Neurobehavioral Organization Research Articles

Evidence for neurobehavioral risk phenotypes at birth.

Observations of newborn behavior provide clinicians and researchers with a first description of the neurobehavioral organization of the newborn that is largely independent of the postnatal environment. The Neonatal Network Neurobehavioral Scale (NNNS) was developed in 2004 to evaluate how prenatal exposure to substances such as cocaine is related to neurobehavioral outcomes. There are now 156 empirical articles published using the NNNS, which we review and summarize. Z-scores from published studies using the NNNS were compiled and aggregated supporting the replicability of three newborn neurobehavioral phenotypes: one typical and two that are predictive of later cognitive and behavioral delay; hyper- and hypo-dysregulated newborns. These phenotypes emerged from independent samples and research groups and were identified in a variety of populations, including infants with prenatal substance exposure, preterm infants, and healthy term infants. Our findings show that newborn neurobehavior can be measured in a reliable and valid manner and that certain behavioral phenotypes, identifiable at birth, can predict neurodevelopmental challenges. These findings have important clinical utility. Intervening early with infants exhibiting these risk phenotypes may prevent later neurodevelopmental delay. IMPACT: We reviewed all empirical studies published using the Neonatal Network Neurobehavioral Scale and found evidence for two replicable stress phenotypes that predict later behavioral outcomes. This study highlights the utility of the Neonatal Network Neurobehavioral Scale for early identification of newborn neurodevelopmental risk phenotypes. Early identification of neurodevelopmental risk, when neuroplasticity is high, may ultimately reduce the burden of subsequent neurobehavioral problems through early intervention.

Neonatal PT Improves Neurobehavior and General Movements in Moderate to Late Preterm Infants Born in India: An RCT.

To examine whether a structured neonatal physical therapy program (SNP) improves neurobehavior and general movements in moderate to late preterm (MLP) infants. Sixty MLP infants participated in this clinical trial. After baseline assessment using the Neurobehavioral Assessment of Preterm Infant (NAPI) and Prechtl General Movements (GMs) Assessment, infants were randomly allocated to a usual care (n = 30) or an SNP group (n = 30) and continued receiving usual care. The SNP group received intervention for 90 minutes/day, 6 days/week until discharge. Changes in neurobehavior and GMs were assessed at hospital discharge. Changes in scores on scarf sign and motor development and vigor clusters of NAPI document an improvement in the SNP group. The proportion of infants with poor repertoire GMs also decreased more in the SNP group than in the usual care group. The SNP may be effective in improving some aspects of neurobehavior and quality of GMs in MLP infants. The addition of a structured neonatal physical therapy program to usual care can promote neurobehavioral organization and improve the quality of general movements in moderate and late preterm infants in India.

Comparative study on the effect of oral motor intervention protocols on oral motor skills of preterm infants from tertiary care hospital in metropolitan city: pilot study

Background: Premature infants often have feeding difficulties leading to morbidity or developmental co-morbidities. Premature infant oral motor intervention (PIOMI), has shown the positive effects on feeding progression of the premature infants. PIOMI with the massage technique, may help in improving oral motor activity, weight gain in preterm infants along with better neurobehavioral organization. The study was done to analyse effect of this combined protocol on achieving oral motor control and Neurobehavioral state regulation and evaluate its efficacy against PIOMI.Methods: A total 72 clinically stable infants admitted in premature care unit, fulfilling inclusion criterion were enrolled. They were allocated in control and experimental group. Infants from control group received PIOMI and experimental group received PIOMI with massage therapy (M technique), for 10 minutes each day. Data was collected for oral motor abilities, behavioural assessment, weight and day of achieving full feeds.Results: Gestational age at full feeds was 33.65 weeks and 32.89 weeks in control and experimental groups respectively with ‘p’ value 0.002. The number of days of full feed in experimental group was 3.7 days earlier (p=0.04). Infants from experimental group showed higher oral motor score and more weight gain with significant difference The behavioral regulation in infants of both the groups improved after 8 day.Conclusions: PIOMI with M technique was well tolerated by preterm infants. The modified protocol has resulted in achieving early oral feeds and reducing hospital stay. It has also shown the benefit of behavioural regulation along with better oral motor control.

