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4Prenatal and Neonatal Development

“Life is always a rich and steady time when you are waiting for something to happen or to hatch.”

Charlotte’s Web (E. B. White, 1952)

Learning Objectives

After studying this chapter you will be able to:

ሁ Define and differentiate between the prenatal and neonatal stages of development. ሁ Describe how and when conception takes place and the signs and symptoms of early pregnancy. ሁ Name the phases of prenatal development and the changes that occur with each. ሁ Identify the components of a healthy lifestyle during pregnancy and how they contribute to a healthy child.

ሁ Explain the function and influence of genetics on child development. ሁ Identify the signs and stages of the birth process. ሁ Describe typical development during the neonatal period.

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Section 4.1 What Are Prenatal and Neonatal Stages of Development?

Chapter Outline Chapter Overview

4.1 What Are Prenatal and Neonatal Stages of Development?

4.2 Prenatal Development

4.3 A Healthy Pregnancy Lifestyle

4.4 Genetics

4.5 The Birth Process

4.6 The Neonatal Period

Summary and Resources

Chapter Overview As E. B. White suggests in his well-known children’s book Charlotte’s Web, the time when a little one is growing, thriving, and waiting to be born is a time full of wonder, anticipation, and hope. In fact, research is discovering more every day about just how important the beginning periods of life are to a child’s later development. Everything that a baby encounters in the womb, during birth, and over the critical first 4 weeks of life can have positive or negative effects as the child’s development progresses.

Because of the deep influence of this stage on later child development, this chapter focuses on how conception occurs, the phases of healthy development in utero, healthy lifestyles dur- ing pregnancy, and the role that genetics plays in this development. In this chapter, we also describe the availability of testing for certain diseases before birth, the stages of the birth process, and the importance of a newborn’s first month.

4.1 What Are Prenatal and Neonatal Stages of Development?

When considering the importance of child development, it is common to think of contexts that begin during infancy and continue through toddlerhood, including nutrition, learning, and building relationships. However, a child’s developmental journey truly begins at conception. Chapter 2 explored the importance of genetics and experiences during the time before birth. The period from conception through birth is called the prenatal stage. During this time, the mother and her support team are ultimately responsible for providing the child with every- thing needed to grow physically and mentally. They are equally as responsible for protecting the child from harm during this period. The prenatal period is crucial for preparing the child for exposure to the outside world.

The next developmental stage in this journey begins immediately after birth and continues through the first 4 weeks of life. This is called the neonatal stage. Babies are especially vul- nerable during this time period. Every detail about how they eat, sleep, and interact with other people can have huge implications for their future development. These implications are important for early childhood caregivers to recognize, regardless of the age at which the child begins receiving care.

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fallopian tubes

ovary egg

(ovum)

uterus

fertilization

zygote

ovary

vagina

sperm

uterine wall

implantation

Section 4.2 Prenatal Development

4.2 Prenatal Development What occurs from conception to birth is a complex and intricate process. In discussing this process, we focus first on how conception occurs, the distinction between gestational age and fetal age, and the phases of prenatal development.

Conception Each month in the female body, an egg is released from the ovary as part of the reproductive cycle. The process of releasing the egg, or ovum, is called ovulation. Ovulation typically occurs halfway through a woman’s menstrual cycle, approximately 14 days after menstruation begins. After ovulation, the ovum travels down the fallopian tube toward the uterus (see Fig- ure 4.1). On a typical month, the ovum continues its journey to the uterus alone and is flushed out along with the uterine lining in the menstruation process. However, if the woman has recently had intercourse, or has intercourse after the ovum is released and before it is flushed out of the body, the process can potentially be altered. The male reproductive cell, called the sperm, is designed to penetrate the wall of the recently released ovum. If a sperm success- fully penetrates the ovum wall, it results in fertilization. Sperm can live in the female body for roughly 3–5 days, and a released ovum is viable for fertilization for anywhere from 24 to 48 hours after it is released. This means that every month there is a small, but significant, window of time in which a woman can become pregnant. Even if intercourse occurs days before ovulation takes place, fertilization is still possible.

Figure 4.1: Female reproductive system ሁ An ovum is released by the ovary and fertilized in the fallopian tube. After completing the journey

through the fallopian tube and into the uterus, the fertilized egg implants in the uterine wall, where it will begin to grow.

fallopian tubes

ovary egg

(ovum)

uterus

fertilization

zygote

ovary

vagina

sperm

uterine wall

implantation

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Section 4.2 Prenatal Development

Once fertilized, the egg is called a zygote. However, fertilization alone does not mark the beginning of a pregnancy, only the start of a new process. The zygote begins to multiply cells rapidly while continuing to travel down the fallopian tube toward the uterus. The traveling ball of cells is called a blastocyst. Once the blastocyst reaches the uterus it should attach itself to the thick uterine wall and begin to burrow into the lining. If achieved, this step is called implantation. If implantation is successful, it triggers the body to begin producing human chorionic gonadotropin, or hCG (this is the same hormone that home pregnancy tests detect). Production of hCG signals the body not to shed the uterine lining this month, but instead to switch into pregnancy mode.

Following successful implementation, a woman typically recognizes her missed period and soon after discovers that she is pregnant. In addition to a missed period, a number of symp- toms indicate that a woman is pregnant. Early pregnancy symptoms include the following (Womenshealth.gov, 2010a):

• Sore, heavy breasts • Nausea, vomiting, or just the feeling of needing to vomit (commonly referred to as

“morning sickness,” although the sensation can occur at any time of the day) • Darkening and/or widening of the area around the nipples • Mood swings • Sensitivity to smells • Aversion to food (sometimes even favorite foods) or cravings • Fatigue • Frequent urination • Headaches • Cramping • Backaches • Bloating and/or constipation • Dizziness and/or fainting • Spotting (sometimes as a result of implantation, called implantation bleeding)

Keep in mind that every pregnancy is as unique as the mother carrying the child and as the child who is developing. Some women may experience very few or all of these symptoms, and symptoms may come and go throughout the pregnancy. Early symptoms from a woman’s first pregnancy may also differ greatly from her experiences in subsequent ones.

Gestational Age Versus Fetal Age Women are advised to visit a doctor as soon as they suspect they are pregnant; the doctor can confirm the pregnancy and provide the woman with a wellness check. Some medical testing may be needed as well as confirmation that the expectant mother’s immunizations are up-to- date (Womenshealth.gov, 2010a).

The doctor will want to know how far the pregnancy has already progressed. Because women discover their pregnancies in different ways, and at different times during the course of

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Section 4.2 Prenatal Development

their pregnancies, calculating the progression of the pregnancy is not always easy. Most doc- tors calculate the age starting with the first date of the woman’s last menstrual period. This method is used to calculate the gestational age. For example, if Amanda’s last menstrual period began on January 16 and her doctor confirmed her pregnancy on March 22, the ges- tational age would be 9 weeks and 2 days. This is the most common method used by doctors and expectant mothers to calculate the progression of the pregnancy because it does not rely on knowing the exact date of conception. When speaking in terms of gestational age, an aver- age full-term pregnancy is 40 weeks.

A more accurate method for calculating the progression of a pregnancy assumes that the exact date of fertilization is known, and begins from that date. The exact age of a growing embryo or fetus is called fetal age. In some cases, especially with alternate methods of conception such as in vitro fertilization, this type of calculation is possible. If Amanda’s last menstrual period began on January 16, but Amanda underwent a successful in vitro fertilization procedure on February 4, then her doctor would know that the fetal age on March 22 is 6 weeks and 4 days. Because this method does not account for the 2 weeks following the last menstrual period, prior to fertilization, fetal age is usually approximately 2 weeks less than gestational age.

Phases of Prenatal Development The development of the fetus during prenatal development can be separated into certain phases. Commonly, the phases that occur during a woman’s pregnancy are discussed as tri- mesters, which segment the pregnancy into three phases. However, an alternative way of dis- cussing the phases of a pregnancy is based on what is occurring in fetal development. These are called the germinal, embryonic, and fetal phases.

