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pain influences maternal behavior, but not stress responsiveness
in rat offspring. Dev Brain Res. 2003;140(2):253.
414. Walker SM, Franck LS, Fitzgerald M, et al. Long-term
impact of neonatal intensive care and surgery on somatosensory perception in children born extremely preterm. Pain.
2009;141(1-2):79.
415. Ward K. Perceived needs of parents of critically ill infants in a
NICU. Pediatr Nurs. 2001;27(3):281.
416. Weise K, Nahata M. EMLA for painful procedures in infants. J
Pediatr Health Care. 2005;19(1):42.
417. Wereszczak J, Miles M, Holditch-Davis D. Maternal recall of
the neonatal intensive care unit. Neonatal Netw. 1997;16(4):33.
418. Whitfield M, Grunau R. Behavior, pain perception and the
extremely LBW survivor. Clin Perinatol. 2000;27(2):363.
419. Wilder R. Local anesthetics for the pediatric patient. Pediatr
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420. Williams AL, Khattak AZ, Garza CN, Lasky RE. The behavioral
response to heelstick in preterm neonates studied longitudinally: description, development, determinants and components.
Early Human Dev. 2009;85(6):369.
421. Worley A, Fabrizi L, Boyd S, Slater R. Multi-modal pain assessments in infants. J Neurosci Methods. 2012;205(2):252.
422. Yin T, Yang L, Lee TY, et al. Development of atraumatic
heel-stick procedures combined treatment with non-nutritive
sucking, oral sucrose and facilitated tucking: a randomized, controlled trial. Int J Nurs Stand. 2015;52(8):1288.
423. Zhu J, Hono-Gu H, Zhou X, et al. Pain relief effect of breastfeeding and music therapy during heel lance for healthy-term
neonates in China: a randomized controlled trial. Midwifery.
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424. Zimmerman KO, Smith PB, Benjamin DK, et al. Sedation,
analgesia and paralysis during mechanical ventilation of premature infants. J Pediatr. 2017;180:99.
425. Zargham-Boroujeni A, Elsagh A, Mohammadizadeh M. The
effects of massage and breastfeeding on response to venipuncture pain amon hospitalized neonates. Iran J Nurs Midwifery Res.
2017;22(4):308.
RESOURCE MATERIALS AND WEBSITES
American Chronic Pain Association at www.theacpa.org or
1-916-632-0922.
American Nurses Association. Pain Management Nursing Scope and
Standards of Practice. 2nd ed. Washington, D.C: ANA; 2017.
American Pain Foundation at www.painfoundation.org or
1-888-615-PAIN.
American Pain Society at www.ampainsoc.org or 1-847-375-4715.
Anand KJS, Stevens BS, McGrath PJ. Pain in Neonates and Infants. 3rd
ed. Philadelphia, PA: Elsevier; 2007.
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Campbell-Yeo M, Dol J, Disher J, et al. The Power of a
Parent’s Touch: evaluation of reach and impact of a targeted evidence-based YouTube video. J Perinat Neonatal Nurs.
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Carter B. Carter book. In: Carter B, Levetown M, eds. Palliative Care
for Infants, Children and Adolescents. Baltimore, MD: Johns Hopkins
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City of Hope. City of Hope/Palliative Care Resource Center at.
www.cityofhope.org/prc.
Continuing education for professionals at www.painedu.org.
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Study of Pain Press; 2004.
End-of-Life Nursing Education Consortium (ELNEC): ELNEC
Pediatric Palliative Care Training Program—a comprehensive national pro-
gram to improve end-of-life care for neonatal and pediatric patients at www.
aacn.nche.edu/ELNEC.
Field M, Behrman R. When Children Die: Improving Palliative and
End-of-Life Care for Children and their Families. Washington, DC:
Institute of Medicine, National Academies Press; 2004.
Finley GA, McGrath P, eds. Acute and Procedure Pain in Infants and Children.
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Folk LA. Guide to capillary heelstick blood sampling in infants. Adv
Neonatal Care. 2007;7(4):171.
Gardner SL. Non-pharmacologic interventions for neonatal pain:
evidence-based nursing practice. Nurse Currents. 2011;5:1.
Available at: www.anhi.org. Free continuing education credits.
Gregory GA, Andropoulos DB. Gregory’s Pediatric Anesthesia. 5th ed.
Hoboken, NJ: Wiley-Blaclwell; 2011.