Reach-To-Grasp Movements: A Multimodal Techniques Study.

The aim of the present study was to investigate the correlation between corticospinal activity, kinematics, and electromyography (EMG) associated with the execution of precision and whole-hand grasps (WHGs). To this end, motor-evoked potentials (MEPs) induced by transcranial magnetic stimulation (TMS), EMG, and 3-D motion capture data have been simultaneously recorded during the planning and the execution of prehensile actions toward either a small or a large object. Differences in the considered measures were expected to distinguish between the two types of grasping actions both in terms of action preparation and execution. The results indicate that the index finger (FDI) and the little finger (ADM) muscles showed different activation patterns during grasping execution, but only the FDI appeared to distinguish between the two types of actions during motor preparation. Kinematics analysis showed that precision grips differed from WHGs in terms of displayed fingers distance when shaping before object’s contact, and in terms of timing and velocity patterns. Moreover, significant correlations suggest a relationship between the muscular activation and the temporal aspects concerned with the index finger’s extension during whole-hand actions. Overall, the present data seem to suggest a crucial role played by index finger as an early “marker” of differential motor preparation for different types of grasps and as a “navigator” in guiding whole-hand prehensile actions. Aside from the novelty of the methodological approach characterizing the present study, the data provide new insights regarding the level of crosstalk among different levels concerned with the neuro-behavioral organization of reach-to-grasp movements.

NICU Network Neurobehavioral Scale: 1-month normative data and variation from birth to 1 month.

BackgroundThe Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) is a standardized method for infant neurobehavioral assessment. Normative values are available for newborns, but the NNNS is not always feasible at birth. Unfortunately, 1-month NNNS normative data are lacking.AimsTo provide normative data for the NNNS examination at 1 month and to assess birth-to-one-month changes in NNNS summary scores.Study designThe NNNS was administered at birth and at 1 month within a longitudinal prospective study design.SubjectsA cohort of 99 clinically healthy full-term infants were recruited from a well-child nursery.Outcome measuresBirth-to-1-month NNNS variations were evaluated and the association of neonatal and sociodemographic variables with the rate of change of NNNS summary scores were investigated.Results and conclusionsNNNS scores from the 10th to the 90th percentile represent a range of normative performance at 1 month. A complex pattern of stability and change emerged comparing NNNS summary scores from birth to 1 month. Orienting, Regulation, and Quality of movements significantly increased, whereas Lethargy and Hypotonicity significantly decreased. Birth-to-1-month changes in NNNS performance suggest improvements in neurobehavioral organization. These data are useful for research purposes and for clinical evaluation of neurobehavioral performance in both healthy and at-risk 1-month-old infants.

Patterned feeding experience for preterm infants: study protocol for a randomized controlled trial.

BackgroundNeurobehavioral disabilities occur in 5–15 % of preterm infants with an estimated 50–70 % of very low birth weight preterm infants experiencing later dysfunction, including cognitive, behavioral, and social delays that often persist into adulthood. Factors implicated in poor neurobehavioral and developmental outcomes are hospitalization in the neonatal intensive care unit (NICU) and inconsistent caregiving patterns. Although much underlying brain damage occurs in utero or shortly after birth, neuroprotective strategies can stop lesions from progressing, particularly when these strategies are used during the most sensitive periods of neural plasticity occurring months before term age. The purpose of this randomized trial is to test the effect of a patterned feeding experience on preterm infants’ neurobehavioral organization and development, cognitive function, and clinical outcomes.MethodsThis trial uses an experimental, longitudinal, 2-group design with 120 preterm infants. Infants are enrolled within the first week of life and randomized to an experimental group receiving a patterned feeding experience from the first gavage feeding through discharge or to a control group receiving usual feeding care experience. The intervention involves a continuity of tactile experiences associated with feeding to train and build neuronal networks supportive of normal infant feeding experience. Primary outcomes are neurobehavioral organization as measured by Neurobehavioral Assessment of the Preterm Infant at 3 time points: the transition to oral feedings, NICU discharge, and 2 months corrected age. Secondary aims are cognitive function measured using the Bayley Scales of Infant and Toddler Development, Third Edition at 6 months corrected age, neurobehavioral development (sucking organization, feeding performance, and heart rate variability), and clinical outcomes (length of NICU stay and time to full oral feeding). The potential effects of demographic and biobehavioral factors (perinatal events and conditions of maternal or fetal/newborn origin and immunologic and genetic biomarkers) on the outcome variables will also be considered.DiscussionTheoretically, the intervention provided at a critical time in neurologic system development and associated with a recurring event (feeding) should enhance neural connections that may be important for later development, particularly language and other cognitive and neurobehavioral organization skills.Trial registrationNCT01577615 11 April 2012.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-015-0781-3) contains supplementary material, which is available to authorized users.

