Clinical Assessment of Newborns

If we accept the notion of the newborn as an active participant in early interaction, the careful assessment of an individual infant should help us to understand the infant's side of the dialogue. Also, any professional who wants to support early attachment will find it useful to illuminate the nature and capacities of the baby for the parents.

A newborn's behavior will have already been shaped for nine months in the uterus. We need to be aware of the powerful influences on fetal development of acute infections, toxins, and maternal bleeding, as well as more prolonged intrauterine influences such as nutrition, hormones, medication, drugs, alcohol, caffeine, smoking, and even of maternal activity and attitudes. Although many of these factors can affect the developing brain, the nervous system of the fetus is mar-velously plastic and may have recovered from an insult and appear to function normally. Nevertheless, with careful observation, subtle "soft" signs, such as hypersensitive behavioral responses or problems in state organization, may show up which call for special vigilance and care.

Sometimes the most valuable use of assessment is in reassuring parents that events beyond their control have not impaired the baby's future. Fortunately, it is rare that one event or one factor will affect the baby's development. Ordinarily, the synergistic interaction of several factors is necessary to create real problems in development of the fetal nervous system. However, parents must be informed of any important variations in the baby's behavior that might call for special attention and consultation. Gestational age is important in understanding the baby's behavior (Dubowicz et al., 1970)¹. Immaturity of even two weeks can result in behavioral differences that can in turn influence the parents' reaction to their baby if they don't understand the reason for them. Acute depletion of fat, sugar, and liquid stores resulting from an inadequate placenta will produce a long, lean, peeling, jittery baby who looks worried and anxious. The infant may well be hypersensitive to all usual stimuli and may overreact by withdrawing from his or her parents' ministrations-by sleeping, crying, or frowning. Parents can be alerted to the reasons for their baby's hypersensitivity and hyper-reactivity, so that they will not take it personally. They will be able to nurture the baby with more gentle handling, knowing that time will help restore the balance.

Apgar scores reflect a newborn's immediate responses to labor, delivery, and to the new environment, but they cannot be used alone as an index of stress at birth. The likelihood of future neurological problems is increased if these scores are low at 1, 5, and 15 minutes, and are also an index of a difficult delivery. However, we now know that a baby who is in good condition as a fetus before a difficult delivery can withstand an amazing amount of stress and even a lack of oxygen without resultant brain damage. The condition of the brain with which a fetus faces a difficult delivery may be more critical than the stressful events themselves.

As long as the newborn was thought to function at a brain stem level, essentially not using the brain's cortex or higher centers, assessment of newborn infants did little to predict later outcome. Once it was understood that the newborn arrives with a complex, highly developed nervous system, more sophisticated ways of assessing infants have been developed. A neurological assessment that taps mid-brain behavior does not give enough indication of the potential for recovery. Behavioral assessments seem to offer more useful information and a more reliable way of predicting later development.

Neonatal Behavioral Assessment Scale
The Neonatal Behavioral Assessment Scale (NBAS) was designed to capture newborns' behavioral responses to their new environment (Brazelton, 1984)². In order to record and evaluate some of the capacities of newborns when handled by a skilled observer or parent, we developed a behavioral examination that tests an infant's responses to environmental events in the context of states of consciousness. It is a means of scoring interactive behavior. The infant is not assessed alone, but as an active participant in a dynamic situation. While a few basic neurological observations are included, the NBAS is not a formal neurological assessment.

The NBAS emphasizes and tracks changes in states of consciousness over the course of the examination-their lability and direction. The infant's use of state, in order to control and interact with the environment, points to a capacity for self-organization. The assessment measures newborns' ability to quiet themselves as well as the way they handle stimulation.

The stimuli used in the NBAS include the kinds of stimuli-touch, rocking, voice, facial behavior-that parents use in their handling of infants as they attempt to help them adapt to a new environment. There is a graded series of procedures-talking, placing a firm hand on the newborn's belly, holding and rocking-all designed to soothe or alert the infant. The newborn's responsiveness to human stimuli- for example, the voice and the face-and to inanimate stimuli-for example, a soft rattle, a bell, a bright red ball, a bright light, handling, and temperature changes-are assessed. Estimates of vigor and excitement are measured as well as the kind of motor activity, the muscle tone, and color changes as the infant changes from one state to another.

There are twenty-eight behavioral items. These assess the newborn's capacity (i) to organize states of consciousness, (2) to habituate to disturbing events, (3) to attend to and process simple and, in some cases, complex environmental events, (4) to control motor tone and activity while attending to these events, and (5) to perform integrated motor acts, such as putting a hand in the mouth, maintaining the head upright while sitting, or knocking off a cloth which covers the face. All of these reflect the range of the behavioral capacities of the normal newborn. They seem to demand control over cardiac and respiratory systems and to be dependent on either the cortex or higher brain centers. For newborns to achieve this control, they must have successfully managed the physiological demands of the early adjustment period after delivery. The newborn's ability to attend to, to differentiate, and to habituate to the complex stimuli of an examiner's maneuvers may be an important predictor of future central nervous system organization, as well as of individual temperament.

