TABLE 1113 Recommended Schedule of Childhood Immunizations

NEUROLOGIC ASPECTS Motor development is the major indicator of neurologic health and proceeds in a cephalocaudal fashion. Neonates demonstrate involuntary "primitive" reflexes, such as the suck, grasp, and Moro (startle) responses, which may be elicited to demonstrate muscle tone and should always be symmetric. By 1 month of age, infants can lift their heads, follow a moving object, and demonstrate a social smile. By 4 months, head control is steady, the child will reach for and grasp objects with the whole hand, a cooing response may be elicited, and rolling over has begun. During this period, normal infants learn trust from their parents and will respond positively to a gentle examiner. This is the period of least parental confidence, and many emergency department visits are made because of lack of knowledge and a need for reassurance.

AGE-SPECIFIC APPROACH Assessment is optimally made by direct interaction using a pleasant, confident tone of voice and smiling face directed toward the infant. Observation of muscle tone, spontaneous activity, eye contact, responsive smile, and recognition of parents is most important. Examination of the infant is best performed in the parent's lap, with use of brightly colored or pleasant-sounding objects to elicit a motor response. Feeding the infant or eliciting the sucking reflex with a finger will often result in greater cooperation. Optimal examination is done in order of least to most invasive interactions, i.e., observation, auscultation, and palpation, being careful to avoid uncomfortable procedures such as ear and throat examination until the child's level of consciousness is established. Parental confidence should be directly reinforced. Young infants should be carefully monitored during procedures involving conscious sedation or abnormal positioning, because of the risk of airway compromise. Finally, the motor abilities of young infants result in a limited potential for self-inflicted accidental injury. Whenever an injury is developmentally inconsistent with the stated mechanism, the potential for child abuse must be investigated.

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