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1990;85;17Pediatrics

Howard CabralSteven Parker, Barry Zuckerman, Howard Bauchner, Deborah Frank, Robert Vinci and

Jitteriness in Full-Term Neonates: Prevalence and Correlates

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The online version of this article, along with updated information and services, is located on

ISSN: 0031-4005. Online ISSN: 1098-4275.

PrintIllinois, 60007. Copyright 1990 by the American Academy of Pediatrics. All rights reserved.by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarkedPEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,

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J itte rin e ss in F u ll T erm N eo n a tes :

P E D I A T R I C S V o l. 8 5 N o . 1 J an u a ry 1 9 90 1 7

P re v a le n c e a n d C o rre la te sS te ve n P ark e r M D; B arry Z u c k e rm an M D; H ow ard B au c h n er M D;D e b o ra h F ra n k M D; R o b e rt V in c i M D; a n d H o w a rd C a b ra l M PHF ro m th e D iv is io n o f D e ve lo pm en ta l a n d e h a v io ra l P e d ia trics D e p a rtm en t o f P e d ia tric s

o s to n C ity H o s p ita l a n d o s to n U n ive rs ity S ch o o ls o f M e d ic in e a n d P u b lic H e a ltho s to n Ma s s a c h u s e t t s

A B S T R A C T . T h e p reva lence an d corre late s o f jitte rin e ssw ere eva lua ted in a sam p le o f 9 36 h ea lth y fu ll- termin fan ts . J itte rine ss w as seen in 44 of th is sam ple : 23w ere cla ssif ied as m ild ly jitte ry , 8 as m odera te ly jitte ry ,an d 13 as ex trem e ly jitte ry . J itte r ine ss w as seen m o stcomm only in in fan ts w ho w ere sleep y or ac tive and lea stcomm only in in fan ts w ho w ere qu ie tly w ake fu l du ringthe neon ata l ex am ina tion . J itte ry in fan ts w ere m orelik ely to be d iff icu lt to con so le w h en c ry in g P < .01) an dless v isual ly alert P < .00 1 ) than w ere no n jitte ry in fan ts .J itte rin es s w as seen m ore com m on ly in slig h tly sm a lle rP < 05 and sho rte r P < .001) in fan ts , in tho se m orethan 12 hou rs o ld P < .01 ) , an d in tho se no t exp osed toge ne ra l a ne sthe sia P < .05). In an ex pand ed sam ple o f1054 hea lthy and s ick fu ll-te rm in fan ts, jitter in ess w asobserved m o re comm only in n eo na tes w ho h ad b eenexpo sed prena tally to m ate rna l m arijuana use P < .01 ) ,bu t n o t to coca ine use P = .1 ) , and w ho se m o the rs hada p o sitiv e p o stp a r tu m u r in e a ssa y fo r m a r iju a n a P < .05 )o r c oc ain e P = .06 ) . T h e m agn itu de of these drug effects ,how eve r , w as sm a ll. T hese fin d ing s h av e im portan t im -p lica tion s fo r the early p aren t-in fan t rela tion sh ip , ped i-a tric p rac tice, an d fu tu re re search . Ped ia tr ic s 1990 ;85 :17 -23 ; neona ta l behav ior neona ta l jitte rin es s n eo na ta l n eu -r o lo g ic e x am i na ti o n j i tt er in e ss .

J itter ine ss is de fined as rh y thm ic trem ors o fequ al am p litu de a rou nd a fixed ax is and is the m ostcom m on inv o lu n ta ry m ov em en t o f hea lthy fu ll-te rm in fan ts . S tu d ie s conce rn in g its p reva len ce,how ev er, a re ra re an d h av e y ie lded con flic tin g re -su lts . T o uw en2 obse rved 2 0 o f 5 0 low -risk in fan tsto b e jitte ry du ring spo n taneou s m ov em en ts , and

Rece ived fo r pu b lica tion S ep 22 , 1988; accep ted M ar 20 , 198 9 .P resen ted , in part, a t the ann ua l m ee tin g o f the S oc iety fo rB ehav io ral P ed ia tr ic s , M ay 1988 , Washington , DCReprin t re qu ests to S .P .) D iv isio n of D evelopm en tal a nd B e-hav io ral P ed iatr ics, B os ton C ity H osp ita l, 81 8 H arr ison A ye ,B osto n , M A 02118 .PED IA TR IC S ISSN 0031 4005) . C opyrigh t 1990 by th eAmeric an A cad em y o f P ediatrics.

