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Physiology & Behavior 139 (2015) 2125

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Physiology & Behavior


journal homepage: www.elsevier.com/locate/phb

Review

Palmar grasp behavior in full-term newborns in the rst 72 hours of life


Jadiane Dionsio , Marcus Vinicius Marques de Moraes, Eloisa Tudella,
Werther Brunow de Carvalho, Vera Lcia Jornada Krebs
Department of Paediatrics, University of So Paulo Medical School (FMUSP), Hospital das Clnicas, So Paulo, SP, Brazil

H I G H L I G H T S
Variability of palmar grasp behavior in the rst 3 days of extra uterine life
The inuence of extrinsic and intrinsic factors in palmar grasp behavior
Differences in palmar grasp strength between genders in the rst 3 days of life

a r t i c l e

i n f o

Article history:
Received 16 April 2014
Received in revised form 29 October 2014
Accepted 3 November 2014
Available online 11 November 2014
Keywords:
Newborn
Functional laterality
Motor activity
Hand strength

a b s t r a c t
Background: The palmar grasp behavior is one of the items of an infant's routine neurological tests. Its exacerbated
presence after the fth month of age or absence in the rst day after birth is an important sign of neuro-sensorimotor disorders. This study aimed to describe the palmar grasp behavior of full-term newborns in the rst 72 h
of life.
Methods: This nonrandomized cross-sectional developmental study included 219 typical newborns aged 1224 h,
2548 h and 4972 h. Three measurements were performed with newborns in the supine position, recording the
palmar grasp time and strength. Statistical analysis was applied with signicant level of p b 0.05.
Results: Higher palmar grasp strength was observed in newborns aged 4972 h compared to newborns aged
1224 h and 2548 h (F = 7.42, p = 0.01). There was signicant difference in palmar grasp strength between
hands (F = 6.55, p = 0.01), only in 1224 h, with greater strength in the left hand (t = 2.43, p = 0.01), and difference in palmar grasp between strength (F = 18.7, p = 0.01) with greater strength in females (t = 5.40, p =
0.01) only at the age 4872 h.
Conclusions: It was concluded that the palmar grasp behavior modies in the rst 72 h of life.
2014 Elsevier Inc. All rights reserved.

Contents
1.
2.
3.
4.
5.

6.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
General procedures . . . . . . . . . . . . . . . . . . . . . . . . . .
Test procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1.
Newborns aged 1224 h of life . . . . . . . . . . . . . . . . . .
5.2.
Newborns aged 2548h of life . . . . . . . . . . . . . . . . . .
5.3.
Newborns aged 4972 h of life . . . . . . . . . . . . . . . . . .
5.4.
Comparison between newborns aged 1224, 2548 and 4972 h of life
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Corresponding author at: Pedro Gustin, 64, Bloco 1, Apartment 601, Tubalina, Cep: 38.412-027, Uberlndia, Minas Gerais, Brazil. Tel.: +55 34 9163 9696.
E-mail addresses: jadydionisio@gmail.com, jadydionisio@hotmail.com (J. Dionsio), moraes.mvm@gmail.com (M.V.M. de Moraes), eloisatudella@yahoo.com (E. Tudella),
werther.brunow@icr.usp.br (W.B. de Carvalho), vera.krebs@icr.usp.br (V.L.J. Krebs).
URL's: http://buscatextual.cnpq.br/buscatextual/visualizacv.do?id=K4240216Z8 (J. Dionsio), http://buscatextual.cnpq.br/buscatextual/visualizacv.do?id=K4702540U6
(M.V.M. de Moraes), http://buscatextual.cnpq.br/buscatextual/visualizacv.do?id=K4793969A1 (E. Tudella), http://buscatextual.cnpq.br/buscatextual/visualizacv.do?id=K4780234J0
(W.B. de Carvalho), http://buscatextual.cnpq.br/buscatextual/visualizacv.do?id=K4778053U0. (V.L.J. Krebs).

http://dx.doi.org/10.1016/j.physbeh.2014.11.009
0031-9384/ 2014 Elsevier Inc. All rights reserved.