Harrison D, Reszel J, Dagg B, et al. Pain management during
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Harrison D, Larocque C, Reszel J, Harrold J, Aubertin C. Be Sweet to
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McCaffery M, Pasero C. Pain: Clinical Manual. 2nd ed. St Louis, MO:
Mosby; 1999.
McGrath P, Finley GA, eds. Pediatric Pain: Biological and Social
Context. Seattle, WA: International Association for the Study of
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Mogil J, ed. The Genetics of Pain. Seattle, WA: International
Association for the Study of Pain Press; 2004.
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1-800-533-3231.
Pediatric Pain Sourcebook at http://painsourcebook.ca/index.html.
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[video] Boston: Massachusetts General Hospital; 2000. Available at:
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nann.org/store/product-details?productid=266. Accessed date: 10
February 2018.
Zeller B, Giebe J. Pain in the neonate: focus on nonpharmacologic
interventions. Neonatal Netw. 2014;33(6):336.
THE NEONATE AND THE
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ENVIRONMENT IMPACT
13
or centuries, the newborn baby has been
considered a tabula rasa—a blank slate on
F
which parents and the world “write” to create
the individual. In the first half of the 20th century, research emphasized the contributions of the
environment in shaping the infant and child. Only
recently has the individuality of the infant been
recognized as a powerful shaper of the caregiver, the
care given, and thus the environment.
This chapter explores the psychosocioemotional
development of term and preterm neonates. Infant
development is a reflection of the dynamic
relationship between endowment and environment. Understanding of the dynamic relationship
between endowment and environment is enhanced
by a review of the principles of development in Box
13.1. First, the developmental tasks of infancy are
presented, along with the influences of endowment
and environment on mastery. Home and family life,
in which most infants are raised, is then contrasted
with the experiences of babies in the neonatal
intensive care unit (NICU). Intervention strategies
to normalize the NICU environment also are presented, along with strategies for parent teaching.
The developmental and social outcomes of infants
exposed to the NICU are then presented.
ON DEVELOPMENT
SANDRA L. GARDNER AND EDWARD GOLDSON
DEVELOPMENTAL TASKS OF
THE NEONATE AND INFANT
Neonates begin extrauterine life able to attend
with their sensory capabilities, communicate with
their environment through a complex repertoire
of behaviors, and store remembrances. Infancy
(birth to 12 months) is the time of further development and maturation of these capabilities through
self-mastery and adaptation to the extrauterine
environment.
Biorhythmic Balance: The Primary
Developmental Task of Newborns
In utero, the fetus depends on the mother’s physiologic systems to regulate its own systems. At birth,
the neonate’s basic physiologic needs (i.e., feeding,
elimination, cleaning, heat balance, stroking, communicating) are met in new and different ways.
The process of emerging from a physiologically
dependent state as a fetus into a physiologically
independent neonate introduces new variables for
both mother and infant in the development of their
extrauterine relationship.
The primary task of newborns is to establish
independent biorhythmic balance by stabilizing
the function of sleep-wake cycles, respiratory
and heart rates, blood chemistry levels, metabolic processes, and eating patterns. Biorhythmic
balance is the establishment of innate, cyclic recurrence of biologic functions. Although biorhythmic
balance is internally determined, caregiving interaction between newborn and parent or caregiver
either facilitates or disturbs this transition.
birth, this balance is facilitated by contact with familiar surroundings (the mother’s body) (see Chapter 5).
When immediate recontact between the neonate and the mother is not possible (e.g., when
the mother refuses or is ill) or when the neonate is
334
After
BLUE type highlights content that is particularly applicable to clinical settings.
334
CHAPTER 13 The Neonate and the Environment Impact on Development
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335
BOX
13.1
• Development is a continuous process of increasing complexity from
• Growth (i.e., number and size of cells) and development are influ-
• Development occurs in an orderly sequence largely determined by
• The sequence of development is the same in all children; the rate of
• Development is cephalocaudad (head→foot), centripetal (from
• The first 5 years are marked by a rapid period of growth of all body
• Environmental stimulation influences conceptual development and
• Learning occurs when behavioral change does not result solely from
• Development of the infant occurs within the framework of interaction
• Equifinality postulates multiple paths to the same developmental
Modified from Barnard K, Erikson M. Teaching Children With Developmental Problems.
2nd ed. St Louis, MO: Mosby; 1976; Illingworth RS. The Development of the Infant and
the Young Child. 5th ed. Edinburgh, UK: Churchill-Livingstone; 1972.
