Faculdade de Ciências Médicas, Universidade Estadual de Campinas, (FCM/UNICAMP), Campinas SP, Brasil:1Center of Studies and Research in Rehabilit at ion; 2Depart ment of Neurology and Cent er f or Invest igat ion in Pediat rics; 3Division of Neonat ology, Depart ment of Pediat rics. Support ed by t he Fundação de Amparo a Pesquisa do Est ado de São Paulo (FAPESP), Proc. nº 00/07234-7.
Received 3 Sept ember 2003, received in f inal f rom 30 June 2004. Accept ed 31 July 2004.
Dra. Vanda M aria Gimenes Gonçalves - Depart ament o de Neurologia FCM /UNICAM P - Caixa Post al 6111 - 13081-970 Campinas SP - Brasil. E-mail: vandagg@uol.com.br
VISUAL FUNCTION AND FINE-M OTOR CONTROL
IN SM ALL-FOR-GESTATIONAL AGE INFANTS
Heloisa G.R.G. Gagliardo
1, Vanda M .G. Gonçalves
2, M aria Cecilia M .P. Lima
1,
M aria de Fat ima de C. Francozo
1, Abimael Aranha Net t o
3ABSTRACT - Objective: To compare visual function and fine-motor control of full-term infants small-for-ges-tational age (SGA) and appropriate for gessmall-for-ges-tational age (AGA), in the first three months. Method: We
eval-uated prospectively 31 infants in the 1stmonth; 33 in the 2ndand 34 infants in the 3rdmonth, categorized as full-term; birth weight less than 10thpercentile for SGA and 25thto 90thpercentile for the AGA group. Genetic syndromes, inf ect ions, mult iple congenit al malf ormat ions w ere excluded. The Bayley Scales of Inf ant Development-II were used, especially items related to visual function and to fine-motor control outcomes.
Results: The Motor Index Score (IS) was significantly lower in the SGA group in the 2ndmonth. The items “ attempts to bring hands to mouth” , in the 1stmonth and “ reaches for suspended ring” , in the 3rdmonth showed high-er frequency in the SGA group. Conclusion: The Motor IS was lower in the 2ndmonth and items of fine-motor control in the 1stmonth and in the 3rdmonth showed higher frequency in the SGA group.
KEY WORDS: int raut erine grow t h ret ardat ion, neurodevelopment , visual f unct ion, f ine-mot or f unct ion.
Função visual e cont role m ot or apendicular em lact ent es pequenos para a idade gest acional
RESUM O - Objet ivo: Comparar a f unção visual e o cont role mot or apendicular de lact ent es nascidos a t er-mo pequenos para a idade gest acional (PIG) com lact ent es adequados para a idade gest acional (AIG), no primeiro t rimest re. M ét odo: Amost ra de 31 lact ent es no 1º mês, 33 no 2º e 34 lact ent es no 3º mês,
nasci-dos a termo; peso de nascimento < percentil 10 para o grupo PIG e percentil 25 a 90 para o grupo AIG. Síndromes genéticas, infecções ou malformações congênitas múltiplas foram excluídas. Foram utilizadas as Bayley Scales of Infant Development-II, especialmente itens relacionados com a evolução da função visual e controle motor apendicular. Result ados: Houve dif erença signif icat iva no Index Score (IS) M ot or no 2º mês, havendo
pon-t uação menor no grupo PIG. Os ipon-t ens “ pon-t enpon-t a pon-t razer mão à boca” , no 1º mês e “ alcança aro suspenso” no 3º mês f oram mais f reqüent es no grupo PIG. Conclusão: No grupo PIG, o IS M ot or f oi menor no 2º mês e
maior número de lact ent es execut aram provas de cont role mot or apendicular no 1º e 3º meses.
PALAVRAS-CHAVE: ret ardo do cresciment o int raut erino, neurodesenvolviment o, f unção visual, f unção mot ora apendicular.
