Behavioral development

Introduction

Assessment of growth and development of infants and children typically falls under the domain of the pediatrician or pediatric subspecialist. Delays or deviations from normal often dictate the need to conduct extensive diagnostic evaluations and management strategies. Familiarity with developmental stages may also benefit the pediatric anesthesiologist, allowing the practitioner to recognize the different coping mechanisms children use to respond to the anxiety and stresses throughout the perioperative period. Growth issues, especially failure to thrive, may indicate a serious underlying medical condition that could affect the management and anesthetic plan for children.

A variety of processes are encompassed in growth and development: the formation of tissue; an increase in physical size; the progressive increases in strength and ability to control large and small muscles (gross motor and fine motor development); and the advancement of complexities of thought, problem solving, learning, and verbal skills (cognitive and language development). There is a systematic approach for tracking neurologic development and physical growth in infants, because attainment of milestones is orderly and predictable. However, a wide range exists for normal achievement. The mastering of a particular skill often builds on the achievement of an earlier skill. Delays in one developmental domain may impair development in another ( ). For example, immobility caused by a neuromuscular disorder prevents an infant from exploration of the environment, thus impeding cognitive development. A deficit in one domain might interfere with the ability to assess progress in another area. For example, a child with cerebral palsy who is capable of conceptualizing matching geometric shapes but does not have the gross or fine motor skills necessary to perform the function could erroneously be labeled as having cognitive developmental delay.

It is possible for the anesthesiologist to obtain a gestalt of a child’s growth and development level while recording a preoperative history and during the physical examination. However, the anesthesiologist needs to realize that these assessments are usually done by pediatricians over time and are best performed when the child is physically well, familiar with the examiner, and under minimal stress. Therefore a child who is developing normally could be assessed as delayed during a preoperative assessment.

The goal of this chapter is to review the developmental and behavioral issues faced in routine pediatric practice to help the anesthesiologist tailor an anesthetic plan that is geared to the appropriate age of the child with the goal of decreasing postoperative complications such as behavioral disturbances, emotional reactions, or escalation in medical care that might result from the stress of the perioperative process. A great deal of concern has arisen over the past two decades regarding the safety of administering general anesthesia during early childhood. These issues are more complex than the potential behavioral or emotional changes that may result in the postoperative period because of perioperative stress impacting specific developmental stages of the pediatric patient. They relate to the mounting evidence of animal data showing that early exposure to anesthetics can induce apoptotic neurodegeneration and subsequent maladaptive behaviors in immature animals ( ). The relevance of animal data to anesthetic practice is unknown. The final section of this chapter evaluates some of the current published retrospective and ongoing prospective human studies with regard to this topic. To better understand this issue, there is a need for well-designed clinical studies to generate data regarding the neurodevelopmental risks of pediatric anesthesia. The importance of using neuropsychological testing in future pediatric clinical research as a tool for assessing the neurodegeneration/neurodevelopmental effects of anesthesia on the central nervous system (CNS) during this critical period is reviewed.

Prenatal growth

The most dramatic events in growth and development occur before birth. These changes are overwhelmingly somatic, with the transformation of a single cell into an infant. The first 8 weeks of gestation are known as the embryonic period and encompass the time when the rudiments of all of the major organs are developed. This period denotes a time in which the fetus is highly sensitive to teratogens such as alcohol, tobacco, mercury, thalidomide, and antiepileptic drugs. The average embryo weighs 9 g and has a crown-to-rump length of 5 cm. The fetal stage (more than 9 weeks’ gestation) consists of increases in cell number and size and structural remodeling of organ systems ( ).

During the third trimester, weight triples and length doubles as body stores of protein, calcium, and fat increase. Low birth weight can result from prematurity, intrauterine growth retardation (small for gestational age, SGA), or both. Large-for-gestational-age (LGA) infants are those whose weight is above the 90th percentile at any gestational age. Deviations from the normal relationship of infant weight gain with increasing gestational age can be multifactorial. Potential causes include maternal diseases (e.g., diabetes, pregnancy-induced hypertension, and seizure disorders), prenatal exposure to toxins (e.g., alcohol, drugs, and tobacco), fetal toxoplasmosis-rubella-cytomegalovirus-herpes simplex-syphilis (TORCHES) infections, genetic abnormalities (e.g., trisomies 13, 18, and 21), fetal congenital malformations (e.g., cardiopulmonary or renal malformations), and maternal malnutrition or placental insufficiency ( ).

