1990;85;17 Pediatrics

Howard Cabral
Steven Parker, Barry Zuckerman, Howard Bauchner, Deborah Frank, Robert Vinci and
Jitteriness in Full-Term Neonates: Prevalence and Correlates

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Jitteriness in Full-Term Neonates:
PEDIATRICS Vol. 85 No. 1 January 1 990 17
Prevalence and Correlates
Steven Parker, MD; Barry Zuckerman, MD; Howard Bauchner, MD;
Deborah Frank, MD; Robert Vinci, MD; and Howard Cabral, MPH
From the Division of Developmental and Behavioral Pediatrics, Department of Pediatrics,
Boston City Hospital, and Boston University Schools of Medicine and Public Health,
Boston, Massachusetts
ABSTRACT. The prevalence and correlates of jitteriness
were evaluated in a sample of 936 healthy full-term
infants. Jitteriness was seen in 44% of this sample: 23%
were classified as mildly jittery, 8% as moderately jittery,
and 13% as extremely jittery. Jitteriness was seen most
commonly in infants who were sleepy or active and least
commonly in infants who were quietly wakeful during
the neonatal examination. Jittery infants were more
likely to be difficult to console when crying (P < .01) and
less visually alert (P < .001) than were nonjittery infants.
Jitteriness was seen more commonly in slightly smaller
(P < .05) and shorter (P < .001) infants, in those more
than 12 hours old (P < .01), and in those not exposed to
general anesthesia (P < .05). In an expanded sample of
1054 healthy and sick full-term infants, jitteriness was
observed more commonly in neonates who had been
exposed prenatally to maternal marijuana use (P < .01),
but not to cocaine use (P = .1), and whose mothers had
a positive postpartum urine assay for m arijuana (P < .05)
or cocaine (P = .06). The magnitude of these drug effects,
however, was small. These findings have important im-
plications for the early parent-infant relationship, pedi-
atric practice, and future research. Pediatrics 1990;85:17-
23; neonatal behavior, neonatal jitteriness, neonatal neu-
rologic exam ination, jitteriness.
Jitteriness is defined as rhythmic tremors of
equal amplitude around a fixed axis and is the most
common involuntary movement of healthy full-
term infants. Studies concerning its prevalence,
however, are rare and have yielded conflicting re-
sults. Touwen2 observed 20% of 50 low-risk infants
to be jittery during spontaneous movements, and
Received for publication Sep 22, 1988; accepted M ar 20, 1989.
Presented, in part, at the annual meeting of the Society for
Behavioral Pediatrics, M ay 1988, W ashington, DC
Reprint requests to (S.P.) Division of Developmental and Be-
havioral Pediatrics, Boston City Hospital, 818 Harrison Aye,
Boston, M A 02118.
PEDIATRICS (ISSN 0031 4005). Copyright 1990 by the
American Academy of Pediatrics.
W illemse reported a prevalence of 41% in 138 in-
fants observed in the first hours of life.
The clinical applicability of the available studies
has been limited. First, the investigators examined
relatively few infants and did not docum ent their
prenatal, intrapartum, or postpartum characteris-
tics. Second, they did not report the behavioral
states during which the infants were jittery. Behav-
ioral states (ie, whether asleep, alert, and/or crying)
exert a powerful influence on all aspects of neonatal
neurobehavioral functioning.3 Jitteriness, in partic-
ular, is considered to occur commonly when infants
are crying or stressed. Peiper and Isbert, for ex-
ample, reported jitteriness to occur in two thirds of
infants following elicitation of the M oro response
in the first week of life. On the other hand, jitteri-
ness is considered to be clinically significant if it
occurs when the infant is quiet and alert. Because
studies have lacked documentation of the infants
behavioral states, they have been am biguous as to
the extent and clinical severity of the jitteriness.
Third, from available studies, whether jitteriness in
healthy infants is an isolated finding or occurs in
conjunction with other neurobehavioral signs and
symptoms has not been established. Because of the
limited data, jitteriness in an otherwise healthy full-
term infant remains of uncertain clinical signifi-
cance.