PRINCIPLES OF DEVELOPMENT
conception to maturation (i.e., development also occurs in utero).
enced by genetic traits and environmental experiences.
readiness or maturation.
development is individual.
the outside toward the center), and from gross to specific (e.g.,
peripheral→central→lateralization).
systems. During this time, behavior patterns are developed and are
greatly influenced by the environment.
has an effect on cognitive function.
maturation; learning is facilitated by reinforcement of the behavior
through experience.
with a caregiver and the family.
outcome: complex developmental patterns rather than simple development milestones.
preterm or sick and requires immediate emergency
medical intervention or transport, the primary
“mothering” role is temporarily transferred to
professional (medical and nursing) care providers.
Interactional dynamics necessary for reestablishing
biorhythmic balance and fostering the psychosocioemotional development of the newborn also are
transferred into the NICU.
Just as in a home or family setting, the
infant’s personality and behavioral development
are affected by the nature and dynamics of the
stimuli and relationships encountered with the staff
in a nursery or NICU setting. The level of function or dysfunction in the biorhythmic balance
affects the neonate’s long-range outcomes and is
interwoven with the development of a sense of self
and a basic trust.
Sense of Self
In utero, the fetus has continuous tactile-kinesthetic
stimulation that contributes to the development and
maturation of the central nervous system (CNS)
and establishes kinesthesis as the most natural pathway for growth and development. The interaction
between infants and the extrauterine environment
also is kinesthetic. However, tactile contact and
vestibular stimulation are also essential for (1) the
development of a physical identity (body image), (2)
organization and sorting of stimuli, (3) coordination
of sensorimotor skills, (4) a psychological and social
sense of self, (5) normal neurophysiologic development (physical and cognitive abilities), and (6)
emotional stability and temperament.
Daily caregiving and interactions such as
feeding, diapering, holding, and playing with the
parent or caregiver provide infants with reciprocal stimuli for further developing their identity.
Through the manner in which the infant is handled, he or she receives messages about how the
caregiver feels about him or her.
Response cues given by an infant affect the caregiver’s response to and interaction with the infant.52
As the infant quiets in response to caregiving, the
parent is positively reinforced to continue nurturing
and soothing behavior. Withdrawal, irritability, or
continuous crying is perceived by the caregiver as
rejection or inadequacy and may result in parental
frustration, depression, withdrawal, and decreased
interaction. Repeated exposure to the caregiver’s
style and nonverbal messages thus enables the infant
to adapt to these patterns of caregiving. The self
of the infant is formed through interaction with
people and objects within the environment.
Because the nature (amount and type) of the
kinesthetic interaction between infants and caregivers influences how infants develop and mature,
a lack of appropriate stimulation can have longterm negative consequences. Stimulus deprivation
results in impairment or retardation of, or deviancy in, skill development for productive living. The degree or extent of impairment depends
on the severity of the restrictions and limitations
encountered.
52,392
Institutionally reared infants who
had minimal contact and no social interaction with
their caregivers displayed significant developmental delays.
344
The effect of kinesthetic deprivation
was seen in the minimal expression of social skills
52
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(e.g., cooing, babbling, crying), minimal interest in
objects in the environment, increased self-stimulation (rocking), touch aversion, flat or withdrawn
affect, and retarded mental and motor development.
Environmental deprivation may also affect the
physical growth of the infant. Montagu
287
stated
that infants can overcome mental and nutritional
deprivation as long as they are not deprived of tactile stimulation.
The Psychosocial Task: Trust Versus
Mistrust
Trust versus mistrust in self and the environment
is solidified during infancy.
the environment from the moment of birth is the
means through which neonates continue to develop
trust in themselves and decide on the reliability of
their new environment. Two major factors influ-
ence the development of trust versus mistrust:
(1) the infant’s ability to communicate needs to
the environment and (2) the reliability and contingency of the responding environment.
In the course of routine caregiving, an infant
associates the caregiver with either comfort and
trust or lack of need satisfaction and mistrust. The
infant cries to communicate a need (e.g., “I’m
hungry”; “I’m wet”). The caregiver responds to
the infant and meets the need—the infant is fed;
the diaper is changed. Thus, the newborn learns to
communicate when the need arises again, because
the environment or caregiver has responded and
will respond. This contingent response of the care-
giver to the infant’s need is the necessary reinforcement for the development of trust in self,
others, and ultimately humankind. As a result, the
infant develops a sense of mastery over his or her
world and a sense that it is okay to experience needs
and that they will be met.