Trimesters

A typical, healthy pregnancy lasting 40 weeks consists of three phases referred to as tri- mesters. Trimesters are the most commonly discussed breakdown of phases in a pregnancy. Trimesters are three approximately equal segments of time during pregnancy. This is a use- ful grouping of time periods, typically referred to by gestational age, because each trimester seems to hold its own distinctive symptoms, risks, and developmental progression. The first trimester (weeks 1–12) begins the development of all of the major organs (including the sex organs), the spinal cord, the placenta, and the umbilical cord. At the end of the first trimester, the nerves and muscles begin functioning and the eyelids close over the eyes. The second trimester (weeks 13–28) progresses through the formation of the skeleton and skin. More physical detail develops, including fingernails, eyelashes, eyebrows, fingerprints, and a cov- ering of fine hairs all over the body. By the end of the second trimester, the baby can swallow, hear, and sleep. In the beginning few weeks of the third trimester (weeks 29–40), the baby moves around quite a bit and works to store important nutrients and body fat. As the third trimester comes to a close, the baby may reposition with its head down to prepare for birth (Womenshealth.gov, 2010a). See Table 4.1 for a more detailed description of these core fetal developments during each trimester (by gestational age).

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Section 4.2 Prenatal Development

Table 4.1: The developing fetus by trimester

First trimester (weeks 1–12)

At 4 weeks: • The baby’s brain and spinal cord have begun to form. • The heart begins to form. • Arm and leg buds appear. The baby is now an embryo and one-twenty-

fifth-inch long.

At 8 weeks: • All major organs and external body structures have begun to form. • The baby’s heart beats with a regular rhythm. • The arms and legs grow longer, and fingers and toes have begun to form. • The sex organs begin to form. • The eyes have moved forward on the face and eyelids have formed. • The umbilical cord is clearly visible. • At the end of 8 weeks, the baby is a fetus and looks more like a human.

The baby is nearly 1 inch long and weighs less than one-eighth ounce.

At 12 weeks: • The nerves and muscles begin to work together. The baby can make a fist. • The external sex organs show if the baby is a boy or girl. A woman who

has an ultrasound in the second trimester or later might be able to find out the baby’s sex.

• Eyelids close to protect the developing eyes. They will not open again until the 28th week.

• Head growth has slowed, and the baby is much longer. Now, at about 3 inches long, the baby weighs almost an ounce.

Second trimester (weeks 13–28)

At 16 weeks: • Muscle tissue and bone continue to form, creating a more complete

skeleton. • Skin begins to form. One can nearly see through it. • Meconium (mih-KOH-nee-uhm) develops in the baby’s intestinal tract.

This will be the baby’s first bowel movement. • The baby makes sucking motions with the mouth (sucking reflex). • The baby reaches a length of about 4–5 inches and weighs almost

3 ounces.

At 20 weeks: • The baby is more active. The mother might feel slight fluttering. • The baby is covered by fine, downy hair called lanugo (luh-NOO-

goh) and a waxy coating called vernix. This protects the forming skin underneath.

• Eyebrows, eyelashes, fingernails, and toenails have formed. The baby can even scratch itself.

• The baby can hear and swallow. • Now halfway through the pregnancy, the baby is about 6 inches long

and weighs about 9 ounces.

(continued)

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Section 4.2 Prenatal Development

First trimester (weeks 1–12)

At 24 weeks: • Bone marrow begins to make blood cells. • Taste buds form on the baby’s tongue. • Footprints and fingerprints have formed. • Real hair begins to grow on the baby’s head. • The lungs are formed, but do not work. • The hand and startle reflex develop. • The baby sleeps and wakes regularly. • If the baby is a boy, his testicles begin to move from the abdomen into

the scrotum. If the baby is a girl, her uterus and ovaries are in place, and a lifetime supply of eggs have formed in the ovaries.

• The baby stores fat and has gained quite a bit of weight. Now at about 12 inches long, the baby weighs about 1.5 pounds.

Third trimester (weeks 29–40)

At 32 weeks: • The baby’s bones are fully formed, but still soft. • The baby’s kicks and jabs are forceful. • The eyes can open and close and sense changes in light. • Lungs are not fully formed, but practice “breathing” movements occur. • The baby’s body begins to store vital minerals, such as iron and calcium. • Lanugo begins to fall off. The baby is gaining weight quickly, about

a half-pound a week. Now, the baby is about 15–17 inches long and weighs about 4–4.5 pounds.

At 36 weeks: • The protective waxy coating called vernix gets thicker. • Body fat increases. The baby is getting bigger and bigger and has less

space to move around. Movements are less forceful, but the mother will feel stretches and wiggles.

• The baby is about 16–19 inches long and weighs about 6–6.5 pounds.

Weeks 37–40: • By the end of 37 weeks, the baby is considered full term. The baby’s

organs are ready to function on their own. • As the mother nears her due date, the baby may turn into a head-down

position for birth. Most babies “present” head down. • At birth, the average full-term baby weighs somewhere between 6

pounds 2 ounces and 9 pounds 2 ounces and is 19–21 inches long. Most full-term babies fall within these ranges. But healthy babies come in many different sizes.

Source: Womenshealth.gov. (2010a). Stages of pregnancy. Retrieved from http://womenshealth.gov/pregnancy/you-are-pregnant /stages-of-pregnancy.html.

Science Photo Library/SuperStock

Table 4.1: The developing fetus by trimester (continued)

Second trimester (weeks 13–28) (continued)

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http://womenshealth.gov/pregnancy/you-are-pregnant/stages-of-pregnancy.html

Section 4.3 A Healthy Pregnancy Lifestyle

Germinal, Embryonic, and Fetal Phases

An alternative breakdown of the phases of pregnancy gives more weight to the importance of the type of development taking place and less to the amount of time that passes in each phase. See Figure 4.2 for more detail on these phases. The following time frames for each phase are given in fetal age:

• The germinal phase consists of the first 14 days (2 weeks) following fertilization. As discussed previously, this period of time follows the zygote through many repeti- tions of cell multiplication resulting in a blastocyst, migration of the blastocyst into the uterus, and implantation of the blastocyst in the uterine wall.

• Upon implantation of the blastocyst, the embryonic phase begins (weeks 3–8), and the placenta starts to develop. The placenta, which connects the growing embryo to the uterine wall by means of the umbilical cord, provides for the absorption of nutrients and oxygen as well as the removal of waste from the intrauterine environ- ment. The placenta also filters out harmful substances that can negatively affect the growing baby. The placenta will continue to grow throughout the pregnancy. The embryonic phase also marks the beginning of the development of the baby’s spinal cord, brain, heart, and other organs.

• The fetal phase (weeks 9–38) includes the complete development of the eyes, head, arms, legs, neck, toes, fingers, fingernails, and bones. The baby’s genitals also form during this stage and are visible for the identification of the baby’s sex by ultrasound by the 14th week.

4.3 A Healthy Pregnancy Lifestyle Healthy development of a child begins at conception. As the fetus grows and develops senses, organs, and brain function, the mother’s lifestyle controls the quality of development in all of the important areas. As discussed in previous chapters, child development consists of criti- cal periods when progress can be crucially hindered or helped. Critical periods of develop- ment also occur as a fetus matures. However, it is not possible to pinpoint exactly when these critical periods will occur because all pregnancies and developmental timelines are slightly different. For this reason, it is important for women to make smart choices throughout their entire pregnancies. Proper nutrition, rest, exercise, and avoidance of harmful substances are the first and most important lines of defense for a healthy start to a child’s life.

Poor eating habits, exposure to harmful substances during pregnancy, and lack of sufficient activity and rest can lead to low birth weight, prematurity, and babies who are small for gesta- tional age (Kaiser & Allen, 2008). Children born in these contexts may have certain problems that caregivers need to be aware of when caring for them. These characteristics and behaviors can include delays and disorders in any one or all of the developmental domains in neurologi- cal functioning (Aylward, 2005). Resultant behaviors include learning difficulties, hyperactiv- ity, attention problems, poor executive functioning (see Chapter 2), and others.