Although the im plications of jitteriness in
healthy infants are not well established, it has been
associated with a variety of pathologic conditions,
including hypoglycemia, hypocalcemia, narcotic ab-
stinence syndrome, sepsis, hypoxic encephalopathy,
and intracranial hemorrhage.4 Such problems are
relatively infrequent, however, and the cause of
jitteriness is usually not apparent. In one study,5 34
healthy full-term infants who were jittery without
apparent cause were found to have elevated serum
norepinephrine levels, compared with a control
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18 JITTERINESS
group of nonj i ttery i nf ants. A nother study6 dem-
onstrated depressed serum magnesi um l evel s (wi th
normal cal ci um and gl ucose l evel s) i n 22 j i ttery 1-
day-ol d i nf ants wi th otherwi se normal exami nati on
f i ndi ngs. W hatever i ts eti ol ogy, the preval ence of
j i tteri ness i n heal thy i nf ants markedl y di mi ni shes
by the second week of l i f e and i s general l y absent
af ter that ti me.7
The goal of thi s study was to cl ari f y the cl i ni cal
si gni f i cance of j i tteri ness i n heal thy f ul l -term i n-
f ants and to: (1) determi ne i ts preval ence duri ng
di f f erent behavi oral states; 2) determi ne the asso-
ci ati on between neonatal j i tteri ness and prenatal ,
i ntrapartum, and postpartum vari abl es, i ncl udi ng
maternal ci garette, al cohol , cocai ne, and mari j uana
use duri ng pregnancy; and 3) i denti f y whether j i t-
teri ness i s associ ated wi th other aspects of neonatal
neurobehavi oral f uncti oni ng, especi al l y those that
mi ght af f ect the parent-i nf ant rel ati onshi p.
MATERIALS AND METHODS
Sample Selection and Methods
The sampl e was drawn f rom a cohort of i nf ants
born to mothers parti ci pati ng i n an epi demi ol ogi c
study, conducted f rom 1984 to 1987, i nvesti gati ng
the rel ati onshi p of maternal drug use and other
heal th behavi ors duri ng pregnancy to newborn out-
comes. W omen were consecuti vel y recrui ted f ol l ow-
i ng regi strati on f or prenatal care at the W omen s
and A dol escent Prenatal Cl i ni cs at Boston Ci ty
Hospi tal . El i gi bi l i ty requi rements f or study parti c-
ip a t ion wer e t h e a b ilit y t o com m u n ica t e in E n glish
or Spani sh and wi l l i ngness to provi de i nf ormed
consent.
W omen were i ntervi ewed i n the prenatal and
i mmedi ate postnatal peri od by a trai ned bi l i ngual
i ntervi ewer. The i ntervi ews were semi structured,
and a cl osed-ended, f orced-choi ce f ormat was used.
I nf ormati on was el i ci ted that i ncl uded the women s
demographi c characteri sti cs, nutri ti onal i ntake,
psychol ogi c stress, and use of ci garettes, al cohol ,
cocai ne, mari j uana, and other i l l i ci t drugs.
M aternal uri ne sampl es were obtai ned f ol l owi ng
the prenatal i ntervi ew and duri ng the postpartum
hospi tal i zati on and assayed f or cocai ne and man-
j uana metabol i tes usi ng the enzyme-medi ated i m-
munoassay techni que. Posi ti ve resul ts were recon-
f i rmed by mass spectroscopy/gas chromatography
f or cocai ne metabol i tes and hi gh-pressure l i qui d
chromatography f or mari j uana metabol i tes. A uri ne
assay posi ti ve f or cocai ne suggests use wi thi n the
previ ous 72 hours, and an assay posi ti ve f or man-
j uana suggests use wi thi n the previ ous 10 days.