Postnatal growth

Postnatal growth is measured by changes in weight, length, and head circumference plotted chronologically on growth charts. This is an essential component of pediatric health surveillance, because almost any problem involving physiologic, interpersonal, or social domains can adversely affect growth.

Growth milestones are the most predictable, taking into context each child’s specific genetic and ethnic influences ( ). It is essential to plot the child’s growth on gender- and age-appropriate percentile charts. Charts are now available for certain ethnic groups and genetic syndromes such as trisomy 21 and Turner syndrome. Deviation from growth over time across percentiles is of greater significance for a child than a single weight measurement. For example, an infant at the 5th percentile of weight for age may be growing normally, failing to grow, or recovering from growth failure, depending on the trajectory of the growth curve.

Of the three parameters, weight is the most sensitive measurement of well-being and is the first to show deviance as an indication of an underlying problem. Causes of weight loss and failure to thrive include congestive heart failure, metabolic or endocrine disorders, malignancy, infections, and malabsorption problems. Inadequate increases in height over time can occur secondary to significant weight loss, and decreased head circumference is the last parameter to change, signifying severe malnutrition. Pathologies such as hydrocephalus or increased intracranial pressure may appear on growth charts as head circumference measurements that are rapidly increasing and crossing percentiles. Small head size can be associated with craniosynostosis or a syndromic feature. Notable changes in head circumference measurements in children should alert the anesthesiologist to the potential of underlying neurologic problems.

Because significant weight fluctuation is a potential red flag for serious underlying medical conditions, anesthesiologists should be familiar with the normal weight gain expected for children. It is not unusual for a newborn’s weight to decrease by 10% in the first week of life because of the excretion of excess extravascular fluid or possibly poor oral intake. Infants should regain or exceed birth weight by 2 weeks of age and continue to gain approximately 30 g/day, with a gradual decrease to 12 g/day by the end of the first year. Healthy, full-term infants typically double their birth weight at 6 months and triple it by 1 year of age. Many complex formulas are available to estimate the average weight for normal infants and children. A relatively simple calculation to recall is the “rule of tens”; that is, the weight of a child increases by about 10 pounds per year until approximately 12 to 13 years of age for females and 16 to 17 years of age for males. Therefore one could expect weight gain of 20 pounds by age 2 years, 30 pounds by 3 years, 40 pounds by 4 years, and so on. The weight in pounds can be converted to kilograms by dividing it by 2.2. Expected length in centimeters is estimated by the following formula:

Developmental assessment

Developmental assessment serves different purposes, depending on the age of the child. In the neonatal period, behavioral assessment can detect a wide range of neurologic impairments. During infancy, assessment serves to reassure parents and to identify sensory, motor, cognitive, and emotional problems early, when they are most amenable to treatment. Middle childhood and adolescence assessments often help with addressing academic and social problems.

Milestones are useful indicators of mental and physical development and possible deviations from normal. It should be emphasized that milestones represent the average age for children to attain skills and that there can be variable rates of mastery that fall into the normal range. An acceptable developmental screening test must be highly sensitive (detect nearly all children with problems); specific (not identify too many children without problems); have content validity, test-retest, and interrater reliability; and be relatively quick and inexpensive to administer. The most widely used developmental screening test is the Denver Developmental Screening Test (DDST), which provides a pass/fail rating in four domains of developmental milestones: gross motor, fine motor, language, and personal-social. The original DDST was criticized for underidentification of children with developmental disabilities, particularly in the area of language. The reissued DDST-II is a better assessment for language delays, which is important because of the strong link between language and overall cognitive development. Table 2.1 lists the prevalence of some common developmental disabilities ( ).