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J. Dionsio et al. / Physiology & Behavior 139 (2015) 2125

7.
Conclusions
Funding source .
Acknowledgments
References . . .

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1. Introduction
The palmar grasp behavior is one of the items of an infant's routine
neurological tests. This behavior remains present in the rst months of
life and its intensity is stronger during the rst month and decreases
gradually until it disappears around the fourth month [13]. Its
exacerbated presence after the fth month of age or absence in the
rst day after birth is an important sign of neuro-sensorimotor disorders
[35].
In clinical practice, the palmar grasp behavior is evaluated by
positioning the examiner's nger (or other thin and round-shaped
object) at the base of the metacarpal of middle, ring and little ngers,
that when stimulated produces exion of ngers, closing them strongly,
with no thumb exion [6,7]. Due to the fact that it is a technique based
on the examiner's experience and sensitivity, results may present
signicant variations.
For a long time, the main feature observed during a newborn's
examination was the palmar grasp behavior [4,6,8,9]. Nevertheless,
some authors realized the need to also evaluate the palmar grasp
strength to verify symmetry between limbs, differences between
genders, inuence of testosterone as well as manual preference and
predisposition to laterality [3,1012].
Rochat [9] and Molina and Jouen [13] also observed that the palmar
grasp behavior may vary according to the characteristics of the stimulus
given to the newborn.
To satisfy the need to evaluate other variables of the palmar grasp behavior, Moraes, Tudella, Ribeiro, Beltrame & Krebs [14] developed an instrument capable of measuring the peak palmar grasp strength, the
average strength performed and palmar grasp time. The M-FLEX is a
non-invasive, lightweight and portable equipment able to detect the palmar grasp characteristics in newborns and infants and express them in
millimeters of mercury (mm Hg) and gram-force per square centimeter
(gf/cm2), enabling greater precision and accuracy in motor assessment.
There is evidence that manual preference and laterality are inuenced by genetic factors and are pre-determined from the intrauterine
period [1517]. Coren and Porac [18] found that infants who performed
greater action (force and strength) with the left upper limb during the
evaluation showed laterality in the same limb in adulthood. Accordingly,
Tan and Tan [11] found that newborns with greater palmar grasp
strength in the left hand showed left laterality, whereas newborns showing greater palmar grasp strength in the right side became right-handed
adults.
In order to verify the inuence of gender on muscle strength, Tan
et al. [10] found that female full-term newborns aged two days showed
greater strength in the right hand than in the left hand, while male
full-term newborns showed no difference between hands. The authors
attributed this behavior to laterality and hormonal modulation.
Despite studies showing the importance of assessing the palmar
grasp behavior, Zafeiriou [6] emphasizes that the assessment of reexes
and reactions is a fast, easy and reliable method; however, it should be
used along with rating scales to better attest and diagnose neuro-sensorimotor disorders.
Another relevant item for the assessment of the palmar grasp
behavior is the postnatal physiological adaptation. The characteristics
of the postnatal palmar grasp behavior are unknown in the literature.
It is believed that effects such as mechanical stress, hemodynamic
changes, onset of diuresis and changes in environmental and body temperatures, as well as the action of gravity, are responsible for a relative

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24
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state of disorganization and weight loss in the rst days of life. The impact of the extra-uterine environment can affect neural differentiation
and myelination of glial cells in full-term newborns [19].
With the use of equipment capable of responding to new evidence
about the palmar grasp behavior as well as the need to understand it
in early life, this work is justied by the need to understand the changes
and inuences that occur in the neonatal period on the palmar grasp
behavior.
Therefore, the objective of this study was to describe the palmar
grasp behavior in full-term newborns in the rst 72 h of life.
The hypotheses to be tested are: the palmar grasp behavior
characteristics will modify the rst 72 h of life, the existence of differences in palmar grasp strength and time between right and left hands
and differences in the palmar grasp behavior characteristics between
genders.
2. Method
A nonrandomized cross-sectional developmental study was carried
out and previously approved by the Ethics Committee for Analysis of
Research Projects CAPPesq (Protocol No. 1250/2009).
The study included 219 newborns of both genders considered
healthy in the routine nursery examination. The following inclusion
criteria were adopted: newborns' parents or guardians must have
signed the Informed Consent Form, newborns must have had grades 4
and 5 seconds of the Prechtl and Beintema behavioral scale [20],
Apgar score equal to or higher than seven at 5 min of life; gestational
age between 37 and 416/7 weeks (assessed by early ultrasound and
date of the last menstrual period according to Naegele's rule) and
absence of clinical complications.
Newborns undergoing phototherapy and those with congenital
malformations, genetic syndromes, neurological disorders, metabolic
disorders, as well as children from mothers using tranquilizers or illicit
drugs were excluded. Infants showing dysfunction during routine clinical
examination in the nursery and those who had abnormal ultrasound
skull examination were also excluded.
Neonates were divided into three groups: Group 1: 46 infants with
mean age of 22 h and 41 min ( 0.25), Group 2: 106 infants with
mean age of 44 h and 35 min ( 0. 22) and Group 3: 67 infants with
mean age of 67 h and 13 min (0.23) of postnatal life.
3. General procedures
Collections were held at the nursery in the morning period in the
interval between two feedings. For all newborns, two forms were lled:
identication birth conditions, maternal, and perinatal data and
clinical conditions, and evaluation of behavioral state.
For the proper maintenance of environmental conditions in the
nursery, the temperature was maintained between 25 and 26 C (measured by a digital thermometer), with adequate lighting and minimum
noise.
Newborns were weighed using a digital pediatric scale and total body
length, head circumference, size and circumference of hands were
measured by anthropometric ruler and tape measure, respectively.
Palmar grasp strength and time were measured using the
M-FLEX equipment (TodMed Equipamentos e Servios Ltda, Blumenau,
SC Brasil). The M-FLEX, see Fig. 1, is an instrument that records the