Nutrition During pregnancy, it is essential for a woman to receive proper nutrition in order to sup- port the growing fetus’s development. When identifying nutritional needs, one must consider what a woman should eat, as well as what she should avoid.

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Section 4.3 A Healthy Pregnancy Lifestyle

What to Eat

Just as children, teens, and adults need a well-balanced diet to stay healthy, a fetus needs a variety of nutrients to develop properly. A mother’s body is also doing a considerable amount of extra work during pregnancy, and pregnant women need the right kinds of nutrition to sustain energy and avoid illness. A diet rich in vitamins, proteins, and other nutrients is rec- ommended. Pregnant women are encouraged to eat foods across the major food groups to ensure that all of the necessary nutrients are obtained (visit this website for more informa- tion). Natural and fresh foods typically offer more nutrition than processed boxed or canned foods. A variety of fruits and vegetables is also important to diversify the types of nutrients and allow them to work together to be absorbed into the woman’s body. Eating a rainbow of different-colored fruits and vegetables is an easy way to ensure that a woman is getting the nutritional variety that a growing fetus needs.

Pregnant women need more specific types of nutrients because of their importance in aiding fetal development and protecting against birth defects. Women are encouraged to take pre- natal vitamins to help ensure that the proper nutrients are absorbed daily. Pregnant women specifically need iron, calcium, vitamins A and B12, and folic acid. Folic acid is an especially important nutrient during pregnancy. Diets low in folic acid have been linked to preterm delivery, low birth weight, neural tube defects, and slow fetal growth (Scholl & Johnson, 2000). Table 4.2 describes these five important nutrients for pregnancy and how much a pregnant woman should consume daily.

Table 4.2: Nutrients and pregnancy (daily dose)

Nutrient Daily Requirements During Pregnancy

Folic acid 400–800 micrograms (mcg) (0.4 to 0.8 milligrams [mg]) in the early stages of pregnancy, which is why all women who are capable of pregnancy should take a daily multivitamin that contains 400–800 mcg of folic acid. Pregnant women should continue taking folic acid throughout pregnancy.

Iron 27 mg

Calcium 1,000 mg; 1,300 mg if 18 or younger

Vitamin A 770 mcg; 750 mcg if 18 or younger

Vitamin B12 2.6 mcg

Source: Womenshealth.gov. (2010b). Pregnancy: Staying healthy and safe. Retrieved from http://womenshealth.gov/pregnancy /you-are-pregnant/staying-healthy-safe.cfm.

What to Avoid

Just as eating the right foods is critical to proper growth of the fetus, avoiding the wrong foods is equally as important (see Table 4.3). Some foods that do not pose a threat to a well- developed adult digestive and immune system can be extremely harmful to a vulnerable fetus. Many unpasteurized cheeses, dairy products, and juices, and deli-styles meats, including hot dogs, may contain harmful bacteria and should be avoided (U.S. Food and Drug Administra- tion, 2013). Some fish contain high levels of mercury and should be eaten only in small quan- tities, or not at all. Food preparation is also very important. Making sure that food is cooked thoroughly and that cold food has been refrigerated properly is essential in keeping food safe.

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http://www.ohsu.edu/xd/health/services/women/services/pregnancy-and-childbirth/pregnancy-information/pregnancy-plate.cfm

http://womenshealth.gov/pregnancy/you-are-pregnant/staying-healthy-safe.cfm

Section 4.3 A Healthy Pregnancy Lifestyle

Table 4.3: Food safety in pregnancy

Don’t Eat These Foods Why What to Do

Soft CHEESES made from unpasteurized milk, including Brie, feta, Camembert, Roquefort, queso blanco, and queso fresco

May contain E. coli or Listeria. Eat hard cheeses, such as ched- dar or Swiss. Or, check the label and make sure that the cheese is made from pasteurized milk.

Raw COOKIE DOUGH or CAKE BATTER

May contain Salmonella. Bake the cookies and cake. Don’t lick the spoon!

Certain kinds of FISH, such as shark, swordfish, king mackerel, and tilefish (golden or white snapper)

Contains high levels of mercury. Eat up to 12 ounces a week of fish and shellfish that are lower in mercury, such as shrimp, salmon, pollock, and catfish. Limit consumption of albacore tuna to 6 ounces per week.

Raw or undercooked FISH (sushi)

May contain parasites or bacteria.

Cook fish to 1458 F.

Unpasteurized JUICE or cider (including fresh squeezed)

May contain E. coli. Drink pasteurized juice. Bring unpasteurized juice or cider to a rolling boil and boil for at least 1 minute before drinking.

Unpasteurized MILK May contain bacteria such as Campylobacter, E. coli, Listeria, or Salmonella.

Drink pasteurized milk.

SALADS made in a store, such as ham salad, chicken salad, and seafood salad

May contain Listeria. Make salads at home, following the food safety basics: clean, separate, cook, and chill.

Raw SHELLFISH, such as oysters and clams

May contain Vibrio bacteria. Cook shellfish to 1458 F.

Raw or undercooked SPROUTS, such as alfalfa, clover, mung bean, and radish

May contain E. coli or Salmonella. Cook sprouts thoroughly.

Be Careful with These Foods Why What to Do

Hot dogs, luncheon meats, cold cuts, fermented or dry sausage, and other deli-style meat and poultry

May contain Listeria. Even if the label says that the meat is precooked, reheat the meat to steaming hot or 1658 F before eating.

Eggs and pasteurized egg products

Undercooked eggs may contain Salmonella.

Cook eggs until yolks are firm. Cook casseroles and other dishes containing eggs or egg products to 1608 F.

Eggnog Homemade eggnog may contain uncooked eggs, which may con- tain Salmonella.

Make eggnog with a pasteurized egg product or buy pasteurized eggnog. When you make eggnog or other egg-fortified beverages, cook to 1608F.

(continued)

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Section 4.3 A Healthy Pregnancy Lifestyle

Don’t Eat These Foods Why What to Do

Fish May contain parasites or bacteria.

Cook fish to 1458 F.

Ice cream Homemade ice cream may con- tain uncooked eggs, which may contain Salmonella.

Make ice cream with a pasteur- ized egg product; add the eggs to the amount of liquid called for in the recipe, and then heat the mixture thoroughly.

Meat: beef, veal, lamb, and pork (including ground meat)

Undercooked meat may contain E. coli.

Cook beef, veal, and lamb steaks and roasts to 1458 F. Cook pork to 1608 F. Cook all ground meats to 1608 F.

Meat spreads or pate Unpasteurized refrigerated meat spreads or pate may contain Listeria.

Eat canned versions, which are safe.

Poultry and stuffing (including ground poultry)

Undercooked meat may contain bacteria such as Campylobacter or Salmonella.

Cook poultry to 1658 F. If the poultry is stuffed, cook the stuff- ing to 1658 F. Better yet, cook the stuffing separately.

Smoked seafood Refrigerated versions are not safe, unless they have been cooked to 1658 F.

Eat canned versions, which are safe, or cook to 1658 F.

Source: Foodsafety.gov. (n.d.). Checklist of foods to avoid during pregnancy. Retrieved from http://www.foodsafety.gov/poisoning /risk/pregnant/chklist_pregnancy.html.

Highly processed foods, fried food, and other foods that are high in unhealthy fats and refined sugars are unhealthy for a growing baby and pregnant mother. In many cases, unhealthy foods like these can exacerbate unpleasant pregnancy symptoms for the mother, causing undue stress on the baby. They also provide calories without proper nutrition.

