Behavior of the Premature Infant 1983 (Excerpt)

[music] [music] [music] >> He who sees things from their beginnings will have the finest view of them. >> [music] >> In the human species, there are 40 weeks from conception until term birth. From the first spontaneous movements, the [music] fetus arouses our curiosity about intrauterine behavior. >> [music] >> Though largely uncontrollable, this period of development reveals a fetus capable of sucking, swallowing, and even responding to sound. When an infant is born before term, we have a unique opportunity to understand similar behavior and development more closely [music] during the period of normal development. >> [music] >> This film describes the development of the sensory, motor, and social behaviors of the premature infant. >> [music] >> These behaviors are visible evidence of fetal growth and maturation. Knowledge of these behaviors will help us understand the special needs of preterm infants and how they differ from term infants. Jonathan was born after 26 weeks gestation and weighed only 800 g. >> [music] >> This fragile infant would not have survived several years ago. Recent advances in neonatal intensive care have remarkably increased the survival of these very small preterm infants. But little is known about the long-term effects of the highly artificial environment of the intensive care nursery. However, light, temperature, and sound, as well as medical procedures and handling by many people, do affect the early behaviors of these incubator-bound infants. [music] The major factor which has a profound effect on behavior is the infant's state of consciousness. For the very young preemie, there is mainly one uninterrupted state, an immature type of sleep. Gradually, we will see the emergence of the six states of arousal or consciousness that are present in term babies. >> [music] >> These states alternate many times within 24 hours. There are three awake [music] states. The first is quiet awakeness, an intense alert state [music] in which the infant is most capable of interacting. There is active awakeness and crying. There are two sleep states, active sleep and more restful quiet sleep. And finally, there is a transitional state between the awake and sleep [music] states, which is a drowsy state. Jonathan developed respiratory and feeding difficulties related to immaturity and therefore did not follow the course of a normal, healthy preemie. >> [music] >> Instead, we will follow Elizabeth, who was born after 28 weeks of gestation and weighed 1,200 g. Here she is at 30 weeks gestation, or 2 weeks after birth. She had no significant neonatal problems other than bruising of her face related to the delivery. In addition, we will follow Michelle, who was also born after 28 weeks gestation and weighed 1,100 g. Here she is at 30 weeks gestation. Initially, she had respiratory distress, but now, 2 weeks after delivery, she is able to be out of the incubator for short periods. Filming began once it was determined the infants were healthy and stable. Changes in behavior and development were recorded at regular intervals, beginning at 30 weeks gestation and concluding at 7 months after birth. The limiting sensory, motor, and social behaviors in the young preemie are random and disorganized at first. As the infant matures, physiological and behavioral functions will become more organized and controlled. The emerging behaviors are dependent upon the states of consciousness and are qualitative indicators of neurological maturation. At 30 weeks, the infant is mainly in a restless, undifferentiated sleep state. In this early, immature type of sleep, the infant is seldom quiescent for any length of time. Her face is in continuous restless motion, with chewing, tongue movements, and rapid eye movements, or REMs. Breathing is irregular and mainly abdominal. She is easily roused to brief activity, but is never fully roused. Her eyes may open or they may not. One eye may be open and the other closed. The lids may flutter. The limbs twitch and tremor. One is never sure whether preemies are awake with eyes closed or asleep with eyes open. Since the premature infant sleeps most of the time, many of the social signals which help foster parental attachment and caregiving are lacking. This is frustrating to parents who are trying to get a response. These facial expressions occur spontaneously and often in bursts. They don't appear to communicate specific needs or feelings. While the smile suggests emotional expression, it is not responsive nor does it involve the whole face. Yawns are also infrequent at this age. There is extreme sensitivity to light. The first waking periods are seen as early as 30 weeks, but these occur only for very short intervals. It's only during these brief moments that a parent may receive a response or observe the infant's awareness of her surroundings. Behaviors among preemies of the same age vary. This may be due to individual differences or to the infant's state of arousal at the time of observation. The infant blinks and frowns, but rarely fixates on objects. There is also poor visual acuity and very little ability to accommodate to a following object. Michelle attempts and sometimes seems to fixate on a block, but has very immature eye coordination. In contrast to Michelle, Elizabeth, at 30 weeks gestation, can fixate on a pattern. She is able to distinguish between two striped patterns and prefers the launcher one. Her facial expression is rather dull and lacks interest. The sense of hearing is already well developed by 30 weeks. When tested during the brief awake periods, Michelle startles and alerts to the sound. >> [bell] >> The amount of time spent in this active sleep will progressively decrease as periods of quiet sleep increase. By term, equal time will be spent in these two sleep states. From 32 weeks onward, more time is spent awake. The eyes are wide open, shiny, and bright. This is the quiet awake state. It occurs mainly when the infant wakes spontaneously before feeding. This mouthing activity may signal hunger. The hand-mouth coordination has probably occurred by chance, but it provides an opportunity for sucking. The state of quiet awakeness alternates with an immature drowsy state at this age. This immature drowsiness will decrease with