Motor development

Primitive reflexes

The earliest motor neuromaturational markers are primitive reflexes that develop during uterine life and generally disappear between the third and sixth months after birth. Newborn movements are largely uncontrolled, with the exception of eye gaze, head turning, and sucking. Development of the infant’s CNS involves strengthening of the higher cortical center, which gradually takes over function of the primitive reflexes. Postural reflexes replace primitive reflexes between 3 and 6 months of age as a result of this development ( ). These reactions allow children to maintain a stable posture even if they are rapidly moved or jolted ( Box 2.1 ).

BOX 2.1

Definitions of Primitive Reflexes

• Automatic stepping reflex: Although the infant cannot support his or her weight when a flat surface is presented to the sole of the foot, he or she makes a stepping motion by bringing one foot in front of the other.

• Crossed extension reflex: When an extremity is acutely stimulated to withdraw, the flexor muscles in the withdrawing limb contract completely, whereas the extensor muscles relax. The opposite occurs (full extension, with relaxation of contracting muscles) in the opposite limb.

• Galant reflex: An infant whose back is stroked on one side moves or swings in that direction.

• Moro reflex: When the infant is startled with a loud noise or when the head is lowered suddenly, the head and legs extend and the arms raise up and out. Then the arms are brought in and the fingers close to make fists.

• Palmar reflex: When an object is placed into the infant’s hand or when the palm of the infant’s hand is stroked with an object, the hand closes around the object.

• Asymmetric tonic neck reflex (“fencing”): When the infant’s head is rotated to one side, the arm on that side straightens and the opposite arm flexes.

• Landau reflex: When the infant is held in a horizontal position, he or she raises the head and bring the legs up into a horizontal position. If the head is forced down (flexed), the legs also lower into a vertical position.

• Derotational righting reflex: When the infant turns the head one direction, the body leans in the same direction to maintain balance.

• Protective equilibrium reflex: When a lateral force is applied to the infant, he or she responds by leaning into the force and extending the contralateral arm.

• Parachute reflex: When the infant is facing down and lowered suddenly, the arms extend out in a protective maneuver.

The asymmetric tonic neck reflex (ATNR) or “fencing posture” is an example of a primitive reflex that is not immediately present at birth because of the high flexor tone of the newborn infant. When the neonate’s head is turned to one side, there is increased extensor tone of the upper extremity on the same side and increased flexor tone on the contralateral side. The ATNR is a precursor to hand-eye coordination, preparing the infant for gazing along the upper arm and voluntary reaching. The disappearance of this reflex at 4 to 6 months allows the infant mobility to roll over and begin to examine and manipulate objects in the midline with both hands.

The palmar grasp reflex is present at birth and persists until 4 to 6 months of age. When an object is placed in the infant’s hand, the fingers close and tightly grasp the object. The grip is strong but unpredictable. The waning of the early grasp reflex allows infants to hold objects in both hands and ultimately to voluntarily let them go.

The Moro reflex is probably the most well-known primitive reflex and is present at birth. It is likely to occur as a startle to a loud noise or sudden changes in head position. The legs and head extend while the arms jerk up and out, followed by adduction of the arms and tightly clenched fists. Bilateral absence of the reflex may mean damage to the infant’s CNS. Unilateral absence could indicate birth trauma, such as a fractured clavicle or brachial plexus injury.

Postural reflexes support control of balance, posture, and movement in a gravity-based environment. The protective equilibrium response can be elicited in a sitting infant by abruptly pushing the infant laterally. The infant will extend the arm on the contralateral side and flex the trunk toward the side of the force to regain the center of gravity ( Fig. 2.1 ). The parachute response develops around 9 months and is a response to a free-fall motion, where the infant extends the extremities in an outward motion to distribute weight over a broader area. Postural reactions are markedly slow in appearance in the infant who has CNS damage. Children who fail to gain postural control continue to display traces of primitive reflexes. They also have difficulty with control of movement affecting coordination, fine and gross motor development, and other associated aspects of learning, including reading and writing. Table 2.2 lists the average times of appearance and disappearance of the more common primitive reflexes.