Latent classes in the developmental trajectories of infant handedness.

Handedness for acquiring objects was assessed monthly from 6 to 14 months in 328 infants (182 males). A group based trajectory model identified 3 latent groups with different developmental trajectories: those with an identifiable right preference (38%) or left preference (14%) and those without an identifiable preference (48%) but with a significant trend toward right-handedness. Each group exhibited significant quadratic trends: Those with a right preference increased to asymptote at about 10 months and began decreasing thereafter; those with a left preference increased to asymptote at about 11 months; those without a preference exhibited increasing right-hand use. Since adult handedness reflects different patterns of neural organization which relate to differences in psychological functioning, the observed differences in infant handedness development may relate to differences in the development of infant neurobehavioral organization and functioning. Several methods were used to explore the relation of latent classes to more conventional ways of classifying infant handedness. Classification into handedness groups according to either a monthly z-score or a combination of 4 or fewer months for a handedness index failed to provide reliable estimates of handedness identified by the trajectory analysis. If identified trajectories of handedness development relate to the development of the infant's neurobehavioral organization, researchers who assess infant handedness only once in order to relate it to cognitive, social and emotional functioning may risk misclassifying the handedness of as many as 37-45% of infants.

Gender Development and the Human Brain

Convincing evidence indicates that prenatal exposure to the gonadal hormone, testosterone, influences the development of children's sex-typical toy and activity interests. In addition, growing evidence shows that testosterone exposure contributes similarly to the development of other human behaviors that show sex differences, including sexual orientation, core gender identity, and some, though not all, sex-related cognitive and personality characteristics. In addition to these prenatal hormonal influences, early infancy and puberty may provide additional critical periods when hormones influence human neurobehavioral organization. Sex-linked genes could also contribute to human gender development, and most sex-related characteristics are influenced by socialization and other aspects of postnatal experience, as well. Neural mechanisms underlying the influences of gonadal hormones on human behavior are beginning to be identified. Although the neural mechanisms underlying experiential influences remain largely uninvestigated, they could involve the same neural circuitry as that affected by hormones.

Neurobehavioral Integrity of Chimpanzee Newborns: Comparisons across groups and across species reveal gene-environment interaction effects.

The aims of this article are to describe the neurobehavioral integrity of chimpanzee newborns, to investigate how early experiences affect the neurobehavioral organization of chimpanzees, and to explore species differences by comparing chimpanzee newborns to a group of typically developing human newborns. Neurobehavioral integrity related to orientation, motor performance, arousal, and state regulation of 55 chimpanzee (raised in four different settings) and 42 human newborns was measured with the Neonatal Behavioral Assessment Scale (NBAS) a semi-structured 25-minute interactive assessment. Thirty-eight chimpanzees were tested every other day from birth, and analyses revealed significant developmental changes in 19 of 27 NBAS scores. The cross-group and cross-species comparisons were conducted at 2 and 30 days of age. Among the 4 chimpanzee groups, significant differences were found in 23 of 24 NBAS scores. Surprisingly, the cross-species comparisons revealed that the human group was distinct in only 1 of 25 NBAS scores (the human group had significantly less muscle tone than all the chimpanzee groups). The human group was indistinguishable from at least one of the chimpanzee groups in the remaining 24 of 25 NBAS scores. The results of this study support the conclusion that the interplay between genes and environment, rather than genes alone or environment alone, accounts for phenotypic expressions of newborn neurobehavioral integrity in hominids.

