination was color change across the whole body, which took place during administration of the most stimulating items of the vestibular package. I had to cover the baby up before continuing. The score for the Lability of Skin Color was a 7; however, Lou displayed no tremors or startles. When I evaluated Cuddliness, Lou molded and relaxed in the two positions, horizontally in my arms and vertically on my right shoulder. I then elicited the Rooting response, the Sucking reflex and the Glabella response, all of which were normal.
For the Social Interactive items, I dressed Lou and supported her in my arms, with Mrs. D. beside me, observing. Lou’s response to the red ball and the combined visual and auditoty stimuli, the red rattle, was stunning. The movements of the eyes and of the head were coordinated and smooth, and she tracked with a 180° arc, combined with vertical following, as in a rainbow. Lou’s responses to my face and to my voice, separately and combined, were in the superior range, and she also responded to her mother’s voice. In sum, her alert state was prolonged and she sought out and found the stimulus each time. Lou’s mother was very impressed by her child’s responses.
This baby was still so stable that I could then administer the most stimulating items, the vestibular package. She directly swiped at the cloth for the Defensive Movement, while the asymmetrical tonic neck reflex (ATNR) and Moro reflex were also normal. In terms of her motor maturity, the movements were fluid and harmonious throughout the examination.
Lou had well organized sleep patterns and was in an alert state for most of the examination. She did not reach a crying state at all during the observation.
As I was about to give Lou back to her mother, she began to fuss and became agitated, and began to cry a little. Mrs. D. saw that she was hungry and began to feed her baby. It was then, at this moment, that she returned to her concern about the cytomegalovirus infection and its possible effects on Lou, as well as the memory of her daughter Charlene’s operation for the removal of a cyst, when she was two months old. I asked her to try to focus on what we had just observed during Lou’s NBAS examination. I suggested that she put aside her concerns about the risk of the cytomegalovirus infection and focus instead on the extraordinary robustness of her baby, in particular, the amazing quality of Lou’s orientation and the precision of her movements. I narrated the sequence of the NBAS observation and told her how confident I was about Lou’s development .
I ended my interview with Mrs. D., by reiterating the extraordinary stability of her baby during this evaluation. She asked me to write up this evaluation for herself and for Lou’s father. As we were about to end the session, Mrs. D. turned to Lou and said, “Bravo to Lou who fought well against the cytomegalovirus.” Lou is now fourteen-months old and is developing well.
Aujard Y. (2001). Infections néonatales (II) Encycl Méd Chir (Editions Scientifiques et Médicales Elsevier SAS, Paris, tous droits réservés), Pédiatrie, 4-002-R-92, 10.
Jacquemard F. (2004). Institut de puériculture de Paris, service du Docteur Daffos, 26, boulevard Brune, 75014 Paris, France. Syndrome Infectieux Fœtal. Encycl Méd Chir (Editions Scientifiques et Médicales Elsevier SAS, Paris, tous droits réservés), Pédiatrie, 4-002-X-30, 18.
Brazelton, T. B., and Nugent, J. K (1995). Neonatal Behavioral Assessment Scale 3rd Edition. Cambridge: Mac Keith Press.
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