Cocai ne and mari j uana users duri ng pregnancy
were i denti f i ed by posi ti ve sel f -report and/or a pos-
i ti ve uri ne test. The use of ci garettes, al cohol , and
other drugs was i denti f i ed sol el y by sel f -report. A
more compl ete descri pti on of the study methodol -
ogy has been publ i shed.8 Soon af ter del i very, the
maternal medi cal record was revi ewed and coded
f or prenatal and i ntrapartum heal th-rel ated van-
abl es based on the ri sk f actors devel oped by Hobel
et al .9
The i nf ants of these women were exami ned i n
the hospi tal by one of f i ve pedi atri ci ans who was
unaware of the mother s prenatal on i ntnapartum
hi story. These exami nati ons were conducted 8 to
72 hours af ter del i very. The Neurol ogi cal and A dap-
ti ve Capaci ty Scal e devel oped by A mi el -Ti son, #{ 176}
sel ected i tems f rom the Neonatal Behavi oral A s-
sessment Scal e devel oped by Brazel ton,1 the Neu-
nol ogi cal and Physi cal M aturi ty I ndi ces of the Du-
bowi tz Exami nati on f or Gestati onal A ge, 2 and
standardi zed anthropometni c measurements were
used. Fol l owi ng these assessments, the i nf ants
medi cal records were revi ewed, and perti nent med-
i cal i nf ormati on was abstracted, i ncl udi ng bi rth
wei ght, A pgan scones, number of days of hospi tal i -
zati on, days i n speci al cane, medi cati ons recei ved,
l aboratory data, and other medi cal probl ems.
I nf ants were sel ected f or i ncl usi on i n the anal ysi s
i f they were f ul l -term (def i ned as 37 weeks ges-
tati onal age by Dubowi tz exami nati on) and heal thy
(def i ned as havi ng spent l ess than 24 hours i n the
neonatal i ntensi ve care uni t). The cri teri a f or ad-
mi ssi on to the neonatal i ntensi ve cane uni t at Bos-
ton Ci ty Hospi tal i ncl ude al l i nf ants who are cl i ni -
cal l y j udged to requi re acute medi cal management
and/on cl ose observati on. Speci f i cal l y, al l i nf ants
who experi enced i ntrauteri ne narcoti c exposure,
the most commonl y documented cause of extreme
j i tteri ness at our f aci l i ty, are observed and managed
i n the neonatal i ntensi ve care uni t. I nf ants who are
cl i ni cal l y stabl e are usual l y transf erred f rom the
neonatal i ntensi ve care uni t to the normal nursery
wi thi n 24 hours. I nf ants who spent l onger than 24
hours i n the neonatal i ntensi ve cane uni t were ex-
cl uded f rom most of the anal yses to avoi d the
conf oundi ng ef f ects of i ntercurrent i l l ness on j i tter-
mess and other aspects of neonatal neunobehavi onal
f uncti oni ng.
Description of Infant Assessment Instruments
The Neurol ogi c and A dapti ve Capaci ty Scal e i s a
structured neurobehavi onal exami nati on that i s
used to assess an i nf ant s responses to vi sual and
audi tory sti mul i , passi ve and acti ve tone, pri mary
ref l exes, motor acti vi ty, l evel of al ertness, amount
of cryi ng, and ease of consol abi l i ty. The Neunol og-
i cal and A dapti ve Capaci ty Scal e was perf ormed i n
a qui et room i n the wel l -baby nursery and took
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ARTICLES 19
about 10 mi nutes to compl ete. The components of
the neonatal exami nati on that are the f ocus of thi s
anal ysi s are j i tteri ness and those areas of neurobe-
havi oral f uncti oni ng that coul d have i mpl i cati ons
f or parent-i nf ant i nteracti ons: the i nf ant s predom-
i nant behavi oral state, hi s on hen vi sual attenti ve-
ness to the exami ner s f ace, and the ease of consol -
abi l i ty when cryi ng.
Behavi oral states duri ng the exami nati on were
scored by the si x standard categori es used i n the
Neonatal Behavi oral A ssessment Scal e: 1, qui et
sl eep; 2, acti ve sl eep; 3, drowsy; 4, al ert; 5, i ncreased
motor acti vi ty; and 6, cryi ng. Ji tteri ness duri ng the
exami nati on was scored based on the ni ne-poi nt
scal e of the Neonatal Behavi oral A ssessment Scal e
whi ch i ncl udes the behavi oral state(s) i n whi ch the
j i tteri ness was noted (Tabl e 1). For the anal yses,
the degree of the i nf ant s j i tteri ness was cl assi f i ed
i nto f our categori es: none, mi l d, moderate, on ex-
treme. A n i nf ant was categori zed as not j i ttery i f
no j i tteri ness was observed duri ng the exami nati on
on i f the i nf ant was j i ttery onl y duri ng sl eep. Ji tter-
mess was def i ned as mi l d i f i t occurred onl y when
the i nf ant was i rri tabl e on cryi ng. Ji tteri ness was
consi dered moderate when i t occurred duri ng the
al ert state and consi dered extreme when i t occurred
duri ng several behavi oral states.