Visual-motor and executive functions in children born preterm: The Bender Visual Motor Gestalt Test revisited

Visual-motor development and executive functions were investigated with the Bender Test at age 5½ years in 175 children born preterm and 125 full-term controls, within the longitudinal Stockholm Neonatal Project. Assessment also included WPPSI-R and NEPSY neuropsychological battery for ages 4-7 (Korkman, 1990). Bender protocols were scored according to Brannigan & Decker (2003), Koppitz (1963) and a complementary neuropsychological scoring system (ABC), aimed at executive functions and developed for this study. Bender results by all three scoring systems were strongly related to overall cognitive level (Performance IQ), in both groups. The preterm group displayed inferior visual-motor skills compared to controls also when controlling for IQ. The largest group differences were found on the ABC scoring, which shared unique variance with NEPSY tests of executive function. Multiple regression analyses showed that hyperactive behavior and inattention increased the risk for visual-motor deficits in children born preterm, whereas no added risk was seen among hyperactive term children. Gender differences favoring girls were strongest within the preterm group, presumably reflecting the specific vulnerability of preterm boys. The results indicate that preterm children develop a different neurobehavioral organization from children born at term, and that the Bender test with a neuropsychological scoring is a useful tool in developmental screening around school start.

Neonatal Neurobehavioral Organization After Exposure to Maternal Epidural Analgesia in Labor

To explore relationships between maternal epidural analgesia and two measures of neurobehavioral organization in infants at the initial feeding 1 hour after birth. Prospective comparative design. Inner-city community hospital, Chicago, Illinois. Convenience sample of 52 low-risk, mainly Black and Latino, mother/infant dyads. Mothers self-selected to labor with epidural or no labor pain medication. Neonatal neurobehavioral organization was measured in term infants at the initial feeding 1 hour after birth. A nutritive sucking apparatus generated data on total number of sucks and sucking pressure. Video recordings of infants (before and after the initial feeding) were coded for behavioral states, with analysis on frequency of alertness. Total number of sucks and sucking pressure were not related to epidural exposure, although an epidural drug dosage effect on total number of sucks was evident when gender was a factor. Unmedicated girls demonstrated more sucks than girls in the high-dosage epidural group (p=.027). Overall, girls exhibited stronger sucking pressure than boys (p=.042). Frequency of alertness was not related to epidural exposure, although longer labor was related to greater alertness (p=.003), and Latino infants were more alert than Black infants (p=.002). Results suggest attenuated neonatal nutritive sucking organization in girls after exposure to high maternal epidural dosages. In comparison to boys, girls may have enhanced neurobehavioral organization at birth. Race/ethnicity and alertness may have spurious associations in which hidden factors drive the relationship.

Individualized Developmental Care in the Neonatal Intensive Care Nursery

AbstractAdvances in medical care have improved the success of medical interventions in treating high-risk and premature infants, but long-term developmental outcomes are less positive. The neonatal intensive care unit (NICU) setting influences infant brain development and organization, as well as the parent-infant relationship. One advanced-practice role for a speech-language pathologist (SLP) is that of a newborn developmental specialist (NDS). The NDS working in the NICU understands the influence of medical, environmental, and caregiving interactions on the neurologic and neurobehavioral organization of the infant. The NICU setting advanced practice skills are grounded in an individualized, developmentally supportive care model, such as the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). Neurodevelopmental assessment focuses on the competence of the infant. The developmental assessment and intervention strategies are individualized to support the infant's own goal strivings. In this framework, interactions with infants become modified to increase competence and organization. The SLP working in the NICU is in a unique position to facilitate communication between the infant and the parent, as well as between the infant and professional caregivers. The SLP can help the parent interpret and respond appropriately to the infant's communication by focusing on non-verbal stress and stability cues, and by planning all interactions with a goal of co-regulation. Interactions with infants and families in this Model in the NICU have beneficial lifelong implications.