Teratogens Other substances besides unhealthy foods and bacteria can be extremely harmful for a devel- oping fetus, especially in brain development. Harmful substances that may cause adverse effects during prenatal development are called teratogens. Exposure to teratogens before or soon after birth can have extremely negative effects on the developing brain or on other developing areas of the embryo and fetus (see Figure 4.2). Brain development during the prenatal period is crucial for later years in a child’s life. The brain is the center of the nervous system, and it develops over time, beginning before birth in the mother’s womb and continu- ing into young adulthood. Although brain development is not completed until adulthood, the immature brain is much more susceptible to negative exposures than is the adult brain. This happens because the brain of a fetus or an infant has not yet developed the barrier of protec- tive cells that is part of the mature brain. These cells keep toxic chemicals from entering the bloodstream and having negative effects on brain tissues. Many factors can have an effect on the fetal brain, but the intensity of that effect depends on the type of factor (positive or nega- tive), dose, duration, and timing of interaction.

Table 4.3: Food safety in pregnancy (continued)

Be Careful with These Foods

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http://www.foodsafety.gov/poisoning/risk/pregnant/chklist_pregnancy.html

Usually not susceptible to teratogens

Embryonic period (in weeks) Period of dividing

zygote, implantation, and gastrulation

Weeks 1 2 3 4 5 6 7 8 9 16 20–36 38

Major morphological abnormalities Functional defects and minor morphological abnormalities

Prenatal death

Palate

Teeth External genitals

External genitals

Central nervous system

Heart

Upper limbs

Lower limbs

Ears

Eyes

Teeth

Palate

External genitals

Leg LegArm Arm

Eye Eye Eye Ear Brain Brain Heart Heart

Ear

Heart

Fetal period (in weeks) – full term

Indicates common site of teratogen action

Section 4.3 A Healthy Pregnancy Lifestyle

For example, toxic substances can weaken the brain’s structure in a way that creates perma- nent and lifelong damage, with consequences on academic achievements and physical and mental health. This poisonous effect is called neurotoxicity because it affects brain struc- tures of the neural circuits and neurons. Illnesses such as rubella occurring during the prena- tal period can have the same effect. The National Scientific Council on the Developing Child (2006) divides harmful chemical substances into three categories: environmental chemicals such as lead and mercury; recreational drugs such as alcohol, nicotine, and cocaine; and pre- scription medications such as anticonvulsants and some drugs used for treatment of severe acne. Table 4.4 distinguishes scientific facts about toxins in the prenatal environment from long-held misperceptions of science on this topic.

Note, in particular, that smoking during pregnancy exposes the fetus to the harmful substance nicotine. This exposure to nicotine affects both the structural development of the brain and the way the developing brain functions (National Scientific Council on the Developing Child, 2006). Additionally, when a pregnant mother smokes, a decreased amount of oxygen reaches the fetus, which reduces fetal growth and can lead to low birth weight (Centers for Disease Control and Prevention, 2013; National Scientific Council on the Developing Child, 2006). Smoking can also cause certain complications during a woman’s pregnancy, can lead to a pre- mature birth, and has been associated with certain birth defects (Centers for Disease Control and Prevention, 2013).

Similarly, the harmful effects of fetal exposure to alcohol during the pregnancy (and partic- ularly higher levels of exposure) can lead to a number of problems that are characterized

Figure 4.2: Sensitivity to teratogens during periods of prenatal development

ሁ During fetal development, the degree of sensitivity to teratogens and the physical components most susceptible are dependent on the timing of exposure.

Source: Moore, K. L., & Persaud, T. V. N. (2008). Before we are born: Essentials of embryology and birth defects (7th ed., p. 313). Philadelphia: Saunders Elsevier

Usually not susceptible to teratogens

Embryonic period (in weeks) Period of dividing

zygote, implantation, and gastrulation

Weeks 1 2 3 4 5 6 7 8 9 16 20–36 38

Major morphological abnormalities Functional defects and minor morphological abnormalities

Prenatal death

Palate

Teeth External genitals

External genitals

Central nervous system

Heart

Upper limbs

Lower limbs

Ears

Eyes

Teeth

Palate

External genitals

Leg LegArm Arm

Eye Eye Eye Ear Brain Brain Heart Heart

Ear

Heart

Fetal period (in weeks) – full term

Indicates common site of teratogen action

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Section 4.3 A Healthy Pregnancy Lifestyle

collectively as fetal alcohol syndrome (FAS). Features of FAS have been identified as reduced growth (both before and after birth), facial features characteristic of the syndrome (including a thin upper lip, the lack of a vertical groove between the lip and nose, and a smaller length from one corner of the eye to the other), and abnormalities within the central nervous system leading to delays in development and often significant impairment in the cognitive devel- opment domain (O’Leary, 2004). These features can differ based on race and ethnicity and can present differently over time; however, the cognitive delays and impairments have been shown to persist across developmental stages (O’Leary, 2004).

Table 4.4: Popular misperceptions of science: toxins and prenatal development

Popular beliefs about which chemical substances are more or less toxic to the developing embryo, fetus, infant, and child are most commonly related to their relative abundance and legal status in society. In this context, it is essential that we distinguish scientific facts from widespread misperceptions.

Myth: Illegal recreational drugs have the most damaging impact on brain development and function for the growing fetus.

Fact: Although illegal recreational drugs and alcohol are both damaging to the developing fetus, exten- sive research indicates that alcohol, while legal, is one of the most dangerous neurotoxins that can affect the brain during the period between conception and birth.

Myth: The adverse impact of toxic substances on the developing architecture of the brain is an all-or- none phenomenon.

Fact: Neurotoxins can produce a range of outcomes, from mild to severe impairment, which often lead to confusing conclusions about the linkage between exposure to a specific substance and its consequences.

Myth: The absence of cognitive or behavioral problems in childhood indicates that an early exposure to a neurotoxin had no adverse effect on brain development.

Fact: Studies in both animals and humans have demonstrated that some substances cause damage to the brain that is manifested in the delayed onset of learning problems, attention deficits, and changes in emotional regulation, which can have long-term consequences into the teenage and adult years.

Myth: The determination of a dangerous level of exposure to a potentially neurotoxic substance is a straightforward scientific question.

Fact: The determination of a dangerous level of exposure to a potentially neurotoxic substance can present a complicated challenge because the developing brain of a young child is typically more susceptible to damage than the mature brain of an adult, and the immature nervous system of an embryo or fetus is even more vulnerable to toxic exposures than is that of an infant. Therefore, there is no credible way to determine a safe level of exposure to a potentially toxic substance without explicit research that differentiates its impact on adults from the greater likelihood of its adverse influences on the developing brain during pregnancy and early childhood.

Myth: Vaccines containing thimerosal (which has been added as a preservative) are linked to the devel- opment of autism in susceptible children.

Fact: Extensive and repeated studies by highly reputable scientific groups have failed to confirm the claim that there is a link between vaccines containing thimerosal and the development of autism in susceptible children.

Source: National Scientific Council on the Developing Child. Early Exposure to Toxic Substances Damages Brain Architecture. Copyright © 2006 National Scientific Council on the Developing Child and the Center on the Developing Child. Reprinted by permission.

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Extra body supplies for pregnancy

and breastfeading (~2.5–3.5 kg./5–8 lb.)

Blood (~2 kg./4 lb.)

Retention Fluid (varies)

Breasts (~1.5 kg./3 lb.)

Placenta (~0.5 kg./1 lb.)

Baby (~3.5 kg./7.5 lb.)

Uterus (~1 kg./2.5 lb.)

Amniotic Fluid (~1 kg./2 lb.)

Section 4.3 A Healthy Pregnancy Lifestyle

Activity and Rest Just as staying fit and active is an important part of any healthy lifestyle, it is also a fundamen- tal ingredient in the recipe for a healthy pregnancy. Daily physical activity helps to improve blood flow through the body, improves mood, builds stronger muscles and bones, improves immune health, aids in digestion (which is not at its best during pregnancy), and even com- bats stress and improves sleep (HealthyFamilies BC, 2013a). The growing baby benefits from all of these perks, too. It is best practice for expectant mothers to talk to their doctors before starting any new exercise routine, but medical professionals agree that women who exercise regularly before becoming pregnant can continue their normal exercise routines into preg- nancy as long as it does not cause injury or cause them to feel fatigued. Note, however, that with some high-risk pregnancies, doctors may recommend limiting, or even ceasing, activity as a precaution.

