NEUROPEDIATRIC EXAMINATIONPRIMITIVE REFLEXES

Dominant form of movement for last 4 months prenatally and first 4 months postnatally.

Primitive reflexes critical for human survival.

Postural reflexes believed to be foundation for later voluntary movements.

Appearance and disappearance helpful in diagnosing neurological disorders.

The Central Nervous System (CNS) is the control center for all thinking, learning, and moving. The development of an efficient CNS is complex yet a certain amount is understood.

There are many factors which contribute to a person being able to move well, speak fluently, play and develop the skills necessary for every day living and learning.

The development of the CNS commences from conception, develops in a regular sequence and is the same for all humans regardless of cultural influences.

- Survival reflexes occurring sequentially in the first few weeks of fetal development - Automatic, stereotyped movements, directed by a very primitive part of the brain (brainstem). - executed without involvement of higher levels of the brain (the cortex).- Ideally short lived and as each fulfils its function is replaced by more sophisticated structures (Postural Reflexes) which are controlled by the cortex- Considered aberrant and evidence of an immaturity within the CNS if present beyond their time.

Reflexive movements occur during the last 4 months of prenatal life and the first 4 months after birth

Reflexes occur subcortically (below the level of the higher brain centers)

E.g., palmer grasp

Many of the reflexes do not completely disappear

First, they are inhibited by the maturing nervous system

Second, they are integrated into new movement behaviors

Infant reflexes are called primitive reflexes

Asymmetric tonic neck reflexSymmetric tonic neck reflexMoro reflexes

Startle reflex

Primitive reflexes are repressed by 6 months of age

Primitive reflexes are important for

ProtectionNutrition

Sucking reflexRooting reflex

Survival Labyrinthine reflex

Postural reflexes Prevalent belief: automatic movement is

“practice” for future voluntary movement Other experts believe these reflexes may not be

related to future motor development Emanate from higher brain centers These reflexes disappear when voluntary

behavior surfaces

When the stepping reflex is stimulated, walking may begin at an earlier age

Link between stimulation of the reflex preceding the disappearance phase and early movement

Small amounts of practice can lead to significant results

Infant Reflex Future Voluntary Movement

Crawling Crawling

Labyrinthine Upright posture

Palmar grasp Grasping

Stepping Walking

Can help determine the level of neurological maturation

Reflexes are age-specific in normal, healthy infantsMoro reflex

May signify a cerebral birth injury if lacking or asymmetrical

Asymmetric tonic neck reflex May indicate cerebral palsy or other neurological

problem

Reflex Concern when lacking, weak, asymmetrical or persisting

Moro Cerebral birth injury

Asymmetric tonic reflex

Cerebral palsy; other neural damage

Development ExaminationMeasures several infant reflexes from

birth to 24 monthsPurpose: develop profile of child’s

movement in relation to what is expected at a specific age

Useful in determining motor delay

PRIMITIVE REFLEXESGalantPalmar GraspSuckingSearchMoroStartleAsymmetric Tonic NeckSymmetric Tonic NeckPlantar GraspBabinskiPalmar MadibularPalmar Mental

POSTURAL REFLEXESSteppingCrawlingSwimmingHead and Body RightingParachutingLabyrinthinePull Up

If the child is stroke para-vertebrally with one finger, the body will curves

The concavity of pelvis proceed toward the direction of the stimulus given.

The leg and arm ipsilateral will be strach, and the contralateral will be curve

Syn: Spinal reaction Disappear in 2-3 months Patologic: dissapear Spinal

medulla lesion, CNS depression

Palm of hand lifts back of headHand is removed suddenly so that head begins to fall

Head is supportedMoro reflex precedes the startle reflex and causes the arms and legs to extend immediately rather than flexDuration: prenatal 4-6 months postpartumPatologic: disappear CNS depression, persists RM, CNS dysfunction, delay sitting/head control, asymmetrical injury to one side of brain, parese plexus brachialis, fracture clavicula/humerus

Synonim: bow and arrow or fencer’s position

Causes flexion on one side and extension on the other

Not always seen in newborn Facilitates the development of

bilateral body awareness Duration: after birth-3 months Patologic: persist Cerebral palsy

The palmar grasp reflex is one of the most noticeable reflexes to emergeAppears in uteroEndures through the 4th month postpartumNegative palmer grasp: neurological problems (spasticity)Leads to voluntary reaching and grasping

The toes appear to be graspingStimulus is touching the ball of the footThis reflex must disappear before the baby can stand or walkDuration: birth-1 yearsPatologic: negative medula spinalis lesion, perifer nervous system lesion (must disappear before the baby can stand or walk)

Propping reflexesRelated to upright postureThis reflex is a conscious attempt to break a potential fallDuration: 4 months-1 yearsPatologic: (-) CP, asymetris neuromusculer/orthopaedi dysfunction

Stimulus / Response

S: touch of lips R: sucking action

Duration In utero - 3 months postpartum

Concerns No reflex problematic for nutrition

Other Often in conjunction with searching reflex

Stimulus / Response

S: touch cheek R: head moves toward stimuli

Duration Weeks prenatal - 3 months postpartum

Concerns No reflex problematic for nutritionNo reflex or lack of persistence may be sign of CNS or sensorimotor dysfunction.

Other Often in conjunction with sucking reflex. Contributes to head/body-righting reflexes.

Stimulus / Response

S: Same as Moro R: Arms and legs flex

Duration 2-3 months after Moro disappears – 1 year

Other Less severe startle reflexes elicited through lifespan

Stimulus / Response

S: Baby sitting up and tip forward R: Neck and arms flex, legs extend S: Baby sitting up and tip backward R: Neck and arms extend, legs flex

Duration After birth – 3 months

Concerns Persistence may impede many motor skills and cause spinal flexion deformities

Stimulus / Response

S: Stroke bottom or lateral portion of foot R: Great toe turns downward

Duration Birth – 4 months

Concern Test of the pyramidal tract (i.e. ability to perform conscious / voluntary movement)

Stimulus / Response

S: Pressure to both palms or hair to hand R: Eyes close, mouth opens, and/or neck flexes (which tilts the head forward)

Duration Birth – 3 months

Other Also called the Babkin reflex

Stimulus / Response

S: Scratch base of palm R: Lower jaw opens and closes

Duration Birth – 3 months

Stimulus / Response

S: Infant upright with feet touching surface R: Legs lift and descend

Duration After birth – 5-6 months

Concerns Essential forerunner to walking

Other Sometimes called walking reflexDevelopmental changes in reflex over time

Stimulus / Response

S: Prone position on surface, stroke alternate feet R: Legs and arms move in crawling action

Duration Birth – 3-4 months

Concerns Precursor to later voluntary creeping

Stimulus / Response

S: Infant held horizontally R: Arms and legs move in coordinated swimming type action

Duration 2 weeks after birth – 5 months

Other Recognition of reflex led to popularity of infant swim programs

Stimulus / Response

S: Supine, turn body in either direction R: Head “rights” itself with the body S: Supine, turn head in either direction R: Body “rights” itself with the head

Duration Head:1-6 months; Body: 5 months-1 year

Concerns Related to voluntary rolling movements.

Stimulus / Response

S: Baby held upright, tilted in one direction R: Baby tilts head in opposite direction

Duration 2-3 months – 1 year

Concerns Related to upright posture

Other Also considered primitive reflex

Stimulus / Response

S: Sitting/standing, hold hands, tip in one direction R: Arms flex or extend in to maintain upright position

Duration 3 months – 1 year

Concerns Related to upright posture