W h en t h e exa m in a t ion wa s com p let ed , t h e ex-
ami ner recorded the i nf ant s predomi nate behav-
i onal state. Thi s i s an assessment of the behavi oral
state i n whi ch the i nf ant spent the most ti me duri ng
the exami nati on and i s i ndependent of the meas-
ures of j i tteri ness whi ch document onl y the behav-
ion a l st a t es in wh ich t h e j it t er in ess occu r r ed . F or
purposes of anal ysi s, the predomi nant behavi oral
state was cl assi f i ed i nto one of three categori es:
sl eepy (state 1 on 2), qui etl y wakef ul (state 3 on 4),
on acti ve (state 5 on 6).
V i sual response to the exami ner s f ace duri ng the
exami nati on was scored based on the standard
three-poi nt scal e of the Neurol ogi cal and A dapti ve
Capaci ty Scal e: 1, persi stentl y asl eep wi th no vi sual
responses; 2, l ethargi c wi th poor eye contact, short
peri ods of attenti on, and/or a sl uggi sh vi sual re-
TABLE 1. Preval ence of Ji tteri ness
Exami nati on of 936 Heal thy Ful l -Ten
Duri ng Neonatal
m I nf ants
Ji tteri ness by State % Degree
None noted 53 None
Duri ng sl eep onl y 3 None
A f ter M ono or startl es onl y 6 M i l d
1-2 ti mes when cryi ng or i rri tabl e 10 M i l d
:3 ti mes when cryi ng or i rri tabl e 7 M i l d
1-2 ti mes when al ert 5 M oderate
:3 ti mes when al ert 3 M oderate
Several states 10 Extreme
Consi stentl y i n several states 3 Extreme
sponse; and 3, qui et al ertness wi th eye contact and
consi stent vi sual responsi veness.
T h e ea se of con sola b ilit y wa s eva lu a t ed wh en t h e
in fa n t cr ied for m or e t h a n 15 secon d s a n d scon ed
based on the standard three-poi nt scal e of the Neu-
nol ogi cal and A dapti ve Capaci ty Scal e: 1, i nconsol -
abl e af ter 60 seconds of cryi ng even wi th a paci f i er,
hol di ng, and/on rocki ng; 2, di f f i cul t but obtai ned
consol abi l i ty; and 3, easi l y obtai ned consol abi l i ty.
Rel i abi l i ty checks between the pedi atri c exami ners
wer e con d u ct ed a n d d em on st r a t ed t h e followin g K
val ues: j i tteri ness, 0.85; consol abi l i ty, 1.00; al ert-
ness, 1.00; and predomi nate behavi oral state, 0.44.
Description of Statistical Methods
For the i ni ti al anal yses, heal thy f ul l -term i nf ants
were cl assi f i ed as ei ther j i ttery or not-j i ttery
based on the presence or absence of j i tteri ness
duri ng the exami nati on. A nal yses were perf ormed
to eval uate the rel ati onshi p between j i tteri ness and
sel ected prenatal , i ntrapartum, and i nf ant van-
abl es. t tests were used to compare the mean scores
of conti nuous vari abl es, and x2 anal yses were used
f or categori cal data. The f our degrees of j i tteri ness
wer e t h en su b st it u t ed for t h e d ich ot om ou s j it t er y/
not-j i ttery vari abl e and the anal yses repeated usi ng
anal yses of vari ance.
To exami ne the associ ati on of maternal cocai ne,
mari j uana, ci garette, and/on al cohol use duri ng
pregnancy wi th neonatal j i tteni ness, the sampl e was
exp a n d ed t o in clu d e in fa n t s wh o sp en t m or e t h a n
24 hours i n the neonatal i ntensi ve care uni t. Thi s
was done because j i tteri ness caused by maternal use
of mari j uana, cocai ne, ci garettes, on al cohol coul d
h a ve n ecessit a t ed ob ser va t ion in t h e n eon a t a l in -
tensi ve care uni t. Such an associ ati on woul d have
been mi ssed i f onl y the data f rom heal thy i nf ants
wer e a n a lyzed . H owever , t h ose in fa n t s wh o exp en i-
enced i denti f i ed i ntrauteri ne opi ate or methadone
exposure were excl uded f rom the anal yses because
of the strongl y establ i shed associ ati on of maternal
narcoti c use wi th neonatal j i tteri ness.