TABLE 2.2

Primitive Reflexes

Reflex	Present by (Months)	Gone by (Months)
Automatic stepping	Birth	2
Crossed extension	Birth	2
Galant	Birth	2
Moro	Birth	3–6
Palmar	Birth	4–6
Asymmetric tonic neck (“fencing”)	1	4–6
Landau	3	12–24
Derotational head righting	4	Persists
Protective equilibrium	4–6	Persists
Parachute	8–9	Persists

Gross motor skills

One principle in neuromaturational development during infancy is that it proceeds from cephalad to caudad and proximal to distal. Thus arm movement comes before leg movement ( ). The upper extremity attains increasing accuracy in reaching, grasping, transferring, and manipulating objects. Gross motor development in the prone position begins with the infant tightly flexing the upper and lower extremities and evolves to hip extension while lifting the head and shoulders from a table surface around 4 to 6 months of age. When pulled to a sitting position, the newborn has significant head lag, whereas the 6-month-old baby, because of development of muscle tone in the neck, raises the head in anticipation of being pulled up.

Rolling movements start from front to back at approximately 4 months of age as the muscles of the lower extremities strengthen. An infant begins to roll from back to front at about 5 months. The abilities to sit unsupported (about 6 months old) and to pivot while sitting (around 9 to 10 months of age) provide increasing opportunities to manipulate several objects at a time ( ). Once thoracolumbar control is achieved and the sitting position mastered, the child focuses motor development on ambulation and more complex skills. Locomotion begins with commando-style crawling, advances to creeping on hands and knees, and eventually reaches pulling to stand around 9 months of age, with further advancement to cruising around furniture or toys. Standing alone and walking independently occur around the first birthday. Advanced motor achievements correlate with increasing myelinization and cerebellum growth. Walking several steps alone has one of the widest ranges for mastery of all of the gross motor milestones and occurs between 9 and 17 months of age. Milestones of gross motor development are presented in Figs. 2.2 and 2.3 . The accomplishment of locomotion not only expands the infant’s exploratory range and offers new opportunities for cognitive and motor growth, but it also increases the potential for physical dangers ( ).

Most children walk with a mature gait, run steadily, and balance on one foot for 1 second by 3½ years of age. The sequence for additional gross motor development is as follows: running, jumping on two feet, balancing on one foot, hopping, and skipping. Finally, more complex activities such as throwing, catching, and kicking balls; riding bicycles; and climbing on playground equipment are mastered. Development beyond walking incorporates improved balance and coordination and progressive narrowing of additional physical support. Complex motor skills also incorporate advanced cognitive and emotional development that is necessary for interactive play with other children. Fig. 2.3 shows the red flags to watch for in the abnormal physical development of the infant.

Fine motor development

At birth, the neonate’s fingers and thumbs are typically tightly fisted. Normal development moves from the primitive grasp reflex, where the infant reflexively grabs an object but is unable to release it, to a voluntary grasp and release of the object. By 2 to 3 months of age, the hands are no longer tightly fisted, and the infant begins to bring them toward the mouth, sucking on the digits for self-comfort. Objects can be held in either hand by age 3 months and transferred back and forth by 6 months. In early development, the upper extremities assist with balance and mobility. As the sitting position is mastered with improved balance, the hands become more available for manipulation and exploration. The evolution of the pincer grasp is the highlight of fine motor development during the first year. The infant advances from “raking” small objects into the palm to the finer pincer grasp, allowing opposition of the thumb and the index finger, whereby small items are picked up with precision. Children younger than 18 months of age generally use both hands equally well, and true “handedness” is not established until 36 months ( ). Advancements in fine motor skills continue throughout the preschool years, when the child develops better eye-hand coordination with which to stack objects or reproduce drawings (e.g., crosses, circles, and triangles). Fig. 2.4 lists and demonstrates the chronologic order of fine motor development.

Language development

Delays in language development are more common than delays in any other developmental domain ( ). Language includes receptive and expressive skills. Receptive skills are the ability to understand the language, and expressive skills include the ability to make thoughts, ideas, and desires known to others. Because receptive language precedes expressive language, infants respond to several simple statements such as “no,” “bye-bye,” and “give me” before they are capable of speaking intelligible words. In addition to speech, expression of language can take the forms of gestures, signing, typing, and “body language.” Thus speech and language are not synonymous. The hearing-impaired child or child with cerebral palsy may have normal receptive language skills and intellect to understand dialogue but needs other forms of expressive language to vocalize responses. Conversely, children may talk but fail to communicate; for example, a child with autism may vocalize by using “parrot talk” or echolalia that has no meaningful content and does not represent language.

