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NORMAL DEVELOPMENT OF THE NERVOUS SYSTEM
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Table 28-4 Neurologic functions and disturbances in infancy
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AGE NORMAL FUNCTIONS PATHOLOGIC SIGNS
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Blinking, tonic deviation of eyes on turning head, sucking, rooting, swallowing, yawning, grasping, brief extension of neck in prone position, incurvation response, Moro response, exion postures of limbs Biceps re exes present and others variable; infantile type of exor plantar re ex; stable temperature, respirations, and blood pressure; periods of sleep and arousal: vigorous cry Supports head Smiles Makes vowel sounds Adopts tonic asymmetrical neck postures (tonic neck re exes) Large range of movements of limbs, tendon re exes usually present Fixates on and follows a dangling toy Suckles vigorously Period of sleep sharply differentiated from awake periods Support and stepping unelicitable Vertical suspension legs ex, head up Optokinetic nystagmus elicitable Good head support, minimal head lag Coos and chuckles Inspects hands Tone of limbs moderate or diminished Turns to sounds Rolls over from prone to supine Grasping, sucking, and tonic neck re exes subservient to volition Babbles Reaches and grasps Vocalizes in social play Discriminates between family and strangers Moro and grasp re exes disappear Tries to recover lost object Begins to sit; no head lag on pull to sit Positive support reaction Tonic neck re exes gone Landau response (holds head above horizontal, arches back when held horizontally) Begins to grasp objects with one hand; holds bottle Creeps and pulls to stand; stands holding on Sits securely Babbles Mama, Dada, or equivalent Sociable; plays pat-a-cake, seeks attention Drinks from cup Landau response present Parachute response present Grasps with thumb to fore nger Stands alone May walk, or walks if led Tries to feed self May say several single words, echoes sounds Plantar re exes de nitely exor Throws objects
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2 3 months
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Lack of arousal (stupor or coma) High-pitched or weak cry Abnormal (incomplete or absent) Moro response Opisthotonus Flaccidity or hypertonia Convulsions Tremulous limbs Failure of tonic deviation of eyes on passive movement of head or of head and body Absence of any or all of the normal functions Convulsions Hypotonia or hypertonia of neck and limbs Vertical suspension legs extend and adduct
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Lack of head support Motor de cits Hypertonia Lack of social reactions Tonic neck re exes present Strong Moro response Absence of symmetrical attitude Altered tone Obligatory postures Cannot sit or roll over Hypo- or hypertonia Persistent Moro and grasp Persistent tonic neck re exes No Landau response
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9 months
Fails to attain these motor, verbal, and social milestones Persistent automatisms and tonic neck re exes or hypo- or hypertonia
12 months
Failure to attain 12-month milestones Persistence of automatisms
500 PART 3
GROWTH AND DEVELOPMENT OF THE NERVOUS SYSTEM AND THE NEUROLOGY OF AGING
Table 28-4 (Continued) Neurologic functions and disturbances in infancy
AGE NORMAL FUNCTIONS PATHOLOGIC SIGNS
15 months
18 months
24 months
Walks independently (9 16 months), falls easily Moves arms steadily Says several words; scribbles with crayon Requests by pointing Interest in sounds, music, pictures, and animal toys Says at least 6 words Feeds self; uses spoon well May obey commands Runs stif y; seats self in chair Hand dominance Throws ball Plays several nursery games Uses simple tools in imitation Removes shoes and stockings Points to two or three parts of body, common objects, and pictures in book Says 2- or 3-word sentences Scribbles Runs well; climbs stairs one at a time Bends over and picks up objects Kicks ball; turns knob Organized play Builds tower of 6 blocks Sometimes toilet-trained
Retardation in reaching milestones expected at this age Persistent abnormalities of tone and posture Sensory discriminations defective Cannot walk No words
Retarded in all motor, linguistic, and social adaptive skills
SOURCE:
Modi ed by permission from Gesell et al
underachievement, ineptitude, and intrinsic awkwardness; a member of this group will easily stand out and be designated as an awkward child Such awkwardness is to be clearly distinguished from the motor impairment associated with a number of cerebral diseases
Sensory Development
Under normal circumstances, sensory development keeps pace with motor development, and at every age sensorimotor interactions are apparent However, under conditions of disease, this generalization may not hold; ie, motor development may remain relatively normal in the face of a sensory defect, or vice versa The sense organs are fully formed at birth The neonate is crudely aware of visual, auditory, tactile, and olfactory stimuli, which elicit only low-level re ex responses Moreover, any stimulus-related response is only to the immediate situation; there is no evidence that previous experience with the stimulus has in uenced the response; ie, that the newborn can learn and remember The capacity to attend to a stimulus, to xate on it for any period of time, also comes later Indeed, the length of xation time is a quanti able index of perceptual development in infancy Information is available about the time at which the infant makes the rst interpretable responses to each of the different modes of stimulation The most nearly perfect senses in the newborn are those of touch and pain A series of pinpricks causes distress, whereas an abrasion of the skin seems not to do so The sense of touch clearly plays a role in feeding behavior Newborn infants react vigorously to irritating odors such as ammonia and acetic
acid, but discrimination between olfactory stimuli is not evident until much later Sugar solutions initiate and maintain sucking from birth on, whereas quinine (bitter) solutions seldom do, and the latter stimulus elicits avoidance behavior Hearing in the newborn is manifest within the rst few postnatal days Sharp, quick sounds elicit responsive blinking and sometimes startle In some infants, the human voice appears to cause similar reactions by the second week Strong light and objects held before the face evoke reactions in the neonate; later, visual searching is an integrating factor in most projected motor activities Sensation in the newborn infant must be judged largely by motor reactions, so that sensory and motor developments seem to run in parallel; but there are discernible maturational stages that constitute sensory milestones, so to speak This is most apparent in the visual system, which is more easily studied than the other senses Sustained ocular xation on an object is observable at term and even in preterm infants; at these ages it is essentially a re exive phototropic reaction However, it has been observed that the neonate will consistently gaze at some stimuli more often than others, suggesting that there must already be some elements of perception and differentiation (Fantz) This type of selective attention to stimuli is spoken of as differential xation So-called voluntary xation (ie, following a moving object) is a later development Horizontal following occurs at about 50 days; vertical following, at 55 days; and following an object that is moving in a circle, at 25 months Preference for a colored stimulus over a gray one was recorded by Staples by the end of the third month By 6 months the infant discriminates between colors, and saturated colors can be matched at 30 months Perception of form, judged by the length of time
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