Certain fetuses do not grow to normal size in ute-rus and manifest signs of chronic malnutrition. Their long-t erm grow t h and development may be im-paired as a result of t heir int raut erine experience. These infants are most readily identified on a weight-f or-gest at ion basis, and t hereweight-f ore t he t erms “ int ra-uterine growth restriction” (IUGR) and “ fetal growth rest rict ion” (FGR) are diff erent ent it y of “ small-f or-dat e” or “ small-f or-gest at ional age” (SGA). But at t imes t he t erms are used synonymously. The ident i-f icat ion oi-f new borns t hat present an abnormalit y of int raut erine grow t h remains a problem bot h f rom t he mult i-f act orial aspect of f et al grow t h and
f rom st at ist ical def init ion1. Concept ually, a grow t h
rest rict ed new born is def ined as an inf ant w ho has not achieved it s genet ic grow t h pot ent ial in ut ero2,
in ref erence t o t he genet ic grow t h pot ent ial of in-f ant s. The w ord IUGR supposes t hat t he in-f et us w as retarded in its growth and development by a patho-logical process during f et al lif e.
birt h crow n-heel lengt h is at least 2 st andard devia-t ions bellow devia-t he mean f or devia-t he inf andevia-t ’s gesdevia-t adevia-t ional age, based on data derived from a reference popula-t ion. Also has been def ined in some publicapopula-t ions as birt h w eight or lengt h below t he 10t h, 5t hor 3rd
per-cent ile f or gest at ional age3. The same st at ist ical
li-mit s are used at birt h t o ident if y an inf ant as SGA or IUGR. Recently a new concept considered the esti-mat ion of an individualized birt h w eight limit , t ak-ing int o account t he genet ic grow t h pot ent ial, under t hat a new born must be considered as hav-ing FGR. This approach allowed to identify two new groups: a “ const it ut ionally small” group, w hich should be considered as normal according t o t heir low individual grow t h pot ent ial; and a non-SGA group, classically considered as having an appropri-at e w eight , but w hich are grow t h rest rict ed, consi-dering their high individual growth potential1. Fetal
malnut rit ion result ing in grow t h ret ardat ion may have consequences f or t he brain and t he head cir-cumference. The consequences of prenatal nutrition-al deprivat ion f or t he rapidly grow ing brain are dependent on t he t iming, durat ion and severit y of t he rest rict ion4. In t he human t he phase of
neuroblast mult iplicat ion occurs at a more highly prot ect -ed early period of gest at ion. When t he brain spurt begins, about t he middle of gest at ion, t he adult n u m b er o f n eu r o n s h as al r ead y b een l ar g el y achieved. A def icit in part icular regions of t he cere-bellum has been seen (w it h t he lat e-dividing gran-ular neurons) after undernutrition in the 3rdtrimester
of pregnancy. That early malnutrition in rats will cur-t ail cur-t he racur-t e of cell division if icur-t occurs during cur-t he period of hiperplasia5. During t he period of rapid
cellular prolif erat ion, undernut rit ion w ill aff ect t he rat e of cell division in any brain area w here cells are dividing and in any cell t ype in t he process of divi-sion. Regional grow t h in t he human brain is some-w hat diff erent t han in t he rat brain; but it suggest s that cell division can be curtailed by maternal under-nut rit ion, w hich demonst rat es t hat t hese changes are permanent , and may permanent ly reduce t he number of brain cells in her off spring. Considering t he number of SGA children at risk, f ew st udies have been carried out in developing count ries. The only w ell-document ed report s w e are aw are of in Brazil show ed t hat SGA f ull-t erm inf ant s had poor-er development t han appropriat e f or gest at ional (AGA) inf ant s at 6, 12 and 24 mont hs6,7,8or
abnor-mal neurological examinat ion9,10.
Cognit ive f unct ioning in American inf ant s w as similar bet w een SGA and AGA t erm born children by age of 1 year, except f or a low er Bayley M ent al
Development Index in SGA as measured by t he Bayley Scales of Inf ant Development and t he Fagan Test of Inf ant Int elligence11,12. Int erest has now
shif t ed t o t he out come of inf ant s f rom progressive-ly low er birt h w eight groups in w hom an increased incidence of more subt le problems, such as poor visual-motor integration, deficits in spatial relations, language disorders, reading and behavior problems has been report ed13. M ore dif f erences have been
f ound in 3 t o 5-years-old or older children14,15,16.