Language development can be divided into the three stages of prespeech, naming, and word combination. Prespeech is characterized by cooing or babbling until around 8 to 10 months of age, when babbling becomes more complex with multiple syllables. Eventually random vocalization (“da-da”) is interpreted and reinforced by the parents as a real word and the child begins to repeat it. The naming period (ages 10 to 18 months) is when the infant realizes that people have names and objects have labels. Once the infant’s vocalizations are reinforced as people or things, the infant begins to use them appropriately. At around 12 months of age, some infants understand as many as 100 words and can respond to simple commands that are accompanied by gestures. Early into the second year, a command without a gesture is understood. Expressive language is slower, and an 18-month-old child has a limited vocabulary of around 25 words. After the realization that words can stand for things, the child’s vocabulary expands at a rapid pace. Preschool language development begins with word combination at 18 to 24 months and is the foundation for later success in school. Vocabulary increases from 50 to 100 words to more than 2000 words during this time. Sentence structure advances from two- and three-word phrases to sentences incorporating all of the major grammatic rules. A simple correlate is that a child should increase the number of words in a sentence with advancing age—for example, two-word sentences by 2 years of age, three-word sentences by age 3 years, and so on ( Table 2.3 ).

Language is a critical barometer of both cognitive and emotional development ( ). Mental retardation may first surface as a concern with delayed speech and language development around 2 years of age; however, the average age of diagnosis is 3 to 4 years. All children whose language development is delayed should undergo audiologic testing. If a child’s expressive skills are advanced compared with his or her receptive skills (e.g., child speaks five-word sentences but does not understand simple commands), a pervasive development disorder could be the cause.

Cognitive development

The concept of a developmental line implies that a child passes through successive stages. The psychoanalytic theories of Sigmund Freud and Erik Erikson and the cognitive theory of Jean Piaget describe stages in the development of cognition and emotion that are as qualitatively different as the milestones attained in gross motor development.

At the core of Freudian theory is the idea of biologically determined drives. The core drive is sexual, broadly defined to include sensations that include excitation or tension and satisfaction or release ( ). There are discrete stages: oral, anal, oedipal, latent, and genital. During these stages the focus of the sexual drive shifts with maturation and is at first influenced primarily by the parents and subsequently by an enlarging circle of social contacts. Defense mechanisms in early childhood can develop pathologically to disguise the presence of conflict. The emotional health of the child and adult depends on the resolution of the conflicts that arise throughout these stages.

chief contribution was to recast Freud’s stages in terms of the emerging personality. For example, basic trust, the first of Erickson’s psychosocial stages, develops as infants learn that their urgent needs are met regularly. The consistent availability of a trusted adult creates the conditions for secure attachment. The next stage establishes the child’s internal sense of either autonomy versus shame and doubt and corresponds to Freud’s anal stage. A sense of either identity or role confusion corresponds to the crisis experienced in Freud’s genital stage (puberty) ( Table 2.4 ).

Piaget’s name is synonymous with the study of cognitive development. A central tenet of his theory is that cognition is qualitatively different at different stages of development ( ). During the sensorimotor stage, children learn basic things about their relationship with their environment. Thoughts about the nature of objects and their relationships are acted out and tied immediately to sensations and manipulation. With the arrival of language, the nature of thinking changes dramatically, and symbols increasingly take the place of things and actions. Stages of preoperational thinking, concrete operations, and formal operations correspond to the different ages of preschool, school age, and adolescence, respectively. At all stages, children are not passive recipients of knowledge but actively seek out experiences (assimilation) and use them to build on how things work.

Cognitive development and neuromaturational development are closely related, and it is sometimes difficult to distinguish between the two in the infant and child. Early in the neonatal period, cognitive development begins when the infant responds to visual and auditory stimuli by interacting with surroundings to gain information. Activities such as mouthing, shaking, and banging objects provide information to the infant beyond the visual features. Infant exploration begins with the body, with activities such as staring intently at a hand and touching other body parts. These explorations represent an early discovery of “cause and effect,” as the infant learns that voluntary movements generate predictable tactile and visual sensations (e.g., kicking the side of the crib moves a mobile). Signs of abnormal cognitive development are outlined in Box 2.2 .