The behavioral items are:

Response decrement to light (a flashlight shone briefly into infant's eyes)
Response decrement to rattle (shaken 10-12 inches from infant)
Response decrement to bell (rung 12-15 inches from infant)
Response decrement to a light pinprick on heel
Orienting response to inanimate visual stimulus (a red ball)
Orienting response to inanimate auditory stimulus (a soft rattle)
Orienting response to animate visual stimulus (examiner's face)
Orienting response to animate auditory stimulus (examiner's voice)
Orienting response to inanimate visual and auditory stimuli (red rattle)
Orienting responses to animate visual and auditory stimuli (examiner's face and voice)
Quality and duration of alert periods
General muscle tone, in resting and in response to being handled (passive and active)
Motor maturity (how smooth and vigorous the newborn's motions are)
Responses of arms, shoulders, and head as newborn is pulled to sit
Cuddliness (responses to being cuddled by the examiner)
Defensive movements (reaction to a cloth over face)
Consolability (number of maneuvers examiner must make to quiet the upset newborn)
Peak of excitement and capacity for self-control (during whole exam)
Rapidity of buildup to crying state
Irritability during the examination
Kind and degree of activity (during whole exam)
Tremulousness (during whole exam)
Amount of startling (during whole exam)
Changes in skin color
Number of changes of states during entire examination
Self-quieting activity (observable efforts and successes)
Hand-to-mouth activity
Smiles (both grimaces and replicas of social smiles, occurring at apparently appropriate moments)

The NBAS has been used extensively since 1973 in the United States and abroad. It was designed to help newborns produce their best available responsiveness to stimulation and to measure newborns' capacity to handle the stress of labor, delivery, and a new, demanding environment. Since any single assessment should be seen in the context of a curve of recovery from stress, it is not sufficient to predict future adaptation. Several exams, plotted against the known stressors which a newborn encounters (such as length of medication and anesthesia given to the mother, stresses of low oxygen, duration of labor, difficulty of labor and resuscitation), are better evidence of the baby's ability to handle future stress. Together with colleagues (Lester et al., 1985)³, we have used recovery curves of behavior over the first few weeks to predict development at eighteen months. Certain behavior, such as motor activity reflexes, is stable and less available to shaping from the environment. The way a newborn handles states of consciousness and social stimulation is more responsive to environmental input and changes most significantly over the first few days and weeks. These responses predict cognitive and affective development at eighteen months with significant reliability. The NBAS has been used in many different situations and cultures to measure influences that might affect a baby's future. For instance, it has been used in Guatemala to investigate the effect of maternal malnutrition. In the U.S., it has been used to measure the effects of medication given during labor, and the effects of alcohol and narcotics addiction during pregnancy. The impact on newborns of phototherapy given for elevated bilirubin levels has also been studied by means of the NBAS (Brazelton, 1984)².

Two uses of the assessment -- to help parents understand their particular baby, and to identify newborns whose behavior may make them difficult to handle -- are most pertinent. For example, a quiet newborn who takes a long time to respond will not be easy for parents to read. If such babies do not become clearly alert, the parent will inevitably worry about brain damage. If they do not cry in protest, parents may not feed or tend them appropriately. Delayed changes from state to state make for a sluggish baby, and adults are likely to turn away from such a baby in subtle as well as in important ways. Hypersensitive, disorganized babies can be almost impossible to understand. Not only do they overreact to stimuli, but they may react negatively with relentless crying or habituation in the attempt to control input from the environment. State changes will be abrupt, and such babies may "shoot" from one state to another -- sleep to crying and down again -- without any time for parents to reach them for consoling or for response (Brazelton et al., 1971)⁴. A parent will feel shut out and ineffective with either of these extreme kinds of babies. Their future interaction may well be endangered unless parents are helped to understand them. The NBAS was designed to help professionals judge the baby's style of response and thereby support parents in their effort to reach out. Its best use may be not as a test, but as a way of demonstrating the newborn's behavior to parents so that they can understand the baby and their own job better from the beginning.

¹Dubowicz, L. M. S., V. Dubowicz, and C. Goldberg. "Clinical assessment of gestational age in the newborn infant." J. of Pediatrics 77(1970):1-10.

²Brazelton, T. B. Neonatal Behavioral Assessment Scale, 2nd edition. Philadelphia: Lippincott; London: Blackwell, 1984.

³Lester, B. M., J. Hoffman, and T. B. Brazelton. "The rhythmic structure of mother-infant interaction in term and preterm infants." Child Development 56(1984):15- 27.

⁴Brazelton, T. B., G. G. Young, and M. Bullowa. "Inception and resolution of early developmental pathology." J. of the Amer. Academy of Child Psychiatry 10(1971):124.