Rest is equally important for the healthy development of the fetus (National Sleep Founda- tion, 2013b). With pregnant bodies working overtime to manufacture a perfectly healthy baby in 38 short weeks, it is no wonder that ample rest is crucial for a successful outcome. When the body shuts down in rest, it rejuvenates energy sources and allows a mother’s body to concen- trate on the growing fetus. It also helps to regulate the bodies’ systems and counteracts the effects of daily stress on the body.

Weight Gain Gaining weight is an inevitable and important component of pregnancy. However, the concept of “eating for two” is outdated and misleading. A pregnant mother needs only an addi- tional 300 calories per day to prop- erly nourish the growing baby. A woman in the normal weight range entering into pregnancy is expected to gain approximately 30 pounds throughout the pregnancy. Of course, this weight isn’t all contained in the baby. Other components in the intra- uterine environment, fluids, and even extra blood contribute to the overall weight gain during pregnancy. Women who are overweight or obese need to gain slightly less, and women who are underweight should gain slightly more (HealthyFamilies BC, 2013b). Figure 4.3 shows where weight is gained in a women’s body during a healthy pregnancy.

Figure 4.3: Components of weight gain in pregnancy

ሁ Only a fraction of a woman’s weight gain in pregnancy is due to the growing baby. Fluids and other supplies stored in the breasts and uterus account for the majority of extra weight.

Extra body supplies for pregnancy

and breastfeading (~2.5–3.5 kg./5–8 lb.)

Blood (~2 kg./4 lb.)

Retention Fluid (varies)

Breasts (~1.5 kg./3 lb.)

Placenta (~0.5 kg./1 lb.)

Baby (~3.5 kg./7.5 lb.)

Uterus (~1 kg./2.5 lb.)

Amniotic Fluid (~1 kg./2 lb.)

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Section 4.3 A Healthy Pregnancy Lifestyle

Pregnancy Complications Even with appropriate attention to the mother’s health prior to and during pregnancy, com- plications are possible. Understanding these complications is the best way to prevent them or to recognize symptoms early enough to receive proper treatment. Although there are many possible complications during pregnancy, some of the most common include gestational dia- betes, a baby being small for gestational age, and various infections.

Gestational diabetes is glucose intolerance that presents for the first time during pregnancy. Its symptoms can mimic typical pregnancy symptoms, such as hunger and fatigue, or it may present with no symptoms at all. Therefore, it is difficult to diagnose without testing for sugar levels in the blood. Gestational diabetes can be controlled with diet, exercise, and even insulin injections. Untreated, gestational diabetes can result in a large baby with added delivery com- plications, babies with low blood sugar, or even fetal death; it may also cause later complica- tions for the mother after pregnancy (American Diabetes Association, 2004).

Babies who do not grow at the rate they should for their age during the prenatal period are considered small for gestational age, or SGA. SGA babies have a higher risk of complications during the first 4 weeks of life. Later in life, those who were small for gestational age as babies may experience diabetes, cardiovascular disease, and hypertension (Karlberg & Albertsson- Wikland, 1995). Strauss (2000) found that although individuals who were SGA at birth had decreased academic and professional achievement, they did not present with long-term defi- cits in the social-emotional realm, based on employment, marriage, and life satisfaction.

Infections may occur during pregnancy from a variety of causes. Some infections may be iden- tified from discolored or odorous discharge, burning or itching, muscle aches, or diarrhea or other flu-like symptoms. Some infections during pregnancy can be dangerous, resulting in miscarriage, preterm birth, or low birth weight (Schieve, Handler, Hershow, Persky, & Davis, 1994). Practicing safe sex, a healthy diet, good personal hygiene, and an overall healthy life- style are the best ways to prevent infections.

TIPS ON RECOGNIZING PRENATAL DEPRESSION Prenatal depression can have many adverse effects on a developing baby. Learn to recognize the following signs and symptoms of prenatal depression in preg- nant woman:

• Dramatic increase or decrease in typical eating patterns • Disturbed sleeping patterns • Difficulty concentrating • Extreme mood swings • Excessive crying • Easily angered or agitated • Feelings of emptiness or worthlessness • Unjustified feelings of guilt • Lack of interest in previously enjoyed activities • Withdrawn behavior, especially from friends and family • Incessant anxiety or worrying • Severe lethargy • Frequent headaches or other body aches and pain

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A G

A C G A

TDNA (double helix)

Chromosome

Nucleus

Cell

Section 4.4 Genetics

4.4 Genetics Every child has a unique genetic code that influences the child’s appearance, behavior, prefer- ences, special talents, and any physical or mental limitations. No two children, or adults, throughout history have ever been the same. The encoded instructions for creating all of the cells in our body are carried on sections of our DNA called genes (genes were also discussed in Chapter 2). A collection of many genes make up long DNA molecules, which are packaged tightly into chromosomes (see Figure 4.4). Every cell in the human body, with the exception of sperm and ovum cells, houses 46 chromosomes (23 pairs) in the control center of the cell called the nucleus. Sperm and ovum cells contain only 23 chromosomes each. In the Concep- tion section, we discussed the process of the sperm and ovum joining to create new life. When this occurs, the sperm brings its 23 chromosomes and the ovum brings its 23 chromosomes. Combined, they form 23 sets of chromosomes, or 46 chromosomes in total. The complete set of all genes in a child is called the structural genome. Each child’s genome contains approxi- mately 23,000 genes.

One very important pair of chromosomes determines the baby’s gender. Every female car- ries two X chromosomes, making an XX chromosome pair. Every male carries one X and one Y chromosome, making an XY chromosome pair. Because an ovum carries only one of its

Figure 4.4: Cells, chromosomes, and DNA ሁ A collection of many genes make up DNA molecules, which are packaged tightly into

chromosomes. A cell’s nucleus contains these chromosomes.

A G

A C G A

TDNA (double helix)

Chromosome

Nucleus

Cell

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Section 4.4 Genetics

chromosomal pair, it has no choice but to carry an X, every time. However, each sperm may carry either an X chromosome or a Y chromosome. If an X-carrying sperm fertilizes the X-car- rying ovum, the result is an XX chromosome pair . . . it’s a girl. Alternatively, if the ovum is fer- tilized by a sperm carrying a Y chromosome, the result is an XY pair, or a baby boy. Consider the irony of the often-told story of King Henry VIII, who executed his wives because they did not produce a male heir. The gender was determined by him all along!

Sometimes the process of manufacturing, pairing, or replicating chromosomes does not occur as it should. When an irregularity occurs in a set of chromosomes, it is known as a chromosome abnormality. The National Human Genome Research Institute (2011) catego- rizes chromosome abnormalities into two groups, numerical abnormalities and structural abnormalities. Numerical abnormalities are the result of missing a chromosome from a pair or having more than two chromosomes present in a pair. For example, Down syndrome occurs when an individual has three copies of the 21st chromosome. Children with Down syndrome may have physical and mental limitations within a wide range of abilities. Early intervention is highly recommended to lessen the impact of these limitations. If a female is born with only one X chromosome, she is diagnosed with Turner syndrome. Females with Turner syndrome may have a variety of symptoms that involve atypical growth and atypical physical sexual characteristics. However, with medical care and monitoring by a doctor, most children with Turner syndrome lead a normal life. Klinefelter syndrome is the presence of more than one X chromosome with a Y chromosome in a male baby. Babies born with this syndrome have an atypical hormone level and may be affected in their physical and cognitive development. Yet, many males with this syndrome live normal lives and discover they have it only during or after puberty. Medical treatments are available.