Neurodevelopmental support and early intervention in NICU

Methods of routine care delivery affect outcomes for infants exposed to the lifesaving rigors of newborn intensive care. The vulnerable immature or sick infant responds to environmental and caretaking stressors with deleterious physiologic and behavioral effects which compromise physiologic stability and the attainment of target neuromotor, behavioral, and growth milestones. When care is structured to support the individual infant's physiologic stability and neurobehavioral organization, stress is reduced for that infant. Routines of intensive care should be altered and adapted based on specific observations of each infant's response to care giving and environmental stimuli. This article will briefly review the four major categories of interventions that nurses can incorporate into their daily care for the infant to help improve outcomes for the premature infant.

Behavioral organization of the fetus in early pregnancy

Purpose: The behavior of the human fetus consists of complex dynamic relationships. To date, previous methods of measuring fetal behavior have failed to capture the complexity of behavior. However, as behavior is a reflection of neural functioning it is only when quantitative assessment of this complexity has been undertaken that underlying neural organization can be elucidated. In order to reveal fundamental features of neurobehavioral organization and development, the present study provided a quantitative description of the complex spatial (sequential) and temporal (synchronous and asynchronous) patterning of behavior in the human fetus in early pregnancy.Methods: Twenty fetuses from normal singleton pregnancies were scanned at two weekly intervals for a period of 1 h from 9 to 17 weeks' gestation. An ethogram of the timing and sequencing of right and left arm and leg movements was constructed from each videotaped session. A description of sequential and synchronous relationships between limb movements was determined using stochastic modeling. The temporal patterning of activity in arm, leg and all limb movements was examined by quantitatively determining bout criterion using survivor analysis.Results: Fetuses exhibited within and between limb synchronous, sequential and temporal patterning from the appearance of single limb movements indicating that initial patterning may be genetically hard‐wired. Self‐organization of behavior was apparent in increasing synchronous, sequential and temporal patterning with advancing gestation. These changes coincided with rapid increases in neurulation, synaptogenesis and myelinization in early pregnancy. Different sequential, synchronous and temporal organization was found in arm and leg movements indicating differential neural control of co‐ordination in these limbs. Furthermore, lateralization and gender differences were found to be important features of behavioral organization.Conclusions: The present study has revealed that quantitative assessment can define and measure behavioral complexity and this can elucidate fundamental neurobehavioral organization in early pregnancy.

From gavage to oral feedings: just a matter of time.

The ability to safely and efficiently feed by mouth is based on oral-motor competence, neurobehavioral organization, and gastrointestinal maturity. Although most infants successfully make the transition to oral feedings as they approach term gestation, infants who were very immature at birth have historically had the most difficulty achieving this milestone. Postnatal complications (chronic lung disease, intraventricular hemorrhage, seizures, and so on) are also associated with delays in the onset of the first feeding, as well as with delays in achieving full enteral intake. Weaning the infant to breast is a slow and gradual process that may necessitate supplemental gavage or bottle feedings. A variety of measures--such as positioning, containment, reduced milk flow, and imposed rest breaks--may help to facilitate better oral intake, but infants probably benefit most from the passage of time. Frequently, the older the infant is at first feeding, the shorter the time required to make the transition to full oral feedings. Rather than attempting to accelerate the inherent maturational processes that form the basis for oral feeding, efforts might better be spent in providing adequate nutritional support while avoiding unnecessary stress and fatigue.

Laterality in animals: relevance to schizophrenia.

Anomalies in the laterality of numerous neurocognitive dimensions associated with schizophrenia have been documented, but their role in the etiology and early development of the disorder remain unclear. In the study of normative neurobehavioral organization, animal models have shed much light on the mechanisms underlying and the factors affecting adult patterns of both functional and structural asymmetry. Nonhuman species have more recently been used to investigate the environmental, genetic, and neuroendocrine factors associated with developmental language disorders in humans. We propose that the animal models used to study the basis of lateralization in normative development and language disorders such as dyslexia could be modified to investigate lateralized phenomena in schizophrenia.