J. Dionsio et al. / Physiology & Behavior 139 (2015) 2125

palmar grasp strength applied on the rubber balloon (cuff). Both


numerical and in the graphic form, they express the time that the cuff
was pressed, the maximum pressure and the mean pressure. The cuff
has an outer diameter of 11 mm and internal diameter of 8 mm. Its wall
has hardness of 40 Shore. The thickness of the tube that connects the
cuff to the device is 1.25 mm.
The equipment has a self-calibration system that res immediately
when the examiner presses the start key. This self-calibration system
is based on the reading of the pressure in the system (cuff + tube that
connects the cuff to the equipment) at the time and interprets it as
zero. From the rst pressure on the cuff, the data are expressed in
mm Hg (millimeters of mercury) or g/cm2 (g/squared cm). Such
self-calibration procedure allows for a mean square error of 1%,
according to the manufacturer.
The device has the ability to store the infants' names and to hold up
to 32 readings. These readings can then be transferred to a computer
(le in DAT or TXT format) to be treated by the statistical package.
Additionally, an 8-bit micro controller, 128 64 points graphic liquid
crystal display, an analog/digital converter (A/D) with resolution of 8
bits and a ash memory were used to store the readings. Also, a pressure
sensor and an instrumentation amplier that condition the electrical
signal of the sensor to the A/D converter were used. The equipment
has touch screen technology and a USB interface that enables communication of the equipment with the personal computer. The equipment is
supplied with main electricity and/or charger and batteries.
The physical characteristics of the equipment provide the completion
of data collection in different environments. This enables the investigation of the infant's interaction with the environment without losing the
ecological validity [14]. The M-FLEX equipment is validated for
full-term newborns of up to 4 months of age (Fig. 1).

4. Test procedure
The evaluation began with the lling of data sheets, followed by the
recording of anthropometric measurements. After this procedure, the
infant was kept in supine position, in his own cradle, with head in the
midline. Then, the examiner stimulated the newborn's hand opening,
positioning the rubber balloon across the base of the last three ngers
(middle, ring and little), not allowing its sliding over the region
described [14].
After positioning, the examiner began the data collection by pressing
the start key of the equipment. The measurement was stopped and
automatically recorded by the equipment when the baby stopped
performing the palmar grasp. Three measurements were performed
on each hand, and the value was represented by the average of the
three measurements, since when analyzing each measure individually
and comparing them, normalization was observed between them. The
test had maximum total time of about 6 min.
The equipment stored the newborn's name and the readings
(graphical and numerical) of the palmar grasp strength and time,

