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The Journal of Genetic Psychology: Research and Theory on Human Development Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vgnt20

Observations of Postnatal Developmental Activity in Infants with Fetal Malnutrition James E. Goggin Hassanein

a b

a b

, Grace E. Holmes

& Shirley B. Lansky

a b

, Khatab

a b

a

Texas Tech University Health Sciences Centers , USA b

University of Kansas Medical Center , USA Published online: 04 Sep 2012.

To cite this article: James E. Goggin , Grace E. Holmes , Khatab Hassanein & Shirley B. Lansky (1978) Observations of Postnatal Developmental Activity in Infants with Fetal Malnutrition, The Journal of Genetic Psychology: Research and Theory on Human Development, 132:2, 247-253, DOI: 10.1080/00221325.1978.10533336 To link to this article: http://dx.doi.org/10.1080/00221325.1978.10533336

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The Journal of Genetic Psychology, 1978, 134,247-253

OBSERVATIONS OF POSTNATAL DEVELOPMENTAL ACTIVITY IN INFANTS WITH FETAL MALNUTRITION* Downloaded by [Memorial University of Newfoundland] at 05:17 21 January 2015

Texas Tech University Health Sciences Centers and University of Kansas Medical Center JAMES

E. GOGCIN,GRACEE. HOLMES,KHATABHASSANEIN, AND SHIRLEY B. LANSKY

SUMMARY Malnutrition in utero or in early infancy has generally been assumed to contribute to irreversible developmental delay in infants. This prospective study utilized an observation technique to measure various parameters of developmental activity of 20 malnourished babies with low ponderal indices (PI) as compared to 16 normal control babies and 13 obese, high ponderal index babies. During each well child visit throughout the fist postnatal year all children were observed for 40 minutes with the use of an objective technique which measured several behavioral activities. The malnourished group did as well as the control and obese babies in their motor activity, in exploratory behavior and in specific coordinated acts. They demonstrated significantly higher levels of babbling than did the control babies. These findings do not support the hypothesis that babies malnourished in utero will have lower activity levels than well nourished newborns. In spite of this normal activity level of the low PI children, parents of low PI babies gave more negative feedback to their infants than did control parents and parents of high PI babies. In addition, the ratio of negative to positive feedback was greater among parents of low PI babies than among other parents. The latter findings suggest an impaired parendinfant interaction among babies with fetal malnutrition. A. INTRODUCTION Attempts have been made to correlate the nutritional status of the newborn with subsequent development and activity. Studies on fetal growth and

* Received in the Editorial Office, Provincetown, Massachusetts, on October 27, 1976. Copyright, 1978, by The Journal Press. 247

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nutrition have depended on descriptions of small-fordates and large-fordates babies based primarily on birth weight (2, 3, 5 , 7 , 8, 14). Several patterns of more specific atypical fetal growth have been diagnosed and described by Miller and Hassanein (16). Rather than using birth weight alone, they utilized both weight and height in the calculation of Rohrer’s ponderal index (PI). This index is calculated by the following formula (16): weight in grams x 100 f (body length in ~ m )The ~ . index helps to identify the fullterm, thin newborn with a low ponderal index and the obese baby with a high ponderal index, as well as babies with normal weight and height measurements and normal ponderal indices. Babies with low PIS at birth have little or no subcutaneous fat and appear malnourished. Their malnourished state at birth is a reflection of inadequate nutrition in utero and has been implicated as a possible cause of impairment of future physiological and psychological development ( 1 1 ) . Animal studies have demonstrated severe growth retardation following malnutrition during myelination of the central nervous system (6). Winick (20, 2 1 , 2 2 ) cites the gestational period and the first six postnatal months in humans as the critical period for brain development and suggests that severe undernutrition during this time period might curtail cell division in all organs including the brain. In evaluating long-term effects of postnatal malnutrition in older infants, Stoch and Smythe (18,19) noted that the two striking characteristics in these malnourished children were a slow rate of somatic growth and a low physical and behavioral activity level. We hypothesized that babies malnourished in utero with low ponderal indices at birth would display a similar low level of activity. In the present study we followed newborn infants with low PIS during their first year after birth, observing various parameters of activity and comparing them with other newborns who had either high or normal ponderal indices. The following variables were studied: activity level, ratio of passive to exploratory behavior, ratio of specific coordinated acts to global patterns of behavior, and degree -of verbal babbling. The parents of all infants were assessed regarding the amount of negative feedback which they gave to their infants. The ratio of negative to positive feedback provided by parents to their infants was also measured. B. 1.