Caregiving that ignores or delays needs gratification is noncontingent on the infant’s cues
for care. Need meeting that is externally defined by
the caregiver’s agenda (e.g., feeding schedule, rigid
or inflexible routines, medical or nursing procedures
in the NICU) discourages the infant from being
aware of and experiencing needs and communicating them. Such infants eventually detach themselves
(emotionally and kinesthetically) from the sensation
of their needs, thus no longer experiencing or communicating them.
122
52,122
The response of
53
As a result, these infants conclude that they and
their needs (which they perceive as one and the
same) are not important and that they have no
effect on their environment. They do not cultivate
their sense of self or their own existence, physically
(where their boundaries end and another’s begin)
or psychologically (their identity, which exists independent of another).
Survival depends on the caregiver’s meeting
the newborn’s needs. Need meeting is either contingent on the infant’s cues or noncontingent on
an external agenda. The degree of the mother’s
emotional investment and connectedness with
the newborn will determine the nature and
quality of the caregiving. Likewise, the temper-
ament and responsiveness of the infant will affect
the mother’s feelings of competence, success, and
emotional connectedness to her infant.53 This
relationship facilitates the ongoing development
of a good sense of self (e.g., esteem, confidence,
emotional security) and mastery of the world.
Caregivers who do not perceive infants as individuals do not respond to their “need cry” or
interact with them during caregiving. This style
fosters the development of mistrusting, suspicious,
helpless, emotionally insecure, and isolated children and adults.
ENDOWMENT
Infants possess innateness and individuality. Primitive
reflex behaviors, higher cognitive abilities,
temperament, and sensorimotor competencies
are the endowment of the individual infant.
Individual variation and use of these endowments
are influenced by the environment of the newborn.
Even before conception, the genetic endowment
of the parents and preceding generations affects the
fetus or newborn. Everything that the individual
will inherit from his or her parents is determined
at the moment of conception. Of the vast number
of possible combinations of chromosomes, chance
determines which characteristics the individual
receives. Thus each individual, except monozygotic
twins, is genetically and biologically different from
every other person. Either a faulty gene (e.g., sickle
cell anemia) or an altered number of chromosomes
(e.g., Down syndrome) is responsible for inherited
defects (see Chapter 27).
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337
Although after the moment of conception,
hereditary endowment can never be changed,
it is influenced by the intrauterine environment. Some birth defects are caused by terato-
gens or poisons—any environmental agent (e.g.,
drugs, virus, chemical, pollutant) that interferes
with normal fetal development. An individual’s
potential for growth and development is strongly
influenced by his or her genetic endowment. As
Montagu
287
stated, “Genetic endowment determines what we can do—environment what we
do do.”
The exact influence of genetics for most psychological traits is unknown. Introverted (timid,
shy, withdrawn) and extroverted (active, friendly,
outgoing) personality types may be partially genetically controlled. The degree to which intelligence is
inherited is currently unknown, although the intelligence of children is most often similar to parental intelligence (i.e., intelligence is more similar
between child and biologic mother than between
child and adoptive mother).
Freedman
145
studied newborns of many ethnic groups to determine whether there were any
similarities in disposition within the group or differences from other ethnic groups. He found that
Chinese American newborns were more adaptable,
less irritable, and easier to console than white
American newborns. Maneuvers such as the Moro
and covering the face with a cloth elicited different responses, depending on the newborn’s ethnic
origin.
The same environmental stimuli elicit different
behavioral responses, which are individual and
genetically influenced. These genetically influenced behaviors are also influenced by environment—both internal and external. Thus, an
individual may be more vulnerable to or more
resilient in a specific environment. Therefore, we
are totally endowment and totally environment
(100% endowment + 100% environment = an
individual).
145
Temperament
qualities enable the following three basic types of
infants to be identified:
• The “easy” child, who is seen as regular, pleasant,
and easy to care for and love
• The “difficult” child, who is difficult to rear and
reacts with protest and withdrawal to strange
events or people
• The “slow to warm” child, who reacts with
withdrawal or passivity to new events
Neurologic Development
Brain growth of the fetus and newborn occurs in
two stages.
STAGE I
Stage I is from 10 to 18 weeks of pregnancy. The
number of nerve cells that the individual has
develops during this period. Any environmental
perturbation (e.g., maternal malnutrition, medications, infections) that affects brain growth during
this stage also may affect neonatal behavioral
responses.