23

which were subsequently transferred to a Core2 computer (DAT or


TXT le format), and treated in a software for statistical calculations.
The independent variables were analyzed using the Pearson correlation coefcient between age, body length at birth and weight on the day
of assessment. Dependent variables were: time and palmar grasp
strength, right hand and left hand, male and female, the parametric
ANOVA two-way test was used, with post-hoc Tukey considering
p b 0.05 signicant.
5. Results
There was no relationship between body length (r = 0.015, p =
0.599) and weight on the day of assessment (r = 0.012, p = 0.679)
when compared with palmar grasp strength. Likewise, variable
palmar grasp time did not show positive correlation with body length
(r = 0.007, p = 0.809) and weight (r = 0.052, p = 0.063) at ages
1224, 2548 and 4972 h of life.
5.1. Newborns aged 1224 h of life
There was no signicant difference in palmar grasp strength
between gender (F = 3.01, p = 0.08). However were signicant differences in variable palmar grasp strength between hands (F = 6.55, p =
0.01), with higher strength in the left hand (t = 2.43, p = 0,01) when
compared with the right hand. Variables palmar grasp time showed no
signicant differences when compared with hands (F = 0.01, p = 0.89)
and gender (F = 0.11, p = 0.73) (Fig. 2).
5.2. Newborns aged 2548h of life
There was no signicant difference in palmar grasp strength
between hands (F = 0.19, p = 0.66) and between genders (F = 1.00,
p = 0.31). As there as was no difference in variable palmar grasp time
with hands (F = 0.00, p =0.94) and genders (F = 0.10, p = 0.74).
5.3. Newborns aged 4972 h of life
There was no signicant difference in variable palmar grasp strength
between hands (F = 0.45, p = 0.50), however, variable gender showed
signicant difference (F = 18.7, p = 0.01), in which female newborns
had higher strength compared with males (t = 5.40, p = 0.01)
(Fig. 3). Already this variable palmar grasp time showed no difference
between genders (F = 2.80, p = 0.09) and hand (F = 2.24, p = .013).
5.4. Comparison between newborns aged 1224, 2548 and 4972 h of life
Signicant difference in palmar grasp strength was observed
between ages, and newborns aged 4972 h of life had higher palmar
grasp strength when compared to those aged 1224 and 2548 (F =
7.42, p = 0.01) hours of life (Fig. 4).

Fig. 1. M-FLEX equipment and palmar grasp behavior.

24

J. Dionsio et al. / Physiology & Behavior 139 (2015) 2125

Fig. 2. Palmar grasp strength (gf/cm2) of right hand and left hand in newborns aged
1224 h of postnatal life.

Variable palmar grasp time showed no difference between ages (F =


0.75, p = 0.47).
6. Discussion
This study aimed to describe the palmar grasp behavior of full-term
newborns in the rst 72 h of life.
When comparing the palmar grasp strength and time, it was observed that newborns aged 4972 h had higher palmar grasp strength
than those aged 1224 h and 2548 h. The hypothesis that the palmar
grasp behavior characteristics will change during the rst 72 h of life
is then admitted.
The exposure to the extrauterine environment requires a number of
perinatal adaptations, such as thermoregulation, gas exchange, cardiac
regulation and lung ination, which probably contributed to this result.
In addition to adjustments in the period immediately after birth, the
amniotic uid decreased gradually over the past 14 weeks of gestation,
which generates mechanical stress represented by reduced myosin and
bone demineralization, determining a musculoskeletal disorder with
consequent muscle strength changes [2123]. The results also indicated
that neonates aged 1224 h of life have greater palmar grasp strength in
the left hand compared with the right hand. Some authors suggest that

Fig. 4. Palmar grasp strength (gf/cm2) between newborns aged 1224 h, 2548 h and
4972 h of postnatal life.

manual preference and laterality are inuenced by genetic factors and


are pre-determined from the intrauterine period [3,11,12,1518,24,25].
Regarding the difference in palmar grasp strength associated with
gender, the results showed that female newborns have higher palmar
grasp strength when compared to male newborns aged 49 and 72 h of
life, agreeing with the results by Tan [3]. Despite this nding, few studies
have demonstrated differences in palmar grasp strength between
genders, and most authors have only observed similarities in palmar
grasp strength between genders in childhood, being differentiated in
puberty, with increased strength among males [12,2629]
7. Conclusions
The events of physiological adaptation such as cortical maturation,
mechanical stress, hemodynamic changes and weight loss in the rst
days of life, as well as adjustments related to the external environment,
are responsible for a relatively disorganized state of the individual,
directly interfering in the motor behavior of newborns.
Based on the study population, on the environmental conditions determined in the nursery and on the proposed protocol, it was concluded
that the palmar grasp behavior is modied in the rst 72 h of life and the
gradual increase in palmar grasp strength is a function of gender and
manual preference, while the palmar grasp time remains stable during
the rst postnatal days.
Funding source
Coordination for the Improvement of Higher Education Personnel
(4341485) (CAPES, Brazil).
Acknowledgments
We thank the Coordination for the Improvement of Higher Education
Personnel (CAPES, Brazil).
References

Fig. 3. Palmar grasp strength (gf/cm2) between males and females in newborns aged
4972 h of postnatal life.

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