Structural abnormalities occur when the chromosome takes on an atypical form. There are five possible structural abnormalities. They include missing or deleted parts of chromosomes, extra genetic material, parts of a chromosome or complete chromosomes exchanging places, genetic material that is inverted, and rings or parts of a chromosome that fall off (National Human Genome Research Institute, 2011). The most common examples of these abnormali- ties include Cri du Chat syndrome and Pallister Killian syndrome, both of which often include a variety and range of physical and mental disabilities.

A set of a child’s gene codes is called a genotype. The observable characteristic that is physi- cally shown as a result of the genotype is called the phenotype. However, genotypes and their phenotypes are not the only elements at play in determining how a person looks, thinks, and acts. The epigenome controls the unique expression of the gene. The epigenome is made up of chemical compounds that mark the genome with proteins and enzymes in a way that turns genes “on” and “off.” The epigenome is the link between the genome and the environment (National Human Genome Research Institute, 2011). The epigenome is built over time and is influenced by experiences, relationships, nutrition, physical activity, drugs and medications, and toxins in the environment. Epigenomes can temporarily or permanently modify genes and thus influence brain structures, which in turn influences the child’s behavior. This can happen in a fetus and be passed on to later generations. For example, recurring, highly stress- ful experiences can cause epigenetic changes that have been observed to cause persistent stress responses (National Scientific Council on the Developing Child, 2010). Persistent stress responses have been associated with detrimental changes in brain structure and function, and thus can have a detrimental effect on a child’s growth and development (National Scien- tific Council on the Developing Child, 2010). By contrast, positive, supportive relationships

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Section 4.5 The Birth Process

can leave marks that switch on positive genetic potential. This recently discovered biological activity of epigenetics explains why early experiences can have long-term impacts and why siblings, even twins, may achieve more or less in school and behave very differently from each other (National Scientific Council on the Developing Child, 2010).

4.5 The Birth Process The labor and delivery process does not have an easily recognizable onset. In fact, the birth process may occur differently for every woman. It is a gradual process that typically begins around 38–40 weeks of pregnancy. The baby’s brain releases certain hormones, including oxytocin and cortisone, which signal the mother’s body to prepare for labor and delivery. As early as 2 weeks before delivery, the mother may notice that she’s carrying the baby lower. This is because the baby has repositioned so that the head is nestled at the opening of the birth canal. A woman may notice bloody discharge as a result of the mucus plug dislodging from the opening of the cervix, and she may experience leaking amniotic fluid, commonly referred to as “water breaking” (American Pregnancy Association, 2007).

There are three commonly recognized stages of the birth process, followed by a recovery stage. The first stage, referred to as active labor, is the longest stage in the process (see Fig- ure 4.5). Active labor usually lasts 12 hours or more for a woman birthing her first child, and a significantly shorter period of time for subsequent births (Mayo Clinic Staff, 2013). During this stage, the cervix softens and opens, or dilates, in preparation for transporting the baby through the birth canal. Typically the cervix is dilated about 2.5 centimeters at the beginning phase of labor. Throughout active labor the woman will experience painful contractions of the uterine muscles. Contractions during this phase will be intermittent and will occur more fre- quently toward the completion of this stage. When the cervix is dilated approximately 10 centimeters, the second stage begins.

AT ISSUE: GENETIC TESTING Parents who are at particularly high risk of carrying genetic diseases, due to family history or ethnicity, are able to undergo genetic testing prior to or dur- ing pregnancy. Two of the most common tests are chorionic villus sampling

(CVS), in which a piece of the placenta is taken, and amniocentesis, in which amniotic f luid is drawn. These tests can reveal if the baby inherited a genetic condition, including cystic fibro- sis or Down syndrome. When a particularly severe disease is identified, parents may elect to terminate the pregnancy.

The ethics of genetic testing for these reasons has long been the subject of debate. Professionals and parents in favor of genetic testing argue the importance of preventing a lifetime of suffering and hardship for the whole family. Those opposed to genetic testing in general argue that genetic testing may not remain in the realm of identifying disease, but eventually could be used on a large scale to preselect traits like gender and hair color, or even traits for intelligence, athleticism, or musical talent, among other characteristics. Do the bene- fits of genetic testing outweigh the potential risks of the tests being abused for frivolous uses? Is it ethical to undergo genetic testing to identify the inheritance of a disease?

Figure 4.5: Stage one: active labor ሁ During active labor the cervix, at the opening of the uterus, proceeds from no dilation (before

labor begins) through full dilation at 10 centimeters.

vagina

cervix

uterus

amniotic membrane

not e�aced no dilation

fully e�aced 1cm dilated

5cm dilation fully dilated at 10cm

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vagina

cervix

uterus

amniotic membrane

not e�aced no dilation

fully e�aced 1cm dilated

5cm dilation fully dilated at 10cm

Section 4.5 The Birth Process

The second stage can last anywhere from 30 minutes to almost 3 hours, but is typically longer for the first birth. This stage begins with a fully dilated cervix and ends with the birth of the baby. During this stage the contractions become much more painful and frequent. The woman may experience a feeling of pressure, the need to defecate, and a desire to push along with the contractions. In a typical vaginal birth, the baby will emerge head-first.

The third and final stage lasts only minutes. During this stage the placenta detaches from the uterine wall and is carried out through the birth canal. The baby no longer needs the placenta for nutrients and oxygen, so the umbilical cord attaching the baby to the placenta is cut. In most settings, after the birth process is complete, the mother’s vital signs will be monitored to ensure that she recovers appropriately. In particular, her blood pressure and pulse, as well as bleeding, are monitored. This is called the recovery stage.

In some cases, the birth process does not proceed as expected and complications arise. Many medical interventions are now available to help a mother through many of these common complications. For example, if a vaginal birth is not possible because of a small birth canal, improper positioning of the baby, labor that is not progressing, or other medical problems,

Figure 4.5: Stage one: active labor ሁ During active labor the cervix, at the opening of the uterus, proceeds from no dilation (before

labor begins) through full dilation at 10 centimeters.

vagina

cervix

uterus

amniotic membrane

not e�aced no dilation

fully e�aced 1cm dilated

5cm dilation fully dilated at 10cm

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Section 4.5 The Birth Process

the mother may have to undergo a surgical removal of the baby through the abdomen (U.S. National Library of Medicine, Medline Plus, 2013a). This surgery is called a cesarean section, or C-section. C-sections have become much more common in the United States in recent years (Martin, Hamilton, Ventura, Osterman, & Mathews, 2013). Although the rate remained stable from 2010 to 2011 (and decreased by one-tenth of a percent from 2009 to 2010), the rate of C-sections in the United States increased by close to 60 percent between 1996 and 2009. In addition, based on certain characteristics of a vaginal delivery, an episi- otomy, or an incision made in the tissue between the vaginal opening and the anus may be needed; however, this procedure is no longer routinely recommended as it had been previ- ously, based on problems with maternal recovery.

If a baby is able to be delivered vaginally, but needs some assistance on the way out, doctors may use forceps placed on the baby’s head or a vacuum device to help gently move the baby through the birth canal. In addition, many medications are now available to mothers to help ease the pain of labor. The most common pain medication given during labor is epidural anesthesia. This medication is inserted into the back, near the spine, and serves to block pain to the lower region of the body.