METHOD Subjects

Sixty-one fullterm infants were included in the study without regard either to maternal race, age, parity, or socioeconomic status or to the sex of the

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infant. The babies were born between 1 March 1973 and 1 November 1974 at the University of Kansas Medical Center. Criteria for inclusion in the study included singleton births, absence of congenital malformation, no evidence of intrauterine infection, metabolic disorder, or medical disease, and a calculated and/or estimated gestational age of 38 weeks or more. Gestational age was calculated in terms of completed weeks of gestation from the first day of the mother’s last menstrual period. Estimated gestational age was based on neurological and physical maturational signs according to the description by Lubchenco (12). None of the mothers was diabetic or prediabetic. All infants were examined and measured within the first 24 hours after birth, and the pattern of fetal growth present in all infants was diagnosed according to measures described previously (16) Ponderal indices at birth were calculated, with the use of Rohrer’s formula (13, 16). The malnourished babies had ponderal indices below the 3rd percentile in a scale plotting ponderal index as related to calculated gestational age described by Miller (16); the obese group had ponderal indices above the 97th percentile and the normal control group had average ponderal indices. Some of the mothers’ pregnancies involved factors thought to retard fetal growth, such as cigarette smoking, poor maternal weight gain during pregnancy, pre-eclampsia, and chronic hypertension. Inclusion of babies for this study was not affected by the presence or absence of these factors in the mothers’ pregnancies. The nature of the follow-up evaluations was explained fully to the mothers who signed a n informed consent form approved by the University of Kansas Medical Center, College of Health Sciences and Hospital. Of the original 61 children selected according to the above criteria, 12 patients were lost to follow-up because of a move out of the area, follow-up by a private physician, or the decision not to continue in the study. There remained 20 children with low PIS, 13 with high PIS, and 16 with normal ponderal indices (control group). 2.

Procedures

General procedure at each clinic visit included measuring and weighing of the baby by the pediatric nursing staff prior to being seen by the pediatrician in the Fetal Growth Clinic. An interval history was taken, and a physical examination carried out at each visit. Prior to the pediatric evaluation of the child, the parent was interviewed in a small waiting room which served also as an observation room. The interviewer was either a child psychiatrist, psychiatric social worker, nurse prac-

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titioner, or a student social worker. Discussion during the interview was varied and ranged from casual conversation to more intensive psychotherapy when the latter was found to be appropriate. An observation device was used to measure objectively the behavioral patterns of infants in terms of type, frequency, and duration (9, 15, 17). The behavioral categories were derived from previous infant research (17) and the methodology was based on systems used by Medley and Mitzel (15) and modified by Goggin (9). Each infant was observed by means of one-way mirrors, once while the primary caretaker (usually the mother) was being interviewed, and afterward in the examining room during the pediatric evaluation. Two 10-minute behavioral samples were observed in each room with a total of 40 minutes of recorded observed behavior for each visit. During the first postnatal year the infants were scheduled to be seen at one month, two months, four, six, nine, and 12 months of age. The observation device contained several behavioral categories with a 10-minute sample divided into 30-second intervals. Each behavior that fit a category observed during the 30-second interval was scored. Thus, an infant could be scored in two, three, or more behavioral categories within each 30-second interval if he changed his behavior within that time. The infant’s behavior was scored immediately after it occurred to reduce the possibility of experimenter bias. If an infant did not change his behavior, he was scored once for each 30-second interval. If he demonstrated two scorable behaviors at the same time, he was scored for each behavior. This scoring system provided a relative index of the amount of motoric verbal behavior demonstrated while being observed. Observer training was conducted during a pilot phase of the study while two observers discussed the behavioral categories and then watched and scored infants’ behavior while monitoring each other:s observations. In this study, observer agreement was used as a measure of objectivity rather than reliability and was defined as the correlation between scores based on observations of the same infant by different observers during the same time-period. The behavioral categories according to the method of Goggin (9) included the following: exploratory behavior with physical, verbal, or a combination of global patterns in addition to specific coordinated physical and verbal behavioral activity; passive behavior including general passivity or various avoidance patterns. In addition to the child’s activity, parental response or feedback to the child was observed and recorded as either negative or positive feedback.