Studies of the outcomes of low-birth weight chil-dren at school age have included measures of visu-al percept ion, f ine mot or skills and visuvisu-al-mot or in-t egrain-t ion. There has been no sysin-t emain-t ic invesin-t iga-t ion of iga-t he prevalence and naiga-t ure of visual-moiga-t or int egrat ion dysfunct ion and the relat ion of the dys-f unct ion t o dys-f ine mot or skills, visual percept ion and perinat al variables in apparent ly normal very low birt h w eight children at school age17. In t he same
w ay, t here has been no syst emat ic invest igat ion of t hese f unct ions in SGA inf ant s. Variabilit y in me-t hodology, me-t erminology, and assessmenme-t s used makes it dif f icult t o draw f irm conclusions. Incon-sist ent t erminology and def init ion such as mot or cont rol, eye-hand coordinat ion and f ine mot or dif f icult ies have been used f or visual-mot or int egrat ion, visual-percept ion and f ine mo-t or skill17. As not ed in one of t he only st udies t hat
differentiated these functions, a weakness with one of t hese component s, in t heir report ed f ine-mot or cont rol, explained a signif icant part of t he def icit in children at school age17.
Visual-mot or int egrat ion is def ined as t he de-gree t o w hich visual (inf ormat ion) percept ion and limb movement s, in t his case f inger-hand act ions, are w ell coordinat e. This rat her general t erm, as f requent ly used in most of t he research described, ref lect s in f act t w o separat e and independent f unct ions: visual percept ion and f ine-mot or con-t rol18. On t he ot her hand, f ine mot or f unct ion may
be described more specif ically as t he development status of finger/hand movements. Although the use of visual inf ormat ion may play a role in t he t ask, assessment f ocus is on mot or act ions.
M ETHOD
The research design w as a prospect ive cross-sect ion-al st udy w it h t w o cohort s of f ull-t erm inf ant s, a SGA group compared w it h a cont rol AGA group. From Sept ember 2000 t o August 2001, a neonat ologist select -ed 42 f ull-t erm SGA and AGA neonat es deliver-ed at Neonat ology Service at t he Cent er of Int egral At t ent ion t o t he Woman’s Healt h (CAISM ) of t he St at e Universit y of Campinas (UNICAM P), São Paulo, Brazil. When a SGA neonat e w as chosen, t he f ollow ing t w o AGA neonat es w ere select ed. Et hical permission w as obt ained f rom t he Research Et hics Commit t ee of t he M edical Facult y of UNICAM P and t he mot hers also gave t he f ully inf or-med consent .
They w ere select ed on t he f ollow ing crit eria: 1) sub-ject s living in Campinas met ropolit an area, 2) neonat es considered in good healt h f or going home w it hin 2 days of birt h, 3) gest at ional age cat egorized as f ull-t erm (37-42 w eeks) by ull-t he Capurro meull-t hod19, 4) expect -ed birt h w eight us-ed by Lubchenco met hod20: birt h w eight less t han 10t h percent ile f or t he SGA group and bet w een 25t h and 90t h percent ile f or t he AGA group. Genet ic syndromes, mult iple congenit al malf ormat ions and verif ied congenit al inf ect ions (syphilis, t oxoplasmo-sis, rubella, cyt omegalovirus, herpes) w ere excluded.
Perinat al variables collect ed and examined w ere gen-der, gest at ional age, birt h w eight , birt h w eight cent ile. All children w ere scheduled f or development al evalua-tion and two professionals who were unaware of the clas-sif icat ion of t he neonat e’s group perf ormed t he assess-ment s of t he inf ant s, in t he presence of t heir mot hers, at 1, 2 and 3 mont hs of age. The Bayley Scales of Inf ant Development -II (BSID-II)21w ere used. The inf ant ’s score f or each it em w as regist ered in t he M ent al and M ot or Scale Record Form. The BSID-II index has a mean of 100 and a st andard deviat ion of 15. The raw scores and index scores (IS) of t he M ent al and M ot or Scales w ere consid-ered. A syst em of w ell-def ined t erminology classif ied t he Development al IS as: accelerat ed perf ormance (115 and above); w it hin normal limit s (85-114); mildly delayed per-f ormance (70-84); signiper-f icant ly delayed perper-f ormance (69 and below). The Mental and Motor performance was clas-sif ied as normal w hen t he IS w as equal or above 85 and alt ered perf ormance w hen t he IS w as less t han 85.