W illem se repo rted a p rev alen ce o f 41 in 138 in -fan ts o bse rved in the firs t ho urs o f life .

T h e c lin ica l ap p licab ility of th e a vaila b le s tu d ieshas b een lim ited . F irs t, the inv es tig ato rs exam inedrela tiv ely few in fan ts an d d id n o t d o cu m en t th e irp ren ata l, in trapa rtum , o r p os tp artum ch arac teris-tic s . S econd , they d id n o t repo rt the behav io ra ls ta te s du ring w h ich the in fan ts w ere ji ttery . B ehav -io ra l s ta tes ie , w h ethe r as le ep , a lert, and /o r c ry in g )exert a p o w erfu l in flu en ce o n a ll asp ects of n eo n ata lneu ro behav io ra l fu nc tio n in g .3 J itte rine ss , in pa rtic -u lar, is co ns id ered to o ccu r com m only w hen in fan tsa re c ry in g o r s tressed . P eip e r and Isb e rt , fo r ex -am p le , rep o rted jit terin e ss to occu r in tw o th ird s o fin fan ts fo llow ing e lic ita tio n o f th e M o ro resp on sein the first w eek o f l ife . O n the o the r h an d , jit teri-ness is con side red to be clin ica lly sign ifican t if itoccu rs w h en the in fan t is qu ie t an d a le rt. B ecau sestud ies h av e lack ed do cum en ta tion o f th e in fan tsb eh av iora l sta tes th ey h ave b een am b ig u ou s as toth e ex ten t an d clin ic al seve rity o f th e jitte rin ess .T h ird , from av ailab le s tu d ie s , w h e the r ji tte rine ss inheal thy in fan ts is an iso la ted fin d ing o r o ccu rs incon jun ction w ith o the r n eu rob eh av io ra l s ig ns an dsym ptom s has n o t been estab lished . B ecause o f thelim ited da ta , jitte rine ss in an o the rw ise hea lthy fu ll-te rm in fan t rem a in s o f u ncerta in c lin ic al s ign ifi-c nce

lth ou gh th e im p lica tio n s o f jitter in ess inhea lthy in fan ts are n o t w e ll es tab lish ed , it ha s beena sso cia ted w ith a v a rie ty o f pa th o lo g ic con d it ion s,in clu d in g h ypog lycem ia , h yp ocalcem ia , na rco tic ab -s tin en ce sy nd rom e, sep sis, h yp ox ic en cep ha lop athy ,and in trac ran ia l h em orrh ag e.4 S uch pro b lem s a rere la tive ly in freq uen t, h ow eve r, and th e cau se o fjit terin e ss is u su a lly no t app aren t . In o ne s tu dy ,5 34hea lthy fu ll- te rm in fan ts w ho w ere jitte ry w ith ou ta p p aren t ca u se w ere fou n d to h ave e leva ted seru mno rep in ep h rin e lev els , com pa red w ith a con tro l

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18 J IT T E R IN E S S

group of nonj i ttery inf ants. A nother study6 dem-onstrated depressed serum magnesium levels (w i thnormal cal cium and glucose lev el s) in 22 j i ttery 1-day -old inf ants w i th otherw ise normal ex aminationf i ndings. W hatever i ts eti ology , the prevalence ofj i tteri ness in heal thy inf ants markedly dim ini shesby the second w eek of l i f e and is general l y absentaf ter that tim e.7

T he goal of this study w as to clari f y the cl inicalsigni f i cance of j i tteri ness in heal thy f ul l -term in-fants and to: (1) determ ine i ts prevalence duringdi f f erent behav ioral states; 2) determ ine the asso-ciat ion betw een neonatal j i tteriness and prenatal ,intrapartum, and postpartum variables, incl udingmaternal cigarette, alcohol , cocai ne, and m ari j uanause during pregnancy ; and 3) identi f y w hether j i t-teri ness i s associated w i th other aspects of neonatalneurobehav i oral f unctioning, especial l y those thatmight af f ect the parent-i nfant relati onship.