RESULTS
Sample
O f t h e eligib le wom en , 8% r efu sed t o p a r t icip a t e
i n the study and 6% di d not parti ci pate f or admi n-
i strati ve reasons. I n the sampl e of 1226 compl etel y
studi ed mother-i nf ant pai ns, there were 1126 l i ve-
bonn i nf ants who were 37 weeks gestati on. Of
these i nf ants, 960 (85%) spent l ess than 24 hours
i n the neonatal i ntensi ve care uni t; 24 of these
i nf ants were not exami ned because of earl y di s-
change on admi ni strati ve errors, resul ti ng i n a f i nal
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20 JITTERINESS
sample of 936 healthy full-term infants. This sam-
ple was used to evaluate the prevalence and come-
lates of jitteriness in clinically healthy infants.
The intnapartum data of this sample were rep-
nesentative of the obstetrical practices at our insti-
tution. No analgesia or anesthesia was administered
for 44% of the deliveries. I ntrapartum local anes-
thesia was used for 25% of the deliveries, epidural
anesthesia for 16%, spinal anesthesia for 6%, and
general anesthesia for 4%. I ntrapartum intravenous
analgesia (usually alphaprodine) was administered
to 34% of the women. The incidence of cesarean
sections was 13%, most commonly done because of
fetal bradycandia and/on failure oflabon to progress.
Of the 166 full-term infants who spent more than
24 hours in the neonatal intensive care unit, 42
were excluded because of identified maternal nan-
cotic use and six were not examined because of
administrative errors, resulting in a cohort of 118
sick full-term infants. The entire sample of 1054
healthy and sick full-term infants was only used
when examining the relationship between maternal
psychoactive drug use during pregnancy and neo-
natal jitteriness.
The demographic characteristics of the mothers
of the study infants were representative of the
population served by Boston City Hospital: prepon-
denantly black (66%) and Hispanic (18%), low in-
come (64% with incomes less than $12 000 pen
year), with low educational attainment (41% did
not graduate from high school).
The health habits of these women during preg-
nancy have been previously published. 3 Of special
interest in this analysis was the prevalence of ma-
tennal substance use during pregnancy (Table 2).
Cigarette use was reported by 40% of the women
and alcohol use by 58%. As ascertained by self-
report on a positive urine assay, cocaine was used
by 15% of the women during pregnancy and man-
juana by 25%. Positive postpartum urine assays for
cocaine and marijuana were determined for 4% and
6% of the samples, respectively. W e previously
reported that, for the entire sample, 16% of the
marijuana users and 24% of the cocaine users de-
nied use and were identified solely by urine assay. 4
For the sample of 936 healthy full-term infants,
the mean weight (3329 g), length (50.0 cm), head
circumference (34.4 cm), and 5-minute Apgar score
(8.9) were within the normal ranges.
P r e v a le n c e o f J it t e r in e s s
The prevalence of jitteriness in each behavioral
state, as ascertained during the examination of the
936 healthy full-term infants, is shown in Table 1.
Jitteriness was seen in 44% of these neonates: mild
jitteriness was observed in 23%, moderate jitteni-
ness in 8%, and extreme jitteriness in 13%.
C o r r e la t e s o f J it t e r in e s s : P r e n a t a l Va r ia b le s
Jitteriness in the 936 healthy full-term infants
was not significantly associated with most of the
selected prenatal risk factors including the presence
and degree ofpnegnancy-induced hypertension, ma-
tennal weight gain, the highest maternal systolic
blood pressure, and maternal psychologic stress
scone.
The relationship between maternal use of ciga-
nettes, alcohol, cocaine, on marijuana during pneg-
nancy and neonatal jitteriness is shown in Table 2.