Inf ant s w ere assessed once a mont h, bet w een 7 days bef ore or af t er t heir birt hday. They should be in st at e of arousal, calm, alert t o t he environment . For t he t est procedure, t he inf ant w as lying on a padded surf ace, on an exam t able in t he supine posit ion w it h t he head at midline. The mat erial used w as a red ring w it h st ring.
Subt est s w ere select ed t o invest igat e visual f unc-t ions and f ine-mounc-t or conunc-t rol. We devounc-t ed caref ul aunc-t unc-t en-t ion en-t o en-t he qualien-t aen-t ive aspecen-t s of some ien-t ems of en-t he M ent al and M ot or Scales. Of great import ance t o us w as t he number of inf ant s t hat perf ormed t hem. In t he 1st mont h, t he visual f unct ions assessed w ere visual f ixat ion and visual t racking: “ regards ring f or 3 seconds” and
“ eyes f ollow ring (horizont al and vert ical excursion)” ; f ine-mot or cont rol w as assessed by t he it em “ at t empt s t o bring hands t o mout h” (purposely at t empt s t o place his hand in his mout h; t he child need not act ually place his hand in his mout h).
In t he 2ndmont h, w e evaluat ed t he same visual f unc-tions as before and the fine motor control were “ attempts t o bring hands t o mout h” , “ inspect s ow n hand(s)” and “ manipulat es ring” . In t he 3rdmont h, all t he it ems be-f ore plus “ keeps hands open” and “ reaches be-f or suspend-ed ring” . The f unct ion “ reaches f or suspendsuspend-ed ring” w as considered w hile looking at t he ring t he inf ant purpose-ly moved his arm in t he ring’s direct ion. This manipula-t ive momanipula-t or pamanipula-t manipula-t ern w as visually elicimanipula-t ed and guided.
The dat a w ere regist ered in a dat abase of t he Epi-demiological Inf ormat ion Program, version 6.02. The SSPS Package w as used f or st at ist ical t est s. The relat ion bet w een cat egorical variables (visual and f ine-mot or cont rol it ems, M ent al and M ot or perf ormance classif i-cat ion) w as invest igat ed using Chi-Square or Fisher Test s. To det ermine t he relat ion bet w een cont inuous vari-ables (birt h w eight , gest at ional age, IS of t he M ent al and M ot or Scales) w as used t he M ann-Whit ney t est . The probabilit y value w as set at p ≤0.05.
RESULTS
A t ot al of 42 inf ant s w ere st udied. The sample f or t he cross-sect ional st udy consist ed of 31 inf ant s in t he 1stmont h, 33 in t he 2ndmont h and 34 inf ant s
in 3rdmont h of lif e. Tw ent y inf ant s w ere repeat
edly evaluat ed all t hree mont hs, 16 w ere evaluat -ed t w o mont hs and 6 in only one mont h (3 f rom t he SGA group and 3 f rom t he AGA group).
No d i f f er en ces w er e o b ser ved f o r g en d er (p=0.650) or gest at ional age (p=0.808). The birt h w eight in t he SGA group ranged f rom 2125g t o 2620g, median of 2370g. In t he AGA group t he birt h w eight ranged f rom 2765g t o 3710g, medi-an of 3220g. Comparison of birt h w eight bet w een groups show ed st at ist ically signif icant dif f erence (p=0.0001). It w as concluded t hat t he met hod f or subject classif icat ion in each group w as correct .
Table 1 show s t he relat ion bet w een chronolo-gical age, t he number and percent of subject s w it h normal perf ormance f or M ent al and M ot or Scales and p-value. Fisher test were carried out to determi-ne comparison bet w een SGA and AGA groups in t he t hree mont hs.
In the Mental Scale, the groups responded diffe-rent ly in t he 1st mont h (p=0.372) and in t he 2nd
mont h (p=0.450), but t here w as no signif icant dif -f erence (p > 0.05). In t he 3rdmont h, bot h
of inf ant s classif ied as normal in t he M ent al Scale, in t he 1stmont h of lif e.