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c . RESULTS AND DISCUSSION Cumulative scores of the various activities throughout the first postnatal year were compiled for each child for whom there was a sufficient number of observations: e.g. at least 160 minutes of recorded activity. This included 12 low PI babies, eight control (average PI), and seven high PI children. A comparison of the cumulative activity level of the three groups of babies (low PI, high PI, control) during their first postnatal year was done by use of one-way analysis of variance (ANOVA). No significant difference in activity level among the three groups was obtained. The ratio of passive to exploratory behavior for the three groups was compared with the use of the Kruskal-Wallis one-way analysis of variance. The result of the analysis of variance was not significant. The ratio of specific coordinated acts to global patterns of behavior of the low PI, high PI, and control groups was compared with the use of the Kruskal-Wallis one-way analysis of variance, and again no significant differences emerged. The analysis of variance and Duncan’s multiple comparison test gave significantly greater babbling behavior among low PI babies as compared with the control group (p = .006). Babbling behavior of babies with low PIS compared with high PI infants and high PI with control babies was not significantly different. By use of the analysis of variance and Duncan’s multiple comparison test, the parents of the low PI group were compared with the control parents and with parents of the high PI group on the basis of negative feedback to their infants. The former group gave significantly more negative feedback to their infants than did the control parents ( p = .006) or the high PI parent group ( p = .03). There was no significant difference in negative response between high PI parents and the control parents. By use of the Kruskal-Wallis one-way analysis of variance and the Wilcoxon Sum Rank Test for multiple comparisons, we compared the ratio of negative to positive feedback for parents of the three groups and found a significantly greater ratio of negative to positive feedback to their babies in the parent group of babies with low PIS than among the parents of either the control or high PI babies ( p < .01). The malnourished infants with low ponderal indices did not differ significantly from the normal controls or the obese, high ponderal index babies in any of the categories of motor activity, thus not showing the expected apathetic behavior of malnourished infants. Also, there was no significant differ-

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ence among the three groups in the more advanced levels of motor activity of coordinated and exploratory behavior. In addition, the low PI children showed significantly more babbling behavior than did the control babies, again contrary to anticipated findings. However, the significantly greater negative feedback to low PI infants by their mothers than that either to control or high PI babies by their mothers supports recent findings by Als et al. (1) regarding a possible impaired materndchild interaction among low ponderal index babies. The greater ratio of negative to positive feedback by the mothers of low PI babies underscores this finding. Clinically, we have found the low PI babies in this clinic to show a great capacity to recover from their malnourished state, as reported by Holmes et al. (10). The somatic growth of the malnourished infants during the first year showed an accelerated weight gain as compared to the other groups, indicating that with appropriate feeding a reversal of their thin, malnourished state at birth could take place. Of two low PI babies who did not show an acceleration in weight, one was a victim of child abuse m d another had mild hypertonicity of her skeletal muscles. With appropriate intervention both showed clinical improvement and accelerated weight gain. The Birch-Craviot (4) model of organic-environmental interaction assumes that nutritional deprivation is a pivotal point of a chain of indirect events in which numerous factors contribute to impaired functioning. However, the relationship between malnutrition in utero and irreversible effects on growth and development is not entirely clear, and in this study detrimental effects on the child's activity level could not be demonstrated for the first postnatal year. REFERENCES 1. 2. 3.

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Observations of postnatal developmental activity in infants with fetal malnutrition.

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