M aternal use of marijuana during pregnancy was
positively associated with neonatal jitteriness (P <
.01). I nfants of cocaine users were also more likely
to be jittery, although this association did not
TAB LE 2 . Jitteriness Among 1054 Healthy and Sick Full-Term Neonat
Use During Pregnancy of Cigarettes, Alcohol, Cocaine, and M arijuana
es and M aternal
Sample % % Not x2
Size (No.) Jittery Jittery
Significance
Cigarettes
Us e 4 2 1 4 5 5 5 . 6 4
Nonuse 633 43 57
Alcohol
Us e 6 1 4 4 5 5 5 . 4 0
Nonuse 440 43 57
Cocaine
Reported used during pregnancy 156 50 50 .10
Reported nonuse 898 43 57
Positive postpartum urine assay 41 59 41 .06
Negative postpartum urine assay 863 44 56
M arijuana
Reporteduse 259 53 47 <.01
Reported nonuse 795 41 59
Positive postpartum urine assay 60 55 45 <.05
Negative postpartum urine assay 724 42 58
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V ariable
TA B L E 3. Relationship Between Jitteriness and I nfant V ariables in 936 Healthy Full-
Term I nfants
Birth weight (mean SD)
Length (mean cm SD)
Head circumference (mean cm SD)
Dubowitz Physical M aturity I ndex
(mean score SD)
Jittery
I nfants
3 2 9 1 5 0 2
49.7 2.5
3 4 . 4 1.5
28.3 1.0
Nonjittery
I nfants
3362 484
50.2 2.2
34.5 1.4
28.2 1.0
Significance
(P V alue)
<.05
<.001
NS
NS
A RTICL ES 21
achieve statistical significance (P = .1). M aternal
cigarette on alcohol use was not associated with
neonatal jitteriness. The effect of exposure to co-
caine on marijuana soon before delivery was also
examined. The pnevalence of jitteriness in infants
whose mothers had a postpartum urine assay posi-
tive for cocaine on marijuana was compared with
that of infants whose mothers reported no cocaine
on marijuana use during pregnancy and had no
positive urine assays. As seen in Table 2, neonatal
jitteriness was significantly associated with a post-
partum maternal urine assay positive for marijuana
(P < .05) and approached significance when there
was an assay positive for cocaine (P = .06).
Co r r el at es o f J i t t er i n es s : In t r ap ar t u m Var i ab l es
I n the sample of 936 healthy full-term infants,
jittery infants tended to be olden than nonjittery
infants at the time of examination (mean of 28 vs
26 hours, P < .05). Further examination of this
relationship indicated that jitteriness was less prey-
alent in infants examined in the first 12 hours of
life (n = 156) compared with older infants (n =
780) (35% vs 47%, P < .01). The prevalence of
jitteriness in infants olden than 12 hours did not
appreciably change with increasing age (up to 72
hours), non was infant age at the time of examina-
tion associated with the other correlates of jitteni-
ness. Finally, infants who were exposed to general
anesthesia (n = 40) had a lower prevalence of
jitteriness than did those (n = 896) who were not
(28% vs 46%, P < .05). I ntrapartum variables that
were not associated with neonatal jitteriness in-
cluded number of doses of intrapartum analgesia,
highest maternal systolic blood pressure during la-
bon, use of oxytocin, duration of labor, prolonged
rupture of membranes, cesanean section, fetal
bradycardia, meconium staining, infant 5-minute
Apgar score, and maternal intention to breast-feed
the infant.
Co r r el at es o f J i t t er i n es s : In f an t Var i ab l es
For the sample of 936 healthy full-term infants,
jittery infants weighed less and were shorten than
TA B L E 4. Relationship Between Jitteriness and Pre-
dominant Behavioral State in 936 Healthy Full-Term
I nfants*
Behavioral State % Jittery
Predom inantly sleepy (n = 210) 53
Predominantly active (n = 289) 49
Predominantly quietly wakeful (n = 437) 38
*x 2 14.1, df= 2, P< .001.
nonjittery infants, despite comparable scores on the
Dubowitz Physical M aturity I ndex (Table 3).
The relationship between jitteriness and the in-
fant s predominant behavioral state was examined
(Table 4). Jitteriness occurred most commonly in
infants who were predominantly sleepy or active
during the examination and least commonly in
infants who were predominately quietly wakeful.
Jittery infants were more frequently described as
visually inattentive compared with nonjittery in-
fants (25% vs 14%, P < .001) and were also more
likely to be difficult to console when crying (13%
vs6%,P< . 0 1 ) .