STAGE II
Stage II is from 20 weeks’ gestation to 2 years of age.
This period marks a brain growth spurt and is the
most vulnerable period of growth of the dendrites
of the human cortex.
The maturity of an infant is reflected in his or
her behavior. Infants of a younger gestational age
have less mature responses than infants of an older
gestational age. A neurologic assessment of the newborn includes evaluation of (1) newborn reflexes,
(2) neonatal states, (3) psychosocial interaction, and
(4) sensory capabilities. The neonate is born with
behaviors that are unlearned, instinctual, and of an
adaptive and survival nature. They reflect the state of
the nervous system and the level of neonatal maturation (Table 13.2). Serial testing of reflex behav-
ior gives more reliable data than one observation.
Observations indicative of major deviations include
asymmetry—total absence or no response on one
side or in upper versus lower extremities.
109
Parents often notice behavioral differences in their
children from the first day. These differences are
obvious in motor activity, irritability, and passivity.
Some infants are quiet and placid, others are irritable and easily upset, and others are somewhere
in between (Table 13.1). These temperamental
Psychological Interaction and
Neonatal States
For years, newborn behavior was thought
to occur only on a reflexive, instinctual
level. Through the work of Brazelton57 and
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TABLE
13.1
TEMPERAMENTAL QUALITY RATING
Activity level Low—Decreased movement when dressed or during sleep
Rhythmicity Regular—Establishes own feeding; sleep and bowel movement patterns are fairly predictable
Approach and withdrawal Positive—Eagerly tries new foods, interested in new surroundings and people
Adaptability Adaptive—Little resistance to first bath; may enjoy bath
Quality of mood Positive—Pleasant, easygoing disposition; easy to comfort; smiles
Intensity of mood Mild—No crying when wet; frets instead of crying when hungry
Sensory threshold (intensity of stimulus
necessary to elicit a response)
Distractibility Distractible—Rocking, pacifier, toy, voice, music decrease fussing
Attention span and persistence
Data from Thomas A, Chess S. Temperament and Development. New York: Brunner-Mazel; 1977.
CRITICAL FINDINGS
Behavioral Categories Descriptive of Individual Temperament
High—Increased movement when asleep; increased wiggling and activity when diaper changed
Irregular—Amounts of sleep, feeding variable; “no 2 days are alike”; no pattern established
Negative—Rejects new foods, new toys, and new environments; apprehensive, cries with new people
Nonadaptive—Startles easily; resists diapering, bathing, and other manipulating
Negative—Fussy; cries easily and is not easily comforted by external stimuli; unable to comfort self easily
Intense—Vigorously cries; rejects food
High—Not startled or interested by noise or other stimuli
Low—Noise, activity, or other stimuli enough to interrupt infant’s behavior
Nondistractible—No stimuli decrease distress until need is met—food; stop changing diaper; bath over
Short—Cries when awakened but stops immediately, mild objection if needs are not immediately met
Long—Repeatedly rejects substitutions for perceived needs (no pacifier until diaper is changed; no water if
milk is wanted)
TABLE
13.2
BEHAVIOR BEGINS (IN UTERO) (WK) INTEGRATES
CRITICAL FINDINGS
Neonatal Reflex Behaviors
Protection
Moro reflex 28 At 6–8 mo to allow sitting and protective extension of the hands
Palmar grasp 28 At 5–6 mo to allow voluntary grasping of objects
Plantar grasp 28 At 7–8 mo with foot rubbing on objects; complete at 8–9 mo for standing and walking
Babinski reflex 28 Same as for plantar grasp
Tonic neck reflex 35 At 4 mo, so rolling over and reaching or grasping may occur
Gaga reflex 36 Protects against aspiration—does not disappear
Blink reflex 25 Does not disappear
Crossed extension 28 Disappears around 2 mo of age
Survival
a
Rooting
a
Sucking
a
Swallowing
a
Although isolated components of feeding behaviors are all present before 28 weeks’ gestational age, they are not effectively coordinated for oral feedings before 32–34 weeks’ gestational
154,278,378
age.
Coordination of respiration with sucking and swallowing during bottle feeding is consistently achieved by infants more than 37 weeks’ postconceptual age.
28 At 3 mo; decreased response if baby is sleepy or satiated
26–28 Not yet synchronized with swallowing
12 32–34 wk, stronger synchronization with sucking; perfect by 34–37 wk
63
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