In t he M ot or Scale, bot h populat ions w ere simi-lar (p=1.00) in t he 1stmont h. The groups
respond-ed diff erent ly in t he 2ndmont h (p=0.561) and in t he
3rdmont h (p=0.725). The AGA group had show n
a proport ionally great er number of inf ant s classif i-ed as normal in t he M ot or Scale, but t here w as no st at iscally signif icant dif f erence (p > 0.05).
Table 2 show s t he relat ion bet w een chronolo-gical age, IS in t he M ent al and M ot or Scales and p-values. M ean comparisons using t he M
ann-Whit ney t est revealed near t he limit t o dif f erence in M ent al Scale and a st at ist ically signif icant diff e-rence in M ot or Scale, bot h in t he 2ndmont h. The
IS show ed marked dif f erences in t he 2ndmont h.
Table 3 show s t he result s of t he specif ic it ems of M ent al and M ot or Scales f or t he assessment of visual f unct ions and f ine - mot or cont rol in t he groups. Table 4 show s p-values f or comparison bet w een SGA and AGA groups.
Tables 3 and 4 show t hat visual f ixat ion evalu-at ed by t he it em “ regards ring f or 3 seconds” and visual tracking evaluated by “ eyes follow ring in
ho-Table 1. Chronological age, normal perf ormance in t he M ent al and M ot or Scale and p-values of SGA and cont rol groups.
Chronological Group n M ent al perf ormance M ot or perf ormance
age ƒ/% p-valuea ƒ/% p-valuea
1stmont h AGA 20 14/70.00 0.372 17/85.00 1.000
SGA 11 10/90.91 9/81.82
2ndmont h AGA 19 12/63.16 0.450 18/94.74 0.561
SGA 14 7/50.00 12/85.71
3rdmont h AGA 21 18/85.71 1.000 12/57.14 0.725
SGA 13 11/84.62 6/46.15
aFisher t est ; AGA, appropriat e f or gest at ional age; SGA, small-f or-gest at ional age.
Table 2. M eans and st andard deviat ion of Index Score in t he M ent al and M ot or Scales and p-values of t he SGA and cont rol groups.
Chronological age Group n M inimum M aximum M ean St andard p-valueb deviat ion
M ent al Index Score
1stmont h AGA 20 64 104 92 10.93 0.834
SGA 11 68 100 92 8.22
2ndmont h AGA 19 62 111 90 11.61 0.052*
SGA 14 68 101 84 9.75
3rdmont h AGA 21 79 124 89 9.59 0.238
SGA 13 73 103 87 7.19
M ot or Index Score
1stmont h AGA 20 76 107 94.5 7.88 0.627
SGA 11 76 101 97 8.07
2ndmont h AGA 19 74 114 93 7.99 0.033* *
SGA 14 81 108 87 7.08
3rdmont h AGA 21 58 101 88 12.23 0.121
SGA 13 67 91 82 8.08
bM ann-Whit ney t est ; AGA, appropriat e f or gest at ional age; SGA, age; * , near t he limit t o signif icant dif f erence; * * ,
rizontal excursion” , more frequently observed in the SGA group, in the 1stmonth, was not statistically
sig-nificantly so. In addition, the item “ attempts to bring hands t o mout h” w as more f requent ly observed in SGA inf ant s in t he 1stand 2ndmont hs, w it h a st at
is-t ically signif icanis-t diff erence in is-t he 1stmont h of lif e.
M oreover, in t his it em, in t he AGA group t here w as an increase w it h age f or t he proport ion perf
orm-ing w ell t he t est and also f or t he SGA group f allorm-ing f rom t he 1stt o t he 3rdmont h.
In t he 3rdmont h, t he reaching movement s f or
suspended ring w ere more f requent ly observed in t he SGA group, w it h st at iscally signif icant dif f er-ence. The it em “ keeps hands open” w as more f re-quent in t he AGA group, near t he limit t o signif i-cant dif f erence.
Table 3. Cell f requency count s of t he SGA and cont rol groups in t he visuomot or it ems.