Because jitteriness was more common in active
infants and these infants were typically more irri-
table than quietly wakeful infants, irritability alone
could have accounted for the association of jitteni-
ness with diminished visual attentiveness and
poorer consolability. A within-group analysis dem-
onstrated that, among the 288 infants who were
predominately active, those who were also jittery
were inattentive more frequently than those who
were not jittery (27% vs 10%, P < .001). Similarly,
infants who were both active and jittery were dif-
ficult to console more frequently than those who
were active but not jittery (26% vs 16%, P < .05).
Thus, the association of jitteriness with inatten-
tiveness and inconsolability remained significant
even after controlling for a high infant activity level
and increased irritability during the examination.
No significant associations between jitteriness and
other variables of the Neurological and Adaptive
Capacity Scale were demonstrated, including pas-
sive and active tone, and the presence of excessive
crying.
To determine whether the degree of jitteriness
altered its relationship with any of the described
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22 JITTERINESS
variables, the four categories of jitteriness (none,
mild, moderate, and extreme) were substituted for
the dichotomous jittery/not jittery variable, and
analyses of variance were performed. The relation-
ships between jitteriness and the prenatal, intra-
partum, and infant variables did not significantly
change with these analyses.
DISCUSSION
Jitteriness is a common clinical finding during
the examination of healthy full-term neonates. In
our sample, almost half of the infants evidenced
some jitteriness during a neurobehavioral evalua-
tion performed at 8 to 72 hours of age. This preva-
lence is higher than previous reports and may ne-
flect the inclusion of jitteriness in all behavioral
states. Thus, although 44% of the sample had some
degree of jitteriness, 23% were jittery solely when
startled, crying, on upset. The remaining 21% were
jittery during periods of alertness or in several
behavioral states.
An important clinical finding emerged from this
study: jittery infants are more likely to be visually
inattentive and difficult to console compared with
infants who are not jittery. Although cause and
effect cannot be ascribed to this association, jitter-
mess appears to serve as a marker for an infant
whose care is more likely to be difficult and unne-
warding. M uch attention has been focused on the
role of the infants temperamental and behavioral
characteristics in shaping his on hen relationship
with cane givens.156Ajitteny, poorly consolable, and
visually inattentive infant may pose special care-
taking difficulties in the neonatal period and ad-
versely affect parent-infant interactions. Early
identification of these behaviors may allow the
provider to facilitate a more positive parental ad-
aptation through discussion of techniques to elicit
visual attention and console the infant and antici-
patory guidance concerning infant behavioral and
temperament issues.
The data demonstrated few significant associa-
tions between jitteriness and prenatal on intrapar-
tum variables in healthy full-term infants. Jitteni-
ness was observed most commonly in infants who
were predominantly sleepy or active and least com-
monly in those who were predominately quietly
wakeful during the examination. Jitteriness was
less common in infants younger than 12 hours of
age and those exposed to general anesthesia. Jittery
infants also tended to be slightly lighter and
shorter, despite similar scones on the Dubowitz
Physical M aturity Index. This finding suggests that
even small variations in the growth parameters of
healthy full-term neonates may be associated with
subtle neurobehavioral differences.
The present analyses failed to demonstrate that
the degree ofjitteniness seen during a single exam-
ination was clinically useful in differentiating
among otherwise healthy neonates. An alternative
hypothesis is that the duration of jitteriness may
be of greaten diagnostic or prognostic value than
the degree of jitteriness seen during a single exam-
ination. The present study allows neither confin-
mation nor refutation of this hypothesis.
Neonatal jitteriness was associated with mater-
nal use of marijuana during pregnancy and soon
before delivery. The infants of cocaine users were
also more jittery than those of nonusers, but this
finding failed to reach statistical significance, pos-
sibly because fewer women used cocaine than man-
ijuana during pregnancy. Neither maternal ciga-
rette non alcohol use during pregnancy was associ-
ated with neonatal jitteriness.
The positive association of maternal marijuana
and possibly cocaine use with neonatal jitteriness
confirms the findings of a few studies suggesting
this association, such as reported by Fried and
M akin17 and Chasnoff et al.18 Although maternal
marijuana and cocaine use was associated with in-
creased jitteriness in this study, the magnitude of
this effect was small. The data revealed 50% to 59%
of the infants of marijuana or cocaine users to be
jittery compared with 41% to 44% of nonusers. In
contrast, of the 42 infants who were excluded from
this analysis because of maternal narcotic use, 88%
were jittery. Unlike withdrawal from narcotic drugs,
jitteriness does not appear to be a reliable clinical
indicator of infant exposure to marijuana or co-
caine.