M A T E R IA L S A N D M E T H O D SS am p le S e le c tio n an d M eth o d s

T he sam ple w as draw n f rom a cohort of inf antsborn to m others parti cipating in an epidem iol ogi cstudy, conducted f rom 1984 to 1987, i nv estigat ingthe relationshi p of m aternal drug use and otherheal th behav i ors during pregnancy to new born out-com es. W omen w ere consecuti v ely recrui ted f ol low -ing registration for prenatal care at the W om en sand A dolescent Prenatal C l inics at B oston Ci tyH ospi tal . El igibi l i ty requi rem ents f or study parti c-ip a t io n w er e t h e a b ilit y t o co m m u n ica t e in E n g lishor Spanish and w i l l i ngness to prov ide i nf orm edconsent.

W om en w ere interv iew ed in the prenatal andimmediate postnatal per iod by a trained bi l inguali nterv iew er. T he interv iew s w ere sem istructured,and a closed-ended, f orced-choice f ormat w as used.Inf orm ation w as el i ci ted that incl uded the w omen sdemographic characteri sti cs, nutri ti onal i ntake,psychologic stress, and use of cigarettes, al cohol ,cocai ne, m ari juana, and other i l l i ci t drugs.

M aternal uri ne samples w ere obtained f ol low i ngthe prenatal interv iew and during the postpartumhospi tal i zati on and assay ed for cocaine and man-j uana metabol i tes using the enzy m e-m ediated im -munoassay technique. Posi ti ve resul ts w ere recon-f i rmed by m ass spectroscopy /gas chrom atographyf or cocaine metabol i tes and high-pressure l iquidchromatography f or m ari juana m etabol i tes. A uri neassay posi ti ve f or cocaine suggests use w i thin theprevious 72 hours, and an assay posi ti ve f or man-j uana suggests use w i thin the prev ious 10 day s.Cocai ne and m ari j uana users duri ng pregnancyw ere identi f i ed by posi ti v e sel f -report and/or a pos-

i ti v e uri ne test. T he use of cigarettes, alcohol , andother drugs w as identi f i ed solely by sel f -report. Am ore com plete descripti on of the study m ethodol -ogy has been publ i shed.8 Soon af ter del i very , thematernal m edical record w as rev iew ed and codedf or prenatal and intrapartum heal th-related van-ables based on the ri sk f actors developed by H obelet al .9

T he infants of these w om en w ere exami ned inthe hospi tal by one of f i ve pediatri cians w ho w asunaw are of the m other s prenatal on intnapartumhi story . T hese ex am inati ons w ere conducted 8 to72 hours af ter del i very . T he N eurological and A dap-t i ve Capaci ty Scal e developed by A miel -T ison, { 176}sel ected i tem s f rom the N eonatal B ehav ioral A s-sessm ent Scale dev eloped by B razel ton,1 the N eu-nological and Physical M atur i ty I ndices of the D u-bow i tz Exam ination f or Gestational A ge, 2 andstandardized anthropometni c measurem ents w ereused. Fol l ow ing these assessm ents, the i nf antsm edical records w ere rev iew ed, and perti nent m ed-ical inf ormation w as abstracted, including bi rthw eight, A pgan scones, number of days of hospi tal i -zati on, days in special cane, medications receiv ed,l aboratory data, and other medical problem s.

Inf ants w ere selected f or i nclusion in the analy sisi f they w ere ful l - term (def ined as 37 w eeks ges-tational age by D ubow i tz ex amination) and heal thy(def ined as hav ing spent l ess than 24 hours i n theneonatal intensive care uni t). T he cri teria f or ad-m issi on to the neonatal intensive cane uni t at B os-ton Ci ty H ospi tal include al l inf ants w ho are cl ini -cal l y judged to requi re acute medical m anagem entand/on close observ ation. Speci f i cal l y , al l i nf antsw ho experienced intrauterine narcoti c ex posure,the most comm only docum ented cause of ex tremej i t teri ness at our f aci l i ty , are observ ed and m anagedin the neonatal intensive care uni t . I nf ants w ho arecl inical l y stable are usual l y transf erred f rom theneonatal intensive care uni t to the normal nurseryw i thin 24 hours. I nf ants w ho spent longer than 24hours in the neonatal intensi ve cane uni t w ere ex-cluded f rom most of the analy ses to avoid theconf oundi ng ef f ects of intercurrent i l l ness on j i tter-mess and other aspects of neonatal neunobehav ionalfunctioning.