It ems Groups 1stmont h ƒ/% 2ndmont h ƒ/% 3rdmont h ƒ/%
Regards ring f or 3 seconds AGA 15/83.33 10/55.56 17/85.00
SGA 10/90.91 6/50.00 9/81.82
Eyes f ollow ring (horizont al excursion) AGA 13/76.47 15/83.33
SGA 9/90.00 10/76.92
Eyes f ollow ring (vert ical excursion) AGA 10/58.82 11/61.11
SGA 4/40.00 6/46.15
M anipulat es ring AGA 4/23.53 7/38.89
SGA 2/14.29 4/36.36
Inspect s ow n hand(s) AGA 3/16.67 8/42.11
SGA 4/28.57 3/25.00
At t empt s t o bring hands t o mout h AGA 6/30.00 9/50.00 12/60.00
SGA 9/81.82 10/71.43 7/58.33
Keeps hands open AGA 13/61.90
SGA 3/27.27
Reaches f or suspended ring AGA 1/05.26
SGA 4/40.00
AGA, appropriat e f or gest at ional age; SGA, small-f or-gest at ional age.
Table 4. P-values in t he visuomot or it ems f or SGA and cont rol group.
It em 1stmont h 2ndmont h 3rdmont h
p-valuea p-valuea p-valuea
Regards ring f or 3 seconds 1.000 1.000 1.000 Eyes f ollow ring (horizont al excursion) 0.621 0.676
Eyes f ollow ring (vert ical excursion) 0.440 0.409
M anipulat es ring 0.664 1.000
Inspect s ow n hand(s) 0.669 0.466
At t empt s t o bring hands t o mout h 0.006* * 0.221 1.000
Keeps hands open 0.063*
Reaches f or suspended ring 0.036* *
aFisher t est ; * , near t he limit t o signif icant dif f erence; * * , signif icant dif f erence; SGA,
DISCUSSION
Since 1994, the Interdisciplinary Group of Studies in Inf ant Development (GIADI) have conduct ed st u-dies at t he Cent er of St uu-dies and Research in Reha-bilit at ion (CEPRE), in collaborat ion w it h t he Depar-t menDepar-t of Neurology and Division of NeonaDepar-t ology at t he CAISM , St at e Universit y of Campinas (UNI-CAM P) Sao Paulo, Brazil. This group w orks mainly in t he st udy of inf ant neurodevelopment regarding aspect s such as: visual and hearing f unct ions, lan-guage, mot or and neurological development . The team has professionals in the health areas: pediatric neurologist , pediat rician, occupat ional t herapist , psychologist , speech pat hologist , physical t herapist and social w orker. The present st udy comprises a group of 42 inf ant s, 36 assessed at least t w ice and among t hese, 20 w ere assessed 3 t imes. So, t he pos-sibilit y of dropout -biased eff ect ment ioned in t he lit erat ure6is very small. How ever t his select ion of
observat ions w as a mat t er of supply and not of st u-dy design. The limit at ions in ensure t he adequat e mont hly evaluat ion w ere f ormidable.
It w as f ound signif icant ly low er IS in t he M ot or Scale in SGA inf ant s in t he 2ndmont h of lif e. No
dif f erences w ere observed in t he 3rdmont h. So at
t he age of t w o mont hs t he SGA inf ant s w ere diff e-rent f rom t he AGA group but in t he 3rdmont h t he
groups w ere equal. We conject ured t hat t his may indicat e t he so called major t ransf ormat ion of neural f unct ion t hat occurs at about t he end of t he 2ndmont h post erm22and many neural f unct ions
change int o a more adapt at ive condit ion t han du-ring t he f irst 2 mont hs af t er birt h at t erm23.
Prenat al mat ernal malnut rit ion (part icularly in relat ion t o t he essent ial f at t y acids, vit amin E and trace elements) may reduce total neuronal cell num-bers and synapse f ormat ion and may also int erf ere with neuronal migration. Between 26 and 34 weeks of gest at ion, t he normal process of neuron loss and axon retraction is at its height, with increased meta-bolic act ivit y and increased vulnerabilit y around t he area of t he basal ganglia, t he caudat e nucleus, the cerebellum and the optic radiations. These areas are implicat ed in crit ical aspect s of mot or cont rol24.
