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To: Harriet McGurk
Date: Mon, Dec 29, 2008, 1:01 PM


I saw a 2 month old baby in the office for well child care. She is not smiling yet. She does focus on objects with contrasting colors, she has been focusing increasingly at mom's and dad's faces, she makes some noises. The fact that she doesn't smile worries me. How much more time do you wait and still say this is within the range of normal? To whom do you refer a child this young (rest of exam is normal). Ophtho to make sure she sees? Neuro? EI?


I agree with you that this is worth thinking about, although you may not come up with a definite yes or no right away. I was surprised to see in Nelson that they refer to a fully developed social smile by 3-5 weeks. I think of it, and it is usually written about, as starting between 6 and 10 weeks, with a few normal stragglers starting as late as 12 weeks. Social smile is hard for parents to distinguish from the earlier reflexive smiles, but it implies the baby initiates it to elicit a response from another person, and it has a reciprocal quality. Blind babies smile, but I suppose the interaction accompanying it must be different. All early neurodevelopmental landmarks should be adjusted for gestional age, and as a week or two is easily overlooked, you don't want to over-react to 10 vs 12 weeks of age for the smile.

If you're starting to worry, there are 3 areas of concern to look at before you necessarily decide it is abnormal: vision, parent-child interaction and major neuro-developmental abnormality. Visual behavior can be judged if the baby is in the right state and mood when he sees you, but a dilated exam by an ophthalmologist is nice to have. Pam Galen says we miss virtually all the cataracts etc in newborns with our "red reflex." The visual behaviors you are describing are okay, but they seem a bit late and certainly not definitive indicators of good vision.

Babies with depressed mothers or those who lack animation in facial expression, don't smile and vocalize in a monotone or not at all can cause older babies to avoid eye contact, and this is something you should be able to observe if you look for it. I'm not sure how it applies at 2 months, but I'd look anyway. That would be an urgent situation in the infant mental health field and you should call me right away if you want help finding a therapist in that area.

Raising the question of neurodevelopmental delay would be too much at this point unless there are other causes for concern, as there were in this baby (outside information), but the smile alone is too indefinite for neuro or EI.

I'll be curious to know how this one turns out. Yours, Harriet McGurk