A communication system develops between the infant and primary caregiver. Accordingly, the infant begins to display anxiety at the end of this developmental period if the person most familiar to the child is not available. The ability to maintain an image of a person develops before that of an object, and therefore the infant may display separation anxiety when a loved one leaves the room. Object permanence, a major milestone, develops around 9 months when the infant understands that objects continue to exist even if they are covered up and not seen. With locomotion the child explores greater areas and develops a substantial sense of social self as well as an early appreciation of the behavior standards expected by adults. Interactive play and pretend play begin at 30 months, and playing in pairs occurs around 24 to 36 months.

Childhood cognitive development and the effect it has on the child’s perception of the hospitalization and surgery are important for the pediatric anesthesiologist to understand how to help the child deal with the stresses during this time. One out of four children will be hospitalized by age 5 years. Although extreme emotional reactions are rare, at least 60% of children demonstrate signs of stress-related anxiety during the perioperative period. Children between the ages of 1 and 3 years, previously hospitalized children, and children who have undergone turbulent anesthetic inductions are at increased risk for exhibiting adverse postoperative behavioral reactions. Stress and anxiety can be manifested by behavioral problems such as nightmares, phobias, agitation, avoidance of caregivers, emotional distress, and regressive behaviors (e.g., temper tantrums, bed-wetting, and loss of previously acquired developmental milestones). Allowing adequate preoperative evaluation and psychological preparation for both the parent and child based on specific needs relative to the child’s developmental stage is a method the anesthesiologist can invoke to reduce the emotional trauma of anesthesia.

describes the infants’ motivations as dependent on the satisfaction of basic human needs (e.g., food, shelter, and love). According to Freud, the child directs all of his or her energies to the mother and fears her loss because her absence may jeopardize the child’s satisfaction, creating tension and anxiety. This dependence is the essence of separation anxiety. Before this stage, infants are able to accept surrogates and respond favorably to anyone holding them. Once stranger anxiety develops, active participation of the parents during the hospitalization should be encouraged to maintain a sense of security for the child and promote bonding ( ).

Toddlers have developed ambulation skills that allow exploration, but they are well bonded to their parents and much less willing to be separated, especially when they are stressed. They are too young to understand detailed explanations, so procedures should be told in simple, nonthreatening language. Comprehension of conversation is more advanced than verbal expression. The receptive and expressive language discordance often results in frustration on the child’s behalf, putting toddlers at increased risk for stormy inductions and postoperative emotional and behavioral reactions. Toddlers also fear pain and bodily harm. Whenever possible, a parent or trusted caregiver should be present for potentially painful or threatening procedures. Children at this age are comforted by a familiar toy or treasured object and respond to magical thinking or stories.

The preschooler’s view of the world is egocentric or self-centered. The child is unable to understand or conceptualize another individual’s point of view, does not comprehend why people do not understand him or her, and has no appreciation for others’ feelings. These children have concerns with bodily integrity and demonstrate the need for reassurances. Anxiety can be allayed by giving the child a sense of mastery and participation, such as allowing him or her to “hold” the mask for induction. Their preoperational thinking is very literal, and it is important to use caution when using similes or metaphors; for example, if a provider states that the child will be given a “stick” (intravenous line or shot), the child may wait to be handed a tree branch. At this stage, any explanation appears to be more important than the actual content of the explanation. Children who were given explanations, whether accurate or not, were found to have fewer postoperative behavioral changes than those who were not given explanations ( ). Although the preschooler’s vocabulary is improving, cognitively the child may have difficulty remembering a sequence of events or establishing causality, leading to misconceptions about procedures.

School-age children, during the “concrete operations” stage, are more independent. Their activities become goal oriented, and their language skills develop rapidly. They have a sense of conscience and can appreciate the feelings of others. Children are able to draw on previous experience and knowledge to formulate predictions about related issues. They have an increased need for explanation and participation. Rather than giving children choices in the operating room (e.g., intravenous injection vs. mask for going to sleep), details about the procedure and options available for the child should be discussed preoperatively in a nonthreatening environment ( ).