A t riple w at ershed zone also aff ect s t he pat hw ays bet w een t hese areas, making t hem part icularly vul-nerable to hemorrhage, ischaemia and disturbances in cerebral blood f low. Int errupt ion of t hese pat h-w ays is t heref ore likely t o aff ect perf ormance in a number of diff erent domains.
The ident if icat ion of poor perf ormance in it ems
of M ent al and M ot or Scales assessing part icular skills might relat e t o specif ic def icit s in t he part s of t he brain cont rolling t he part icular act ivit y being t est ed. It w as surprising t o observe t hat f unct ions of visual f ixat ion in t he midline and horizont al visual t racking w ere more f requent ly observed in t he SGA group, in t he 1stmont h of lif e, alt hough
not st at ist ically signif icant . Those result s suggest t hat t he development of visual f unct ions in SGA inf ant s f ollow dif f erent pat t erns in comparison w it h AGA inf ant s. We observed a qualit at ive t en-dency f or diff use observat ion of t he environment , and an unst eady visual t racking in t he SGA group. The administ rat ion and scoring direct ions of t he BSID-II allow s t he examiners t o repeat t he same it em a maximum of t hree t imes during t he eva-luat ion. So, inf ant s w it h low visual f ocus concent ra-t ion in a specif ic sra-t imulus can perf orm successf ul-ly t he it em. It w as ref erred in SGA neonat es t hat alt hough he comes t o an alert st at e, his responsive-ness is poor25. He does not lock int o social st imuli
easily and does not int eract in a f ocused and mo-dulat ed manner w it h t he animat e or inanimat e environment .
Normally developing inf ant s search and scan t heir environment in a consist ent manner w hen t hey reach t he age of t hree mont hs26. It is ref erred
in normal inf ant s t hat f ew visual connect ions are f ound at birt h (about 10% of t he maximum), w hen visual alert ness is yet very low and visual f ixat ion and f ollow ing are just beginning t o be demonst ra-ble. The rapid burst in synapt ogenesis at t he age of 4 mont hs correlat es w it h a sudden increase in visual alert ness at about t hat t ime27. Clinical
obser-vat ions conf irm t he import ance of t he neurologi-cal mat urat ion of t he visual syst em. In t he last t w o decades, advances have been considered in our un-derst anding of t he mat urat ion of visual f unct ion and in t he w ays t o assess it . It is now w ell accept -ed t hat t he visual syst em f unct ions mainly at a subcort ical level in t he new born and in t he f irst mont hs af t er birt h, and becomes progressively in-t egrain-t ed w iin-t h and dominain-t ed by corin-t ical process-es during t he 1styear28. Longit udinal st udies have
f ollow ed t he onset and t he mat urat ion of dif f er-ent aspect s of visual f unct ion in normal inf ant s t hus providing age-dependent normat ive dat a28,29.
We observed in t he 1stand 2ndmont hs t he f
in t he 3rdmont h. The basic processes evaluat ed w
e-re t he inf ant ’s abilit y t o cont rol mot or behavior and t o perf orm int egrat ed mot or act ions. It ems re-present ing t his dimension included hand t o mout h coordinat ion. M oreover, t he result s show ed a gra-dient in neuromot or compet ence t o at t empt s t o bring hands t o mout h: t here w as an increase in t i-me in the AGA group and a decrease in the SGA gro-up f rom t he 1st t o t he 3rd mont h. We conject ured
t hat t hose diff erences could be at t ribut ed t o a gre-at er occurrence of movement of t he arms observed in SGA group, w hich purposely brought his hand t o his mouth, mainly in the 1stmonth. It is plausible that
t hose diff erences could be at t ribut ed t o a great er speed and great er occurrence of movement s ob-served in SGA group, mainly in t he 1stmont h.
