Transcript Primitive Reflexes

Primitive Reflexes in the baby
Robyn Smith
Department of Physiotherapy
UFS
2012
Objectives for the lecture:
 After this lecture the learner should be:
 familiar with the primitive reflexes present in the
baby at birth,
 identify which of these reflexes are relevant the
neurological examination of the baby,
 be able to explain the role of the primitive reflexes,
 be able to explain the disappearance/integration of
these reflexes,
 be able to explain the clinical significance of the
reappearance or persistence of the primitive
reflexes.
Background
 Primitive reflexes start to emerge during the late
foetal period,
 Most of these reflexes are already present at birth
e.g. Rooting and sucking reflex
 These reflexes are of sub-cortical origin, arising
mainly in the brainstem and to some degree in
the Spinal Cord.
Background
 The majority reflexes are integrated/ disappear by the
age of 6/12 (at latest by 12/12) due to the increasing
inhibitory effect of the maturing cortex. Those with
protective value tend to persist throughout life.
 The persistence or reappearance of these primitive
reflexes after the age of 6/12 is abnormal and usually
indicative of cortical or cerebral damage. These
reflexes lock the child in a “holding pattern” and their
development becomes stuck, significantly impair their
development of postural control, achievement of
milestones and volitional movement.
The levels of hierarchy in motor control
Higher order control
centra
CORTEX
MIDBRAIN
BRAINSTEM
Lower order control
centra
SPINAL CORD
Background
 Some typical developing children continue to have
persistent primitive reflexes e.g. ATNR , which are
strongly associated with developmental challenges
such as dyslexia, dyspraxia and hyperactivity
Eliciting of the primitive reflexes
Why do we test these primitive reflexes in the
neonate?
 Evaluate the developmental status and the
integrity of the neurological system in the
newborn
 Can give an indication of the baby’s gestational
age (in case of prematurely born)
Eliciting of the primitive reflexes
 In some cases e.g. moro, the reflex can be used
to evaluate symmetry and could help identify
possible unilateral pathology of the nervous
system e.g. obstetric brachial plexus injury
 Eliciting these reflexes in the neonate is closely
related to the hunger status and alertness of the
baby e.g. often hard to elicit if baby is sleeping
Classification of primitive reflexes
Primitive Reflexes are divided into 3 groups :
 Functional significance (help birth process)
 Protective value e.g. flexor withdrawal,
crossed extensor
 Early postural reactions e.g. moro and startle
Various Primitive reflexes
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Glabella tap
Dolls eye reflex
Rooting Sucking
Palmar grab
Babinski
Plantar grab
Withdrawal
Crossed extensor
Automatic walking
ATNR
Galant
Moro
Startle
Landau
Parachute
Glabellar tap
 Tap the child with your finger on the forehead just
above nose. He blinks/closes eyes (protective
value)
 Appears at 32 weeks gestation
Clinical implications of persistence ?
• persistence of this reflex
associated Parkinson’s disease
Rooting reflex
 Elicited by gently touching the top lip, and area of the
facial with your finger. The baby will turn his head in
the direction of the stimulus and open his mouth
 Reflex appears around 24-28 weeks and disappears
around 3-4 months
Clinical implications of persistence ?
• persistence of the reflex may contribute
towards a drooling, hypersensitivity in
the mouth and on the lips
•
contributing factor in dyspraxia
Sucking reflex
 Elicited by placing a clean gloved finger, bottle
teet or dummy in the mouth and onto the tongue
 The stimulus in the mouth should elicit a sucking
reflex
Clinical implications of persistence ?
• premature babies often have a
weak suck reflex and
subsequently need tube feeding
Asymmetrical Tonic Neck Reflex (ATNR)
 Elicited head is turned to the side and kept there for
15 seconds (position of the head is the eliciting
stimulus)
 The child assumes a “fencing” position
 The arm and leg on the side of the skull remain in
flexion, whilst the arm and the leg on the face side
extend.
 If the child does not revert to a normal symmetrical
position within seconds this is to be considered an
abnormal reflex.
Asymmetrical Tonic Neck Reflex (ATNR)
Asymmetrical Tonic Neck Reflex (ATNR)
 Reflex is less obvious during the first month,
becoming more obvious during months 2-4.
 Should have disappeared by 6 months
Clinical implications of persistence ?
• Difficulty in visual pursuits (tracking)
• Impaired development bilateral hand function
(midline),writing problems, dyslexia
• Asymmetry & deformities (spine/limbs) or even hip
dysplasia (sublexation)
• Impaired development in prone (crawling)
• Hand-eye co-ordination difficulties
• Balance difficulties in sitting
Startle
 Elicited by a loud noise or by tapping on the sternum
 Abduction of the arms with flexion of the elbows and
adduction of the fingers is noted.