These stages describe the process of a typical birth, but the process may vary greatly among different women, including the presence and severity of symptoms, length of each stage, and levels of pain. Even the same mother may experience differences in the birth process with dif- ferent children. In the vignettes that follow, three mothers give their accounts:

I went into labor and was admitted to the hospital. I slept for hours, waking occasionally because of the contractions. Then the contractions stopped, so they induced me but I didn’t want the epidural. The induction without an epidural caused horrendous pain. It was not worth trying to do without the pain medica- tion. Once I got the epidural, I couldn’t feel anything and it was smooth sailing! I’m currently pregnant and passed my due date. I’m scheduled to be induced in 1 week.—Crysta

My son was almost 2 weeks past his due date. I had planned his birth at a local birthing center with a midwife and doula. I went for a checkup and was told he was totally fine, but in order for me to have him at the birthing center (versus the hospital), I would have to go into labor the next day. Fortunately, I began enough contractions within the time limit to go to the birthing center. I laid in the Jacuzzi the majority of the time with soft music playing, was able to eat food (English muffin with peanut butter, fruit, water) for energy, and my sup- port system was around me. There were no complications, and no medication. The contractions were painful, but I just breathed through it, and focused. I went into labor at about 10:00 p.m., and 3-1/2 hours later, he was here, at 1:30 a.m. . . . 3 hours of “hard labor” with 30 minutes of pushing.—Medina

With my first child, I woke up at 2:00 a.m. in labor and 3 weeks before my due date. Once at the hospital they gave me an epidural. I started pushing at 5:00 a.m., and I gave birth at 7:00 a.m. Only 5 hours of labor. My second was faster and 4 weeks early. My contractions started at 6:00 a.m., and we left for the hospital 30 minutes later. I gave birth at 7:05 a.m. in the hospital waiting room.—Julie

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Section 4.6 The Neonatal Period

4.6 The Neonatal Period The neonatal period begins immediately after birth and lasts for the first 4 weeks of life. This is another critical time in the development of a child, and the most vulnerable in the lifetime of a human. During this time, a child learns how to survive outside of the womb for the first time, transitioning from its protection and resources.

An average newborn weighs 7–7.5 pounds and is approximately 20 inches in length. Even for newborns at a healthy size, the first few minutes are crucial to survival and sometimes require intervention. To gauge a newborn’s health status, a test is given at 1 minute after birth and 5 minutes after birth. This test, called the Apgar scale, assesses the baby’s breathing, heart rate, muscle tone, reflexes, and skin color (Apgar, 1953). Table 4.5 describes the scoring pro- cess for the Apgar scale.

Table 4.5: Apgar scale scoring

Category 0 1 2

Breathing effort Not breathing Slow or irregular Cries well

Heart rate No heartbeat Less than 100 beats per minute

Greater than 100 beats per minute

Muscle tone Loose and floppy Some muscle tone Active motion

Grimace/reflex No reaction Grimacing Grimacing, plus cough, sneeze, or cry

Skin color Pale blue Body is pink, extremi- ties are blue

Entire body is pink

Source: Adapted from U.S. National Library of Medicine, Medline Plus. (2013b). APGAR. Retrieved from http://www.nlm.nih.gov /medlineplus/ency/article/003402.htm.

Most healthy babies will receive an Apgar score of between 7 and 9. Any score under 7 requires medical attention for the child. However, a low score at 1 minute after birth will typically increase by the 5-minute time point (Apgar, 1953).

▶ The first 4 weeks (or 28 days) of life are referred to as the neonatal period, beginning immediately after birth.

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Section 4.6 The Neonatal Period

Sensory Abilities and Reflexes A newborn’s sensory abilities and natural reflexes set the stage for the critical physical and cognitive developments to follow like building blocks. Sight, hearing, smell, touch, and taste

are all natural senses that should begin to function within minutes after birth. Almost immediately an infant shows a preference for looking at human faces, and other stim- uli with face-like characteristics, more than any other stimuli (Johnson, Dziurawiec, Hadyn, & Morton, 1991). In fact, newborns show a preference for their mother’s face and their mother’s smell over any other faces or scents (Mills & Melhuish, 1974; Pascalis, de Schonen, Morton, Deruelle, & Fabre-Grenet, 1995; Porter & Winberg, 1999). A newborn’s sense of hearing is very sophisticated. Newborns are able to dis- tinguish variations in a sound’s frequency, duration, and volume, and can even sepa- rate vowel sounds (Huotilainen, 2010).

Observation of a newborn’s reactions to certain senses at work is a good way to gauge healthy development during this period. A natural response to an external stimulus is called a reflex. A variety of reflexes can be observed in newborns. Table 4.6 describes the stimuli for some of these reflexes and the appropriate responses that can be observed if the senses are develop- ing properly.

Table 4.6: Neonatal reflexes

Reflex Stimulus Response

Moro (startle) reflex A loud sound or a sudden movement imitating a fall

The newborn’s extremities extend quickly and the head jerks back and then the newborn pulls the extremities back in, often gasping in air and crying out.

Rooting reflex Gently stroking the cheek or area near the mouth

The newborn turns toward and searches for the object.

Sucking reflex Placing an object (usually a nipple or fingertip) gently in the newborn’s mouth

The newborn sucks rhythmically.

Babinski (step) reflex

Lightly touching the bottom of the foot to a flat, hard surface

The newborn’s feet move in a stepping or walking motion.

Tonic neck reflex Turning the head of a newborn who is lying on his or her back to one side

The arm on the same side as the newborn’s turned head straightens and stretches away from the body. The opposite arm is pulled into the body, fist clenched.

▶ Placing a finger on the open palm of an infant will elicit the grasping reflex.

(continued)

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Section 4.6 The Neonatal Period

Reflex Stimulus Response

Grasp reflex Placing a finger on the newborn’s open palm

The newborn’s hand will close tightly around the object or finger.

Truncal incurvation Stroking or tapping along the spine while the newborn is lying on his or her stomach

The newborn’s hips twitch in the direc- tion of the sensation.

Source: Adapted from U.S. National Library of Medicine, Medline Plus. (2013c). Infant reflexes. Retrieved from http://www.nlm .nih.gov/medlineplus/ency/article/003292.htm.

All of these reflexes should be observable in the neonatal period following birth but will fade at various stages during the first year. Some additional reflexes seen in infancy actually last into adulthood, such as sneezing, blinking, and gagging.

The work of T. Berry Brazelton was greatly influential for establishing the perspective that newborns, even hours old, are competent and organized in their behavior, with a unique per- sonality from the beginning (Nugent, 2013). He developed the Neonatal Behavioral Assess- ment Scale (Brazelton, 1973), an assessment tool to examine a newborn’s individual differ- ences, strengths, and difficulties (Nugent, 2013). By observing the newborn’s behavioral responses through reflexes and interactions, professionals can identify the child’s neurologi- cal status and unique functioning (Nugent, 2013). This assessment tool has shown individual differences in neonatal behavior to be influenced by prenatal and birth circumstances (such as prematurity or fetal drug exposure), as well as by cultural environments (Nugent, 2013). Today, Brazelton’s contributions continue to influence the perceptions and perspectives of child development (Brandt, 2013).

Feeding and Sleeping Newborns need to be fed around the clock, which means as many as 8–12 times a day or every 2–3 hours (Mayo Clinic Staff, 2012b). However, all babies eat differently, in different amounts, and on dif- ferent schedules. What they do have in common is that they all show obvious interest in eating and sucking. Poor sucking, no interest, or inadequate weight gain are reasons to call the doctor. Sucking that is ineffec- tive or a baby who cannot latch on to a nipple can lead to problems such as poor weight gain. Prematurity, labor and delivery mediations, and poor health con- ditions at birth may cause a newborn to be unable to suck and remove milk from the breast or a bottle (Robert Wood Johnson University Hospital, n.d.). See Table 4.7 for signs of ineffective sucking.

▶ Newborns must be fed around the clock every 2–3 hours, both night and day.

Table 4.6: Neonatal reflexes (continued)

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Section 4.6 The Neonatal Period

Table 4.7: Signs of ineffective sucking

The baby may be sucking ineffectively if he or she regularly:

• Prompts the mother to breastfeed fewer than 8 times, or more than 14 times, within a 24-hour day.

• Resists, pushes away from, or recurrently latches on and off during a breastfeeding.

• Falls asleep within the first several minutes of feeding, or does not awaken on his or her own to prompt feedings.

• Fails to suck consistently during the first 7–10 minutes of feeding, or does not act satisfied after feeding for 45 minutes or more.

• Remains latched on to the same breast for more than 30–40 minutes.

• Resists milk by alternate feeding methods.

• Acts as if he or she has gas, produces frothy, green stools after the first week, or produces fewer than 3 stools within a 24-hour day during the first week.