Adolescents are caught in a difficult period between childhood and adulthood. Physically, they are maturing and may feel self-conscious about their bodies. Psychologically, they are striving to know who they are. Adolescents have developed the ability to recognize and exhibit mature defense mechanisms (e.g., the adolescent whose appendicitis “at least gets me out of my math test”). They are more likely to cooperate with a physician perceived to be attentive and nonjudgmental. Concerns regarding coping, pain, losing control, waking up prematurely, not waking up, and dying are very real for teenagers. Clear explanations and assurances should be provided regarding these issues. The need for independence and privacy is important and should be respected.

Clinical relevance of growth and development in pediatric anesthesia

An overview of basic growth and development can be obtained in a preoperative consultation by reviewing the history and observing for gross and fine motor milestones during the physical examination. A 1-month-old infant displaying well-developed extensor tone when suspended in a ventral position might be interpreted by the parent as having advanced motor development, when, in reality, issues of an upper motor neuron lesion should be considered. Other signs of spasticity are early rolling, pulling to a direct stand at 4 months of age, and walking on the toes. Persistent closing of fists beyond 3 months of age could be the earliest indication of neuromotor dysfunction. An afebrile 2-month-old baby with tachypnea, rales, audible murmur, and failure to gain weight should raise concerns about a significant cardiac lesion and the need for a cardiac consultation. A 7-month-old infant with poor head control who is unable to sit without support or to lift his or her chest off the table in the prone position may indicate hypotonia and a possible neuromuscular disorder. Spontaneous postures, such as “frog legging” when prone or scissoring, may provide visual physical clues of hypotonia or spasticity, respectively. At 9 months of age, the child should stand erect on a parent’s lap or cruise around office furniture, and the 12-month-old child will want to get down and walk. Weakness in the 3- or 4-year-old child may be best discovered by observing the quality of stationary posture and transition movements. The Gowers sign (arising from sitting on the floor to standing using the hands to “walk up” the legs) is a classic example of pelvic girdle and quadriceps muscular weakness. Fine motor evaluation can be easily evaluated by handing the infant a tongue depressor or toy. The newborn infant should grasp it reflexively; by 4 months of age, the infant should reach and retain the object, and by the age of 6 months, the child can transfer an object from hand to hand. The development of fine pincer grasp by 12 months of age allows the child to pick up small objects with precision and increases the risk for foreign body aspiration. The observation of a child who constantly uses one hand while neglecting the other should prompt the clinician to examine the contralateral upper extremity for weakness associated with hemiparesis.

Abnormal head size, significant weight gain or loss, and short stature may be indicative of genetic concerns. The presence of three or more dysmorphic features should raise concerns of a syndrome with possible difficult airway or cardiac issues. Almost 75% of superficial dysmorphic features can be found by examining the head, hands, and skin.

Neuropsychological testing as a tool for assessing the neurodevelopmental effects of anesthesia

The earliest studies attempting to elucidate any risks of anesthesia exposure on young children were limited in outcomes. These studies tended to focus on achievement/presence of a learning disability or IQ scores. However, such outcome measures may not be the most sensitive to subtle insult/injury in the brain ( ).

Assessment of neurocognitive functioning requires a solid understanding of both psychometrics and developmental needs related to assessment ( ; ; ; ). These nuanced challenges are typically best understood by a pediatric neuropsychologist with expertise and training in these domains ( ). The rapidly changing abilities in a child from birth to age 18 preclude the use of a single measure or measures across all time points. For example, measures of executive functioning look different for an 8-year-old, whose frontal lobes are not yet fully developed, and a 14-year-old, who would be expected to engage more easily in problem-solving activities and thinking ahead ( ). Thus an expert with understanding of the challenges of pediatric cognitive assessment can best determine an appropriate outcome battery.

In identifying appropriate outcome measures, it is important to assess all possible neuropsychological domains that may be applicable. The next section describes each primary neurocognitive domain and includes a table of assessments ( Table 2.5 ) useful for assessing each domain. It should be noted that this table is not comprehensive, because many more tests are available. However, these are some of the most commonly used measures.