D es cr ip tio n o f In fa n t A ss es sm en t In s tru m en tsT he N eurologic and A daptive Capaci ty Scale is a

structured neurobehav ional ex am ination that i sused to assess an inf ant s responses to v i sual andaudi tory stimul i , passi ve and acti v e tone, primaryref lex es, m otor act i v i ty , lev el of al ertness, am ountof cry ing, and ease of consolabi l i ty . T he N eunol og-ical and A daptiv e Capaci ty Scale w as perf orm ed i na qui et room i n the w el l -baby nursery and took

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20 J TT R N SS

sample of 936 healthy full-term infants. T his sam-ple was used to evaluate the prevalence and come-lates of jitteriness in clinically healthy infants.

The intnapartum data of this sample were rep-nesentative of the obstetrical practices at our insti-tution. N o analgesia or anesthesia was administeredfor 44 of the deliveries. Intrapartum local anes-thesia was used for 25 of the deliveries, epiduralanesthesia for 16 , spinal anesthesia for 6 , andgeneral anesthesia for 4 . Intrapartum intravenousanalgesia (usually alphaprodine) was administeredto 34 of the women. T he incidence of cesareansections was 13 , most commonly done because offetal bradycandia and/on failure oflabon to progress.

Of the 166 full-term infants who spent more than24 hours in the neonatal intensive care unit, 42were excluded because of identified maternal nan-cotic use and six were not examined because ofadministrative errors, resulting in a cohort of 118sick full-term infants. The entire sample of 1054healthy and sick full-term infants was only usedwhen examining the relationship between maternalpsychoactive drug use during pregnancy and neo-natal j it ter iness.

The demographic characteristics of the mothersof the study infants were representative of thepopulation served by Boston City H ospital: prepon-denantly black (66 ) and H ispanic (18 ), low in-come (64 with incomes less than 12 000 penyear), w ith low educational attainment (41 didnot graduate from high school).

The health habits of these women during preg-nancy have been previously published. 3 Of specialinterest in this analysis was the prevalence of ma-tennal substance use during pregnancy (Table 2).Cigarette use was reported by 40 of the womenand alcohol use by 58 . A s ascertained by self-

report on a positive urine assay, cocaine was usedby 15 of the women during pregnancy and man-juana by 25 . Positive postpartum urine assays forcocaine and marijuana were determined for 4 and6 of the samples, respectively. W e previouslyreported that, for the entire sample, 16 of themarijuana users and 24 of the cocaine users de-nied use and were identified solely by urine assay. 4

For the sample of 936 healthy full-term infants,the mean weight (3329 g), length (50.0 cm), headcircumference (34.4 cm), and 5-minute A pgar score(8.9) were within the normal ranges.

P re va le n c e o f J it t e r in e s sThe prevalence of jitteriness in each behavioral

state, as ascertained during the examination of the936 healthy full- term infants, is shown in Table 1.Jitteriness was seen in 44 of these neonates: mildjitteriness was observed in 23 , moderate jitteni-ness in 8 , and extreme jitteriness in 13 .

C o r r e la t e s o f J i t t e r in e s s : P r e n a t a l Va r ia b le sJitteriness in the 936 healthy full- term infants

was not signif icantly associated with most of theselected prenatal risk factors including the presenceand degree ofpnegnancy-induced hypertension, ma-tennal weight gain, the highest maternal systolicblood pressure, and maternal psychologic stressscone.

T he relationship between maternal use of ciga-nettes, alcohol, cocaine, on marijuana during pneg-nancy and neonatal jitteriness is shown in Table 2.M aternal use of marijuana during pregnancy waspositively associated with neonatal jitteriness P