Clinical implications of persistence ?
• over exaggerated in case of neurological injuries
e.g. CP
• poor balance in sitting
Startle
Moro
 Vestibular reflex elicited by sudden movement of the head
 Tested on a padded surface e.g. on crib cushion or foam
mat Child is held at a 45 degree angle to the supporting
surface. The head is then lifted up slightly. Allow the head
to suddenly fall a couple of centimetres before immediately
supporting the head again (don’t allow head to make
contact with the padded surface though !!!)
 A sudden abduction, extension of the arms associated with
the spreading of the fingers is observed. Followed by and
embracing action of adduction and flexion as the arms
return to the normal position
 This reflex is usually integrated by 3-4 months
Moro
Clinical implications of persistence ?
• Over exaggerated in case of some
neurological conditions e.g. CP
• Hypotonia neuromuscular defects may be
considered if this reflex is decreased o
absent in young baby
• Asymmetry may indicate an obstetric
brachial plexus injury
• Difficulty in transitioning and poor balance
in positions like sitting
• Child is uncertain about their own reactions,
fearful of positional change
• Can be elicited by sound, light, temperature
changes and movement
Palmar Grasp
 When a finger/or other stimulus into the palm of the
child’s hand stimulating the palm on the lateral
aspect
 Fingers flex and the child firmly grasps the hand.
Hand will relax and open directly after reaction
occurred
 Integrated by 2 -3 months of age
 Pathological if tonic part of the reflex (flexion )
persists
Palmar Grasp
Clinical implications of persistence ?
• In some children this reflex is elicited as soon as
something is brought into contact with the hand
and even in some cases the child’s own thumb.
• Difficulty with releasing objects from hand
• Interferes with the development of grasp
• Difficulty with activities requiring WB on an open
hand
Plantar Grasp
 Elicited by pressing on the sole of the foot near
the base of the toes.
 The toes and the ball of the foot curl around the
finger
 Present at birth and disappears by 3 months
Flexor withdrawal
 Elicited when a painful stimuli applied (pin prick)
e.g. sole of the foot is pricked or stimulated with a
sharp object
 In response the leg is flexed in a mass pattern.
 This is a protective reflex
 Already present at birth, and never disappears
Clinical implications of persistence ?
•
over exaggerated in some children with CP, any
stimulation under foot results in flexor withdrawal.
This negatively impact on WB and locomotion
“toe clawing” during gait
Flexor withdrawal
Crossed Extensor Reflex
 Flexion of one leg may be
accompanied by extension
opposite leg
 Strengthens the limb support
on the weight bearing leg.
 Prevents the person from
falling over
Clinical implications of persistence ?
When overactive as is sometimes case
with children with CP it negatively
impacts on gait.
When the one leg is in the swing through
phase of gait, the weight bearing leg’s
extensor tone increases making balance
very difficult
Positive support reflex
 Elicited when placing weight on
the sole of the foot or pressure is
given against the sole of the foot
resulting in extension of legs
Clinical implications of persistence ?
Pattern of extensor spasticity is
strengthened and stimulated.
If overactive it interferes with gait, cocontraction in the limb results in the leg
being rigidly extended.
Spinal gallant reflex
 Reflex emerges at 20 weeks gestation and
should be inhibited by 3-9 months
 Suggested that this reflexes aids the birth
process
 Elicited by holding the baby in ventral
suspension. Pull your finger down the lateral side
of the back muscles unilaterally. The spine and
torso curve towards the side where the fingers
are.
Spinal gallant reflex
Clinical implications of persistence ?
• Absence of this reflex can be valuable in
determining sensory loss in the case of a
myelomenigiocele
• Persistence of this reflex can affect the child’s
ability to sit, poor posture (scoliosis)
Automatic walking
 Baby held supported under axillas with the soles
of the feet on a firm, flat supporting surface
 The baby automatically steps one foot in front of
the other
 Present at birth but disappears within 4-6 weeks
after birth
Clinical implications of persistence ?
• In children with CP can still observe this reflex
when holding the child up, do not confuse with
voluntary gait
Automatic walking
Parachute reflex
 Elicited by holding the baby in ventral suspension with
the head down, extension of the arms should occur to
protect the head
 This is a protective reflex and appears at six moths
and never disappears
Landau reflex
 Elicited by holding the baby in ventral suspension
 The child will extend his head and legs.
 This reflex appears at 3 months and disappears by 1
year of age.
Clinical implications of persistence ?
• In children with myelomenigeocele
no extension of the legs occurs
References
 Images courtesy of GOOGLE (2012)
 PA Henning. Ondersoek van die pasgebore baba.
 Costerus, PJ. 2003. Zooming in on reflexes.