This study has a number of limitations. First, it
is possible that other illicit or licit drugs used during
pregnancy (eg, caffeine) were not identified in the
interviews and could have been related to neonatal
jitteriness. Second, there were few concurrent lab-
oratory tests of most of the healthy jittery infants.
Serum glucose, calcium, or magnesium levels, for
example, were rarely obtained. Third, we did not
quantify the infants caloric intake before exami-
nation, and inadequate caloric intake could have
been associated with neonatal jitteriness. Thus,
these data do not allow speculation as to the etiol-
ogy of jitteriness in infants who appear to be oth-
erwise healthy.
Finally, we did not address the natural history of
jitteriness. Because all examinations were pen-
formed during the first few days of life, jitteriness
may have had a later onset in some cases and gone
undocumented. Additionally, it is unclear whether
the jittery neonates continued to exhibit short-term
and/on long-term neunobehavioral differences from
their nonjittery counterparts.
M ore studies are needed to delineate the etiology,
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ARTICLES 23
natural hi story, and l ong-term cl i ni cal si gni f i cance
of thi s common f i ndi ng of heal thy f ul l -term i nf ants.
Further studi es i n whi ch the ef f ects of maternal
l i ci t and i l l i ci t drug use duri ng pregnancy on neo-
natal j i tteri ness and other areas of neurobehavi oral
f uncti oni ng are exami ned are al so necessary. Such
studi es shoul d i ncl ude uri ne drug assays to accu-
ratel y i denti f y users of i l l i ci t drugs, seri al i nf ant
assessments throughout ti me, and adequate sampl e
si zes to control f or potenti al conf oundi ng vari abl es.
I n summary, j i tteri ness i s commonl y seen duri ng
the exami nati on of f ul l -term heal thy neonates but
appears to be unrel ated to most prenatal or pen-
natal ri sk f actors i n that group. W hen j i tteri ness i s
observed i n an otherwi se l ow-ri sk i nf ant, i t shoul d
serve as a marker f or an i nf ant who i s more l i kel y
to have di mi ni shed attenti veness and poorer con-
sol abi l i ty. The cl i ni ci an shoul d then caref ul l y eval -
uate these and other aspects of the i nf ant s neuno-
behavi oral f uncti oni ng and, based on the exami na-
ti on f i ndi ngs, use the observati on of neonatal
j i tteri ness to hel p the parents better understand
and adapt to thei r i nf ant s earl y behavi ors.
ACKNOWLEDGMENT
Thi s work was supported by grants f rom the Nati onal
I nsti tute of Drug A buse (NI DA -R01DA 03508) and the
Bureau of Heal th Care Del i very and A ssi stance, M aternal
and Chi l d Heal th Branch (grant M CJ-009094).
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ESTIMATION OF EFFECT SIZE IS THE NAME OF THE GAME
Over the past two or three decades the use of stati sti cs i n medi cal j ournal s
has i ncreased tremendousl y. One unf ortunate consequence has been a shi f t i n
emphasi s away f rom the basi c resul ts toward an undue concentrati on on
hypothesi s testi ng. I n thi s approach data are exami ned i n rel ati on to a stati sti cal
nul l hypothesi s, and the practi ce has l ed to the mi staken bel i ef that studi es
shoul d ai m at obtai ni ng stati sti cal si gni f i cance. On the contrary, the purpose
of most research i nvesti gati ons i n medi ci ne i s to determi ne the magni tude of
some f actor(s) of i nterest.
From Gardner M J, A l tman DG. Stati sti cs wi th conf i dence. Br Med J . 1989.
Submi tted by Student
by Herbert Uy on October 20, 2011 pediatrics.aappublications.org Downloaded from
1990;85;17 Pediatrics
Howard Cabral
Steven Parker, Barry Zuckerman, Howard Bauchner, Deborah Frank, Robert Vinci and
Jitteriness in Full-Term Neonates: Prevalence and Correlates

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