Neonatal Reflexes

DEVELOPMENTAL MILESTONES By 3 months of age does your child: Motor Skills • • • • • • •

lift head when held at your shoulder lift head and chest when lying on his stomach turn head from side to side when lying on his stomach follow a moving object or person with his eyes often hold hands open or loosely fisted grasp rattle when given to her wiggle and kick with arms and legs

Sensory and Thinking Skills • • • •

turn head toward bright colors and lights turn toward the sound of a human voice recognize bottle or breast respond to your shaking a rattle or bell

Language and Social Skills • • • • • •

make cooing, gurgling sounds smile when smiled at communicate hunger, fear, discomfort (through crying or facial expression) usually quiet down at the sound of a soothing voice or when held anticipate being lifted react to "peek-a-boo" games

By 6 months of age does your child: Motor Skills • • • • • • • • • • • •

hold head steady when sitting with your help reach for and grasp objects play with his toes help hold the bottle during feeding explore by mouthing and banging objects move toys from one hand to another shake a rattle pull up to a sitting position on her own if you grasp her hands sit with only a little support sit in a high chair roll over bounce when held in a standing position

Sensory and Thinking Skills • •

open his mouth for the spoon imitate familiar actions you perform

Language and Social Skills • • • • •

babble, making almost sing-song sounds know familiar faces laugh and squeal with delight scream if annoyed smile at herself in a mirror

By 12 months of age does your child: Motor Skills • • • • • • • • • • • •

drink from a cup with help feed herself finger food like raisins or bread crumbs grasp small objects by using her thumb and index or forefinger use his first finger to poke or point put small blocks in and take them out of a container knock two blocks together sit well without support crawl on hands and knees pull himself to stand or take steps holding onto furniture stand alone momentarily walk with one hand held cooperate with dressing by offering a foot or an arm

Sensory and Thinking Skills • • • •

copy sounds and actions you make respond to music with body motion try to accomplish simple goals (seeing and then crawling to a toy) look for an object she watched fall out of sight (such as a spoon that falls under the table)

Language and Social Skills • • • • • • •

babble, but it sometimes "sounds like" talking say his first word recognize family members' names try to "talk" with you respond to another's distress by showing distress or crying show affection to familiar adults show mild to severe anxiety at separation from parent

• • •

show apprehension about strangers raise her arms when she wants to be picked up understand simple commands

If you have questions about your child's development or want to have your child tested, • •

call your pediatrician the local health department

Neonatal Reflexes Encyclopedia of Childhood and Adolescence • Neonatal reflexes are the reflexes that are present at birth. They are believed to be inborn and have predictable action patterns. Reflexes, more accurately described as unconditioned reflexes, are not learned or developed through experience. Normally developing neonates (infants up to about four weeks of age) are expected to respond to specific stimuli with a specific, predictable behavior or action. Any variation in, or absence of, response may be a sign of abnormality in development. Further testing of the infant is usually recommended when any response to a stimulus differs from the expected norm. Some neonatal reflexes disappear with maturation; other persist into adulthood. At birth, the neonate must immediately make five major adjustments: • • • • •

Transition from an aquatic environment to a world of air. The first breath begins even before the umbilical cord is cut. Eat and digest his or her own food since the circulatory relationship between mother and baby stops with the severance of the umbilical cord. Excrete his or her own wastes. Maintain his or her own body temperature. Adjust to intermittent feeding since food is now only available at certain intervals.

Although reflex actions are complex, most reflexes can be simplified into four basic steps. In the first step, the stimulus is received by nerve endings involving one of the senses--taste, sight, smell, hearing, or touch. Secondly, the energy created by the stimulus is conducted through the nerves to the central nervous system. Next, the impulses generated by the stimulus are transmitted to the nerves that stimulate muscle action. Finally, the muscles, and sometimes certain glands, respond with an action. Babinski reflex The Babinski reflex is characterized by a fanning of all five toes and the stretching forward of the big toe when the bottom of the foot is stroked or tickled. It is a sign that the infant is neurologically normal. Usually around the age of one this reflex disappears completely. It is replaced with the plantar reflex found