age, while periods of quiet awakeness increase. At 34 weeks gestation, the quiet sleep state is clearly recognizable. The absence of eye and facial movements is characteristic in this state. Respiration is slow and regular. There is very little body activity and only an occasional stirring. With maturation of higher brain centers and an increase in quiet sleep, there is less random activity than was seen earlier. At 34 weeks, Elizabeth can respond to her father's attention by awakening. This developing responsiveness [music] coincides with the appearance of a more mature quiet sleep state. The grasp reflex [music] has appeared, and she shows increasing response to touch. From 34 weeks onward, the infant can safely coordinate sucking with swallowing and breathing, and is ready to begin to feed from the breast or bottle. >> [music] >> Experimentally, when measuring sucking on a blind pacifier, there are bursts of sucks at 34 weeks with the beginning of rhythmicity to the sucking pattern. >> [clears throat] >> With continued growth and stabilization of vital signs, the infant can move from the intensive care nursery. The ability to maintain body temperature outside the incubator usually occurs between 34 and 36 weeks gestation. There is less need for a critical care monitoring, and visiting is now easier and more rewarding. Getting bigger. The infant is more responsive to her mother's face, her soothing touch, and the tone of her voice. By 36 weeks, Michelle's mother can assume all the responsibility for her care, and is now ready to take her home. Michelle responds actively to her mother's care. The crying stage is now seen more frequently in response to discomfort and hunger. The cry of the premature infant is high-pitched, and the tone is different from the lusty cry of the full-term newborn. Usually, no tears are observed until the expected date of delivery or later. Squeaks and grunts are recent additions to the premature communication repertoire. Now, when Michelle hears a bell, she searches for the sound more than previously. She quiets and listens attentively. >> [music] >> Feeding by mouth gives Elizabeth's mother an opportunity to spend time with her and get to know her. The sucking reflex has matured considerably from the 34-week period. This can be shown experimentally by regular bursts of sucks separated by pauses. In contrast, when milk is given, there is a different sucking pattern with a long burst of sucking followed by a pause. The short pause is necessary for the infant to rest and breathe. >> [music] [music] >> Her visual and motor abilities are best tested in the quiet awake state seen here. She can now not only fixate, but follow a red pompom. She alerts to sound. Despite preterm birth and an extrauterine environment, normal development continues. Here is Elizabeth 3 months after birth, which is her expected date of delivery. The development of an infant who has reached the expected date of delivery after many weeks of extrauterine life is very similar to that of a term newborn. However, some subtle differences remain. The baby may look different. Respiration is less regular, and the cycling of the sleep and awake states is less well organized. During infancy, these differences will gradually disappear. Elizabeth has spent close to 3 months in constant light, and yet visual light pattern differentiation has developed. Her interest and attention is obvious. She opens her eyes wide and lifts her upper eyelids. But her alertness and attention still wane after a short while. This may be due to unfamiliarity with the stripes or a change to the drowsy state. Again, with reversal of the patterns, she looks toward the preferred pattern with open eyes and widened pupils, in marked contrast to her immature fixation at 30 weeks. Physical growth is one of the best indicators of a premature infant's health. Michelle was born appropriate for her gestational age. Since birth, her measurements have been plotted on Babson standard growth curves. She failed to grow adequately during the initial 2-week period after birth, and it's taken her until her expected date of delivery, or 40 weeks, to approach her original intrauterine growth curve. Michelle's weight, length, and head circumference were between two standard deviations when we compare her to infants growing in utero. Michelle's weight is up to 3,000 g, and her head circumference is 34 and 1/2 cm compared to 26 cm at birth. Elizabeth was also appropriately grown at birth. She, too, failed to grow during the initial weeks after birth. Her weight was just below two standard deviations at 40 weeks. She was close to achieving full catch-up growth by 6 months. Elizabeth displays the usual pattern of growth for premature infants who had normal intrauterine growth. When we last saw Jonathan, he was 26 weeks gestation. He had a very long hospital stay, but now, 6 and 1/2 months after birth, or 3 months after his [music] expected date of delivery, he has reached his normal growth curve. Incredibly ill or neurologically abnormal infants, and in those with maternal deprivation, catch-up growth may take longer, or they may never occur. Follow-up of premature infants shows that the majority now develop free of significant handicaps. >> [music] >> But for the very low birth weight infant of 1,500 g or less, there's a 10 to 20% risk of neurological or developmental problems appearing at a later age. These problems are most likely to occur in the smallest infants, and in those with severe neonatal complications. >> [music] >> This is Michelle 5 months after birth, or 2 months after her expected date of delivery. While prematurity may have displaced the timing of her birth, it did not affect the basic developmental sequence which begins at the moment of conception. At each stage of development, the premature infant acquires new abilities to interact with her surroundings. The behaviors seen in this film represent stages in the continuum of human brain maturation, and are an impressive testament to the adaptability of the human species. Close attention to these behaviors during the critical preterm period may in the future help us meet the nutritional, psychological, and environmental needs of these high-risk infants. >> [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] >> Aw.