St udies have invest igat ed t he qualit y of gener-al movements in fetuses and infants with intra-uter-ine grow t h ret ardat ion. M ovement s’ qualit y w as found to be impaired30,31. ‘Slow motion’ and
‘chaot-ic’ general movement s are f requent ly observed in inf ant s w it h grow t h ret ardat ion. M any inf ant s w it h grow t h ret ardat ion have t ransient ly abnor-mal general movement s, indicat ing t he import an-ce of obt aining mult iple observat ions. It has been suggest ed t hat abnormalit ies at a young age are relat ed t o lesions of neural subsyst ems w hose role in mot or cont rol ceases af t er 2 t o 3 mont hs. These abnormalit ies may disappear if t he new, post t rans-f ormat ion set orans-f neural rans-f unct ions is not impaired. Af t er birt h, general movement s of t he normal inf ant are commonly ref erred t o as w rit hing move-ment s. At t he age of 6 t o 9 w eeks post t erm, at about t he end of t he 2ndmont h, during t he
so-cal-led major neural t ransf ormat ion22, t he general
movement s of t he normal inf ant acquire a f idg-ety character. Fidgidg-ety general movements are circu-lar movements of small amplitude, moderate speed, and variable accelerat ion of neck, t runk and limbs in all directions. All normally developing infants mo-ve t heir arms and legs w it h gracef ul, small momo-ve- move-ment s31. Abnormal f idget y movement s at t his age
resemble normal movement s, but t heir amplit ude, speed and jerkiness w ere moderat ely or great ly exaggerat ed. A very st riking f eat ure concerned a peculiar t ype of ‘f idget y movement s’ in blind in-f ant s26: t hey w ere exaggerat ed in amplit ude and
jerky in charact er and t heir presence last ed unt il 8 t o 10 mont hs. The aut hors conject ured t hat exaggerat ed f idget y movement s might indicat e an at -t emp-t -t o compensa-t e f or -t he lack of in-t egra-t ion of propriocept ion and vision.
The f unct ion “ reaches f or suspended ring” w as more f requent ly observed in t he SGA group in t he 3rdmont h of lif e, w it h a st at ist ically signif icant
di-f di-f erence. These movement s w ere exaggerat ed in speed and amplit ude, despit e of resemble normal movement s.
The literature referred that the pattern of move-ment f requent ly observed in SGA and pret erm in-fants32, exists only indistinctly in normal full-term
in-f ant s. Similar movement pat t erns w ere ment ioned as “ w indmill mot ions of t he arms”33, or “ w
ind-mil-ling arms movement ”34, or “ cicling movement s”35
or “ arm movement s in circles”36.
Reaching behavior can be observed in normal inf ant s since 3 mont h of lif e, but t he visually con-t rolled prehensile pacon-t con-t erning emerges around con-t he f ourt h or t he f if t h mont hs32. It seems t hat during
t he early period of prehension development in human inf ant s t he init iat ion of reaching at t empt s is predominant ly visually cont rolled, and t he t ac-t ile-kinesac-t heac-t ic inpuac-t associaac-t ed w iac-t h successf ul object capt ure appears t o play a minor role in t he regulat ion of early reaching behavior.
The t echniques used f or assessing visual and f ine mot or f unct ions in t hese inf ant s are non-invasive. It can be done w it hout expensive equipment s and an experienced observer does t he assessment . It is im-portant to mention that we have embarked on a fur-t her review of fur-t hese inf anfur-t s afur-t 12 monfur-t hs of age.
In conclusion, our result s comparing t he Index Score of t he BSID-II in t w o groups of SGA and AGA inf ant s show ed signif icant diff erence in t he M ot or Index Score at 2 mont hs of age. The it em “ at t empt s t o bring hands t o mout h” w as more f requent ly ob-served in SGA inf ant s in t he 1stand 2nd, w it h st at
is-t ically signif icanis-t diff erence in is-t he 1stmont h of lif e.
The result s show ed a gradient in neuromot or com-pet ence t o “ at t empt s t o bring hands t o mout h” : t here w as a decrease in t ime in t he SGA group and an increase in t he AGA group f rom t he 1st t o t he
3rdmonth. In the 3rdmonth, the movements “
reach-es f or suspended ring” w ere more f requent ly ob-served in t he SGA group, w it h st at iscally signif icant difference. The item “ keeps hands open” was more f requent in t he AGA group, near t he limit t o signi-f icant disigni-f signi-f erence.
Acknow ledgem ent s - The aut hors w ould like t o
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