in young children and adults; this reflex involves curling of the toes in response to the stroking of the sole of the foot. Babinski or plantar reflex is triggered by stroking one side of the infant's foot upward from the heel and across the ball of the foot. (The infant responds by hyperextending the toes; the great toe flexes toward the top of the foot and the other toes fan outward.) It generally becomes inhibited from the sixth to ninth month of post natal life Blink reflex The blink reflex is characterized by the involuntary blink of the eyes when an infant is subjected to a bright light, wind, or rapid approach of an object. This involuntary action protects the eyes and is therefore maintained throughout life. False crawling reflex When a newborn infant is placed on her stomach, she may begin to flex her arms and legs in a motion that simulates crawling. This action is due to the baby's natural curled-up position, which gradually changes over the days following birth. After about one week, the infant will be able to lie flat, and the false crawling movements will disappear. Knee-jerk reflex The knee-jerk, or patellar reflex, is a sign of a neurologically healthy baby; the neonate's lower leg and foot involuntarily kick upward or forward when the neonate is tapped on the tendon just below the patella (kneecap). This reflex prevails throughout maturation into adult life. It is checked by applying the stimulus tap to a young child or adult while he or she is in a sitting position. This reflex is so commonly known that the term "knee-jerk" response is an idiom for any reaction that seems to come automatically, with little or no thought.

Landau's reflex At about three months of age, an infant will begin to display the Landau's reflex. When she is placed on her stomach face down, she will raise her head and arch her back. This reflex will persist until around the child's first birthday. Absence of this reflex suggests problems in motor development. The pediatrician may investigate further to rule out such problems as cerebral palsy and mental retardation .

Moro reflex •

•

Also referred to as Moro's reflex, the startle reaction, or the embracing reflex, the Moro reflex is characterized by a "grabbing" motion if an infant is subjected to a loud noise or loss of support. The infant's arms and legs will extend and then come together. The infant's back will also arch, and the infant may cry. This reflex, like other neonatal reflexes, is the sign of a neurologically normal newborn infant. Between the ages of five and seven the child will lose this reflex; if the reflex persists, it is a sign of brain damage, neurological impairment, or motor reflex difficulties. Asymmetrical tonic neck reflex (sometimes called the tonic labyrinthine reflex) is activated as a result of turning the head to one side. As the head is turned, the arm and leg on the same side will extend while the opposite limbs bend, in a pose that mimics a fencer. The reflex should be inhibited by six months of age in the waking state. If this reflex is still present at eight to nine

months of age, the baby will not be able to support its weight by straightening its arms and bringing its knees beneath its body. Symmetrical tonic neck reflex occurs with either the extension or flexion of the infant's head. Extension of the head results in extension of the arms and flexion of the legs, and a flexion of the head causes flexion of the arms and an extension of the legs. This reflex becomes inhibited by the sixth month to enable crawling

. Palmar grasp reflex The palmar grasp reflex is characterized by the grasping of an object that is placed crosswise on the palm of a newborn infant, or neonate. Like the other neonatal reflexes, it is a sign of normal neurological development. Immediately following birth, the hand grip of this reflex is strong enough to support the baby's weight. Within a few hours, this strength will begin to wane, and the reflex usually fades completely after three to four months. Rage reflex The rage reflex is the newborn infant's reponse to having his or her movements suddenly restrained. The infant responds by strongly resisting the restraint, developing redness in the face, or crying. Like the other neonatal reflexes, the rage reflex is a sign of normal neurological development. This reflex tends to diminish in intensity before six months of age. Rooting reflex When a newborn infant's cheek is touched or stroked, she will respond automatically by turning her head toward that side and beginning to suck. This is the reflex that allows the newborn to turn toward the mother's nipple to begin breastfeeding . Usually during the first six months of life, but sometimes as late as 12 months of age, this reflex disappears. The rooting reflex is the sign of a neurologically normal neonate. Sucking reflex The sucking reflex occurs when the mouth of the neonate has been stimulated. It is strongest in the first three to five months of life, and is one of the signs of a neurologically healthy infant. Walking reflex The walking reflex is characterized by stepping motions resembling walking when the newborn infant is held upright with contact between the feet and a resisting surface. This reflex will disappear within about a week, usually recurs between eleven and sixteen months, and is a sign of a neurologically normal infant. Gale Encyclopedia of Childhood & Adolescence. Gale Research, 1998.

The Blantyre Coma Scale is a modification of the Pediatric Glasgow Coma Scale, designed to assess malarial coma in children. It was designed by Drs Terrie Taylor and Malcolm Molyneux in 1987, and named for the Malawian city of Blantyre, site of the Blantyre Malaria Project. • The score assigned by the Blantyre Coma Scale is a number from 0 to 5. The score is determined by adding the results from three groups: Motor response, verbal response, and eye movement. The minimum score is 0 which indicates poor results while the maximum is 5 indicating good results. All scores under 5 are considered abnormal.[1] Eye movement 1 0 - Fails to watch or follow

Watches

Best motor response 