Environmental impact of the NICU on developmental outcomes

The neonate, especially the premature one, is both dependent on and vulnerable to the intensive care environment to support physiologic and neurobehavioral organization. Concerns about this environment have led to suggestions that it may be a major contributing factor in the persistent incidence of behavioral and learning problems among preterm infants. By modifying the neonatal intensive care environment to provide a more developmentally supportive milieu, we can better meet the infant's physiologic and neurobehavioral needs, support the infant's emerging organization, and foster growth and development.

Transition to breast/bottle feedings: the premature infant.

Premature infants present a nutritional challenge to the health care provider for a variety of reasons: reduced gastric capacity, poorly integrated intestinal motility, limited digestive capabilities, neurobehavioral immaturity and limited ability to take feedings by mouth. There is often a prolonged need for oro-gastric/nasogastric supplementation until nipple feedings can commence. Neurobehavioral organization is essential for a smooth and gradual transition to full nipple feedings. This article describes the expected progression of behavioral competencies as reflected in recognizable infant cues which can be identified by care providers to facilitate an optimal feeding interaction. The essential components of nutritive sucking, including the integration of suck-swallow-breathe, are detailed. Common problems with their warning signs and methods of prevention are described. Specific recommendations to limit hypoventilation during feedings are discussed, as well as optimal route and rate of delivery of milk. Prefeeding techniques used to arouse the infant to best performance are delineated including state modulation, correct positioning and oral motor stimulation. The second half of the article focuses on the breast-fed premature infant and includes information on maternal markers for success/failure, a detailed discussion of lactogenesis and the establishment of lactation, and specific recommendations for maintaining lactation in the absence of a suckling infant. Practical guidelines based on neurobehavioral development are provided for facilitating the transition from gavage feeding to nursing. Common concerns encountered at discharge are reviewed, including those parameters which require continued healthcare supervision.

Neonatal stress reactivity: predictions to later emotional temperament.

To investigate the relations among popular measures of neonatal stress and their link to subsequent temperament, 50 full-term newborns from a normal care nursery were examined responding to a heelstick blood draw. Baseline and heelstick measures of behavioral state, heart period, vagal tone, and salivary cortisol were obtained. Recovery measures of behavioral and cardiac activity were also analyzed. Mothers completed Rothbart's Infant Behavior Questionnaire when their infants reached 6 months of age. Baseline vagal tone predicted cortisol in response to the heelstick, suggesting that baseline vagal tone reflects the infants' ability to react to stressors. Greater reactivity to the heelstick (more crying, shorter heart periods, lower vagal tone, and higher cortisol) was associated with lower scores on "Distress-to-Limitations" temperament at 6 months. This finding was consistent with the expectation that the capacity to react strongly to an aversive stimulus would reflect better neurobehavioral organization in the newborn. Recovery measures of cardiac activity approximated and were correlated with baseline measures indicating the strong self-righting properties of the healthy newborn. Finally, vagal tone and salivary cortisol measures were not significantly related, suggesting the importance of assessing both systems in studies of the ontogeny of stress-temperament relations.

Biosocial Factors in Early Infancy as Predictors of Competence in Adolescents Who Were Born Prematurely

In a prospective longitudinal study of a cohort of 105 subjects born prematurely, competence was assessed from infancy through late adolescence. A biosocial model guided the research. Neonatal neurobehavioral organization (a composite of term visual attention, amount of time in active sleep, and 407 EEG pattern) and early social stimulation (the amount of talking the mother addressed to the infant during a home observation when the infant was 1 month old) in conjunction with social class were used to predict competence at key age periods through late adolescence. Intellectual competence, school achievement, social competence, and self perception of cognitive competence were studied. The results indicate that measures taken in the early infancy period were predictive of later competence, particularly intellectual competence, above and beyond social class. Twenty-eight percent of the variance in 18-year IQ scores was explained by the predictor variables. The study highlights the importance of directing efforts to improve the social environment of both the infant and the family.