PH CLINICAL REPORT
SECTION EDITORS
D e b o ra h Pa r k s , M S N , R N , C P N P
U n ive r s i t y o f Tex a s M e d i c a l S ch o o l a t H o u s t o n
H o u s t o n , Tex a s
R o b e r t J . Ye t m a n , M D
U n ive r s i t y o f Tex a s M e d i c a l S ch o o l a t H o u s t o n
H o u s t o n , Tex a s
D e b ra C . A r m e n t r o u t , R N - C , M S N , N N P,
a n d Ju dy C a p l e , R N - C , M S N , N N P
BACKGROUND
Definitions
Jittery is a term to describe a series of
recurrent tremors in infants.
Tremors are involuntary, rhythmic,
oscillatory movements of equal ampli-
tude. Tremors are described as fine or
coarse. A fine tremor is of high fre-
quency (>6 cycles per second [cps])
and low amplitude (<3 cm). Coarse
tremors are of low frequency (>6 cps)
and high amplitude (>3 cm) (Painter,
1995; Rosman, Donnelly, & Braun,
1984).
Incidence/Etiology
Two thirds of healthy newborns exhibit
fine tremors during the first few days
of life. These tremors usually disappear
by the third day of life and are consid-
ered physiologic (Korones & Bada,
1993). Parker et al. (1990) reported that
44% of healthy full-term infants from 8
to 72 hours of age demonstrated some
degree of jitteriness; 23% of the infants
were jittery only when they were star-
tled, crying, or upset, and 21% of the
infants were jittery during periods of
alertness or while in a variety of behav-
ioral states (n = 936). Shuper, Zalzberg,
Weitz, and Mimouni (1991) reported
jitteriness in infants beyond the neona-
tal period extending to a mean age of
7.2 months without long-term compli-
cations, possibly indicating the role of
maturational events.
DIFFERENTIAL DIAGNOSIS
Tremors should be distinguished from
other involuntary rhythmical move-
May/June 2001
PRACTICE
GUIDELINES
The Jittery
Newborn
ments observed in infants, especially of a sudden contraction of a single mus-
myoclonus and seizure activity. Trem- cle, muscle group, or limb in a rhyth-
ors are stimulus sensitive, diminish mic or nonrhythmic sequence, often
with passive flexion of the extremity, migrating from one body area to
and are not associated with abnormali- another; it can be initiated by stimuli.
Seizure activity is often noted in the ex-
tremities and consists of jerky, rhy-
T
thmic, or nonrhythmic movements
unequal in amplitudes; the activity
wo thirds of healthy does not cease with passive flexion
of the extremity. Seizures are often
newborns exhibit fine associated with altered gaze and con-
sciousness (Korones & Bada, 1993;
tremors during the first Painter, 1995; Rosman et al., 1984;
Volpe, 1995).
few days of life. RISK FACTORS
Risk factors include the following:
• Perinatal asphyxia
• Intracranial hemorrhage
ty of gaze or eye movements. Tremors • Low birth weight/prematurity
associated with metabolic conditions • Intrauterine growth retardation
are usually of high frequency and • Maternal diabetes mellitus
low amplitude, whereas the tremors • Electrolyte abnormalities
associated with central nervous sys- • Metabolic disorders
tem disorders are low-frequency, high- • Maternal substance abuse
amplitude movements (Blackburn, • Sepsis
1998). In contrast, myoclonus consists • Hypothermia
This guideline was adapted for use in the Department of Pediatrics at the University of Texas-Houston Health
Science Center; its use should in no way be construed as an endorsement by NAPNAP. Adaptation may be
required (a) to fit the needs of one’s practice setting or (b) to meet the state legislative requirements.
Debra C. Armentrout is Assistant Professor of Pediatrics, University of Texas-Houston Medical School.
Judy Caple is Assistant Professor of Pediatrics, University of Texas-Houston Medical School.
Reprint requests: Debra Armentrout, RN-C, MSN, NNP, Department of Pediatrics, The University of Texas
Medical School at Houston, 6431 Fannin, Suite 3140, Houston, TX 77030; e-mail:
Debra.C.Armentrout@uth.tmc.edu.
J Pediatr Health Care (2001). 15, 147-149.
Copyright © 2001 by the National Association of Pediatric Nurse Practitioners.
0891-5245/2001/$35.00 + 0 25/8/114820
doi:10.1067/mph.2001.114820
147
PH PRACTICE GUIDELINES
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EVALUATION
Infants who exhibit fine physiologic
tremors but who have had a normal
physical and neurologic examination
and are without risk factors do not
require further evaluation. Physiologic
tremors can be confirmed in an infant
who has a normal serum glucose level
when the infant demonstrates a posi-
tive response to the suckling stimula-
tion test. This response is elicited by
placing an infant in the supine position
with head straight and both hands free;
when an examiner places his or her
middle finger in the infant’s mouth, the
tremors cease, and the tremor returns
upon removal of the examiner’s finger.
Pathologic tremors persist despite suck-
ing or other soothing activities in a
noncrying infant (Linder et al., 1989).
Infants who have fine tremors while
quiet or sleeping or whose tremors ini-
tially present beyond the third day of
life require at least a limited evaluation.
All coarse tremors are considered to be
more pathologic and warrant a more
comprehensive evaluation, including
at minimum checking the infant’s
serum glucose level and electrolytes
(Korones & Bada, 1993; Rosman et al.,
1984). The extent of the investigation
should to be determined by the results
obtained (Brann & Schwartz, 1992;
Painter, 1995).
History
Perinatal history should be checked for
the following:
• Maternal substance abuse
• Prenatal teratogenic exposure
• Maternal diabetes
• Maternal thyrotoxicosis
• Maternal infection
• Maternal bleeding
• Signs of placental insufficiency
• Use of anesthesia
• Difficulty of delivery
• Fetal distress
• Resuscitation provided
Postnatal Complications
Possible postnatal complications in-
clude the following:
• Hypoxic-ischemic insult
• Periventricular-intraventricular
hemorrhage
• Congenital central nervous system
malformations
• Neonatal drug withdrawal
• Metabolic complications, including
the following:
148 Volume 15 Number 3
— Hypoglycemia
— Hypocalcemia
— Hypomagnesemia
— Hyponatremia
— Hypernatremia
• Sepsis/meningitis
• Congenital infection
Physical Examination
Gestational age, physical, behavioral,
and neurologic examinations should
be performed.
Assess Tremors
Tremors should be assessed for the fol-
lowing:
• Age at onset of tremors
• Type (fine, coarse)
• Persistence
• Frequency
• Infant state
• Association with precipitating stim-
ulation
• Associated signs and symptoms (de-
termine response to sucking stimula-
tion test)
P arents of jittery infants
may benefit from learning
consoling interventions
and techniques to elicit
visual attention.
Laboratory Studies
Initial studies should include the fol-
lowing:
• Serum glucose level
• Electrolytes, including calcium and
magnesium
• Urine drug screen
If initial studies are normal, consider
the following:
• Sepsis evaluation (complete blood
cell count, blood cultures, cerebro-
spinal fluid analysis and cultures,
urinalysis and culture)
• Arterial blood gas
• Serum rapid plasmin reagin titers
and urine cytomegalovirus culture
• Thyroid studies and serum cortisol
level
Armentrout & Caple
• Serum amino acids and urine organ-
ic acids
Diagnostic Studies
The following diagnostic studies may
be performed in consultation with a
neurologist:
• Electroencephalogram
• Head ultrasound and computed to-
mography scan
• Plain radiographs of the skull
MANAGEMENT
The underlying disorder, not the trem-
or, needs correction. Treatment of un-
explained tremors in an infant who oth-
erwise appears to be healthy usually
includes observation only, after a few
screening laboratory investigations have
been performed, including serum glu-
cose level and serum electrolytes. In-
fants with unexplained tremors who
appear to be more ill should be cared
for in an intensive care nursery until
results of laboratory studies are ob-
tained (Rosman et al., 1984).
Hypoglycemia
If the infant with hypoglycemia is sta-
ble, offer oral feedings. If the infant is
on nothing by mouth status, begin to
administer 10% dextrose intravenously
at 6 to 8 mg/kg/min. If the infant re-
mains hypoglycemic, administer a 2 to
4 mL/kg bolus of 10% dextrose and
transfer the infant to an intensive care
unit (Tsang, Demarini, & Rath, 1998).
Hyponatremia or Hypernatremia
Therapy for an infant with hypona-
tremia or hypernatremia depends on
the suspected etiology (inappropriate
intake, fluid imbalance, excessive loss-
es, pharmacotherapy).
Hypocalcemia
Hypocalcemia may be of early or late
onset. Early onset is usually symptom
free or mild; seizure activity may be
associated with late-onset hypocal-
cemia. Specific therapy for both is dir-
ected at the cause of the hypocalcemia.
Immediate therapy is indicated in the
presence of seizures, ECG changes, or
other manifestations. Therapy in those
situations consists of intravenous infu-
sion of 1 to 2 mL/kg of 10% calcium
gluconate over 5 minutes while closely
monitoring the infant’s heart rate.
Hypomagnesemia
Hypomagnesemia is treated with
intramuscular administration of 0.25
JOURNAL OF PEDIATRIC HEALTH CARE
PH PRACTICE GUIDELINES Armentrout & Caple
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mL/kg of a 50% solution of magne-
sium sulfate followed by daily oral
doses of 0.25 mL/kg (Korones & Bada,
1993; Tsang et al., 1998).
Drug Withdrawal
Initial treatment of drug withdrawal is
supportive (swaddling, decreasing stim-
ulation, small frequent feedings). In-
travenous fluids and electrolytes may
be indicated if the infant becomes clin-
ically unstable. The decision to use
drug therapy depends on the severity
of withdrawal symptoms. Infants with
confirmed drug exposure without with-
drawal do not require therapy. Infants
demonstrating seizures, poor feeding,
diarrhea, vomiting resulting in exces-
sive weight loss and dehydration, in-
ability to sleep, and fever unrelated to
infection are more likely to require
drug therapy (American Academy of
Pediatrics, 1998).
Hypoxic Ischemic Encephalopathy
Treatment of hypoxic ischemic encepha-
lopathy is supportive and based on the
severity of the symptoms (Brann &
Schwartz, 1992).
PROGNOSIS
The outlook for infants who have ex-
perienced jitteriness largely depends
on the underlying cause and the degree
to which it can be corrected. Parker et
al. (1990) reported that jittery babies
are more visually inattentive and diffi-
cult to console compared with nonjit-
tery infants. Parents of jittery infants
may benefit from learning consoling
interventions and techniques to elicit
visual attention. Anticipatory guidance
concerning infant behavioral and tem-
perament issues should also be ad-
dressed.
REFERENCES
American Academy of Pediatrics: Committee on
Drugs. (1998). Neonatal drug withdrawal.
Pediatrics, 101, 1079-1088.
Blackburn, S. T. (1998). Assessment and manage-
ment of neurologic dysfunction. In C. Kenner,
J. W. Lott, & A. A. Flandermeyer (Eds.), Com-
prehensive neonatal nursing: A physiologic perspec-
tive (pp. 564-607). Philadelphia: W. B. Saunders.
Brann, A. W., & Schwartz, J. F. (1992). In A. A.
Fanaroff & R. J. Martin (Eds.), Neonatal-perinatal
medicine: Diseases of the fetus and infant (pp. 704-
715, 729-734). St Louis: Mosby.
Korones, S. B., & Bada, H. S. (1993). In S. B.
Korones & H. S. Bada (Eds.), Neonatal decision
making (pp. 194-199). St Louis: Mosby.
Linder, N., Moser, A. M., Asli, I., Gale, R. Livoff,
A., & Tamir, I. (1989). Suckling stimulation test
for neonatal tremor. Archives of Disease in
Childhood, 64, 44-52.
Painter, M. (1995). Neonatal seizure disorders. In
M. I. Leven & R. J. Lilford (Eds.), Fetal and
neonatal neurology and neurosurgery (pp. 547-
561). New York: Churchill Livingstone.
Parker, S., Zuckerman, B., Baucher, H., Frank, D.,
Vinci, R., & Cabral, H. (1990). Jitteriness in full-
term neonates: Prevalence and correlates.
Pediatrics, 85, 17-23.
Rosman, N. P., Donnelly, J. H., & Braun, M. A.
(1984). The jittery newborn and infant: A
review. Developmental and Behavioral Pediatrics,
5, 263-273.
Shuper, A., Zalzberg, J., Weitz, R., & Mimouni, M.
(1991). Jitteriness beyond the neonatal period:
A benign pattern of movement in infancy.
Journal of Child Neurology, 6, 243-245.
Tsang, R. C., Demarini, S., & Rath. L. (1998).
Fluids, electrolytes, vitamins and trace min-
erals: Basis of ingestion, digestion, elimina-
tion, and metabolism. In C. Kenner, J. W.
Lott, & A. A. Flandermeyer (Eds.), Compre-
hensive neonatal nursing: A physiologic per-
spective (pp. 336-353). Philadelphia: W. B.
Saunders.
Volpe, J. (1995). The neurological examination:
Normal and abnormal (chapter 3); neonatal
seizures (chapter 5). In J. Volpe (ed.), Neurology
of the newborn (pp. 118, 181-182, 211-259).
Philadelphia: W. B. Saunders.

Pediatric
Pearl
Watch your back!
Bending over an examining table and looking into the eyes of an infant is one
of the more enjoyable responsibilities of being a pediatric nurse practitioner.
However, bending too far over a period of time can lead to serious back
problems. Because my height is 5 ft 7 in, the “ergonomically correct” height
for an examining table for me is 40 inches from the floor. However, my prac-
tice had examining tables of 29 inches and 32 inches from the floor. After 15
years of working with examining tables that were too low to the ground, I
needed back surgery. All practitioners should have an ergonomic assessment
to determine the correct height for an examining table and practice good
body mechanics in assessing infants. Adjustable examining tables are avail-
able, but if these prove to be too expensive, pediatric nurse practitioners need
to be creative in conducting infant examinations to avoid placing too much
strain on their backs.
Janet D. Edwards, CPNP
Blaine, Minnesota

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