• Soaks through fewer than 6 diapers within a 24-hour day after the first week.

Source: Adapted from Robert Wood Johnson University Hospital. (n.d.). Ineffective latch-on or sucking. Retrieved from http:// www.rwjuh.edu/health_information/centers_pregnancy_diff ltch.html.

If the baby has difficulties in sucking during feedings, the mother should consult the child’s pediatrician to receive personalized information and suggestions based on the unique cir- cumstances of that mother and child. Burping the baby after feedings can eliminate some of the air the baby may swallow while feeding, which can decrease a baby’s gas and spitting up. Babies should be content between feedings and have several wet diapers and bowel movements a day. Whether babies are breast-fed or bottle-fed formula makes little differ- ence in these feeding and elimination behaviors. Chapter 5 provides additional information regarding feeding (including breast-feeding and bottle-feeding), diaper changing, and other infant care.

Newborn sleep is different from that of an older infant. Newborns wake up frequently during the night and are expected to wake for feedings every few hours. They also fluctuate between deep sleep and active sleep but with irregular patterns. According to the National Sleep Foun- dation (2013a), newborns sleep 10–18 hours a day, in a restless sleep, with only 1–3 hours spent awake at a time. Too little sleep for a newborn may result in poor development and deficient physical growth. Sudden infant death syndrome (SIDS) and other issues regarding sleep are described in Chapter 5.

Bonding Neonates and parents, usually the mother, generally experience attachment and intense emo- tions. This experience is called bonding. Some professionals believe bonding continues the intense feelings of devotion and attachment that often are evident during pregnancy. Yet in the 1980s it was thought to emerge primarily during the sensitive period beginning immedi- ately after birth during the recovery stage (Klaus & Kennell, 1983). Later studies found that bonding can start later and even develop over time for many parents.

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Summary and Resources

active labor The first and longest stage of the birth process, marked by the opening of the cervix.

amniocentesis A genetic test during preg- nancy in which amniotic fluid is examined.

Apgar scale A common assessment of a newborn’s health immediately after birth, measuring the newborn’s breathing, heart rate, muscle tone, reflexes, and skin color.

blastocyst A ball of cells encased by a thin wall resulting from fertilization and later developing into an embryo.

bonding The attachment and early intense emotions generally experienced by neonates and parents.

cesarean section Surgical removal of the baby through the mother’s abdomen.

Bonding is a natural and complicated emotion. It is the feeling of strong affection and tender- ness for the baby and generally results from performing everyday activities like touching, talking to, and gazing at the infant, and by providing care routines like feeding, changing, and cuddling the baby. The neonate is stimulated to bond by hormones that are released during labor and by the sound and smells of the mother. Bonding can be hampered by postpartum maternal depression, parental substance abuse (see Chapter 2), and even by the removal of a neonate from the parents for care in the neonatal unit of the hospital. Parents with an infant in the neonatal unit have been found to experience depression, stress, and anxiety (Obeidat, Bond, & Callister, 2009), which can make bonding with the baby more challenging. However, bonding is a process that grows and changes over time, as parents become more comfortable and confident caring for the baby, as well as with appropriate care of the parents’ unique needs. The timing and characteristics of bonding are unique to each mother and baby, and can occur at different times and in different ways. Any concerns about the bonding process should be discussed with the child’s doctor, in order to gain personalized information and care for both mother and child.

Summary and Resources A child’s optimal development depends on an understanding of how important it is—before, during, and immediately after birth—to avoid harmful substances and behaviors and promote those that lead to healthy, happy children. This understanding starts with the parents’ health as early as the time of conception and through the prenatal phase. For example, it is important that the mother receive proper nutrition, avoid harmful substances, and get healthy levels of activity and rest. The embryo and fetus develop in several phases, and exposure to negative substances and experiences can affect growth at any time during a pregnancy.

Just as a pregnant mother needs proper care, a newborn also needs proper care. The level of care needed will be based largely on whether the birth proceeded without issue, or whether complications arose. It is crucially important that the parents be prepared for the birth and know where to access supports afterward. Recognizing typical newborn characteristics immediately after birth and over the first 4 weeks of life is critical, to ensure that healthy growth and development are occurring. The neonatal period may be perhaps the most vul- nerable period of a child’s life, and identifying complications early allows the newborn to receive necessary care as quickly as possible.

Key Terms and Concepts

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Summary and Resources

chorionic villus sampling (CVS) A genetic test during pregnancy in which a piece of the placenta is examined.

chromosome abnormality Any irregular- ity in the number or structure of a set of chromosomes.

chromosomes Carriers of genetic material in the human body. A human cell contains 46.

embryonic phase The phase of human development following the germinal phase and consisting of weeks 3–8 after conception.

epidural anesthesia Common pain medi- cation administered during the birthing process through the mother’s back near the spine.

epigenome Chemical compounds that con- trol the expression of a gene.

fertilization The process of a male’s sperm penetrating the wall of the ovum.

fetal age The prenatal age of a baby calcu- lated by beginning at the time of conception.

fetal phase The phase of human develop- ment following the embryonic phase and consisting of weeks 9–38.

genes Sections of DNA carrying encoded instructions for all the cells in the human body. A collection of many genes make up long DNA molecules, which are packaged tightly into chromosomes.

genome The complete set of genes inher- ited from the previous generation.

genotype A set of a gene’s codes passed on to the next generation, which includes the possibilities and the limitations of an organ- ism’s growth and development.

germinal phase The phase of human development consisting of the first 2 weeks immediately following conception.

gestational age The prenatal age of a baby calculated by beginning at the first date of the last menstrual cycle.

implantation The process of a blastocyst attaching itself to the lining along the uter- ine wall.

neonatal The period of human develop- ment from birth through the first 4 weeks of life.

neurotoxicity The effect of toxic substances weakening the brain’s structural develop- ment during the prenatal stage.

nucleus The control center of a cell.

ovulation A process in which a female’s ovum is released for potential fertilization.

phenotype The observable characteristics of a genotype.

placenta Component of the intrauterine environment that connects the growing embryo to the uterine wall to absorb nutri- ents, remove waste, and protect against harmful substances.

prenatal The period of human develop- ment from conception through birth.

reflex A natural response to an external stimulus.

small for gestational age Babies who do not grow at the rate they should for their age during the prenatal period.

sperm The male reproductive cell.

teratogen Any substance causing adverse effects during development in the prenatal stage.

trimesters Three consecutive phases of a typical, full-term pregnancy.

zygote A fertilized ovum.

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Summary and Resources

Discussion Questions

1. Why is it important to understand the stages of prenatal development? 2. What are some lifestyle changes a mother may need to make when she learns that

she is pregnant? 3. Is it more appropriate to refer to stages of prenatal development by trimesters or by

germinal, embryotic, and fetal phases? Why? 4. Why might a chaotic home environment be harmful to a baby’s prenatal

development? 5. What types of birthing methods do you know of that aim to reduce the amount of

stress the baby encounters upon birth? Do you agree with these methods? 6. What might you suspect if a newborn does not want to be fed regularly? Should you

seek medical help? 7. Can bonding still occur between parents and adoptive children? Please describe.

Web Resources

Womenshealth.gov

www.womenshealth.gov This website offers information on all areas of women’s and girls’ health.

HealthyFamilies BC

www.healthyfamiliesbc.ca This website offers to families resources on issues related to pregnancy through the first 3 years of life.

Foodsafety.gov

www.foodsafety.gov This website provides information on food safety in the United States, including food recalls, food poisoning, tips for eating safely, and additional resources.

National Human Genome Research Institute

www.genome.gov This website offers information about genetic health, research, and other issues in genetics.

MedlinePlus

www.nlm.nih.gov/medlineplus This U.S.-government-sponsored resource offers information on a variety of health topics for all ages.

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www.womenshealth.gov

www.healthyfamiliesbc.ca

www.foodsafety.gov

www.genome.gov

www.nlm.nih.gov/medlineplus

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