Infant muscle tone |
Regulated tone |
Partially contracted state of the limbs, flexion, midline positioning |
Dysregulated tone |
Hypotonic or hypertonic muscle tone, tremors, flailing, startle, finger splaying |
Unable tone |
Unable to determine infant tone. Infant may be swaddled and arms and legs cannot be seen and infant face may not be visible to determine tone in cheeks. |
Infant physiologic indices |
Regulated physiology |
Pink with patterned breathing |
Unregulated physiology |
Dysregulated breathing, includes signs of nonhomeostatic autonomic functioning, including pallor, grunting, or use of accessory muscles for breathing |
Unable physiology |
Unable to determine infant breathing or color |
Infant behavior |
Regulated behavior |
Infant feeding smoothly; not pulling away from bottle or mother; turns to bottle, opens mouth with tongue down |
Dysregulated behavior |
A change in behavior including averting, pulling/turning away/resisting, body language, including closed/fisted hands in the context of signs of disorganization; has the quality of the infant attempting to protect him/herself |
Unable behavior |
Unable to determine if infant’s behavior is regulated or not; infant’s hands may be swaddled and not visible; unable to determine if infant is pulling away from mom |
Infant emotional |
Regulated emotional |
Infant’s face is relaxed |
Dysregulated emotional |
Facial expressions, including raised eyebrows, frowning, grimacing, crying |
Unable emotional |
Unable to see infant’s face to determine regulation |
Sucking/swallowing |
Regulated sucking |
Actively sucking and swallowing |
Dysregulated swallow |
Infant is coughing, choking, or multiple swallowing |
Not sucking |
Not sucking |
Unable to determine |
Unable to determine if infant is sucking |
Dribbling |
Dribbling |
Formula is seen escaping from infant’s mouth |
Not dribbling |
Formula cannot be seen escaping from infant’s mouth |
Unable to determine |
Cannot determine if formula is escaping from infant’s mouth |
Indices of arousal |
Open/half-lidded |
Infant’s eyes are open, half open |
Closed |
Infant’s eyes are closed |
Unable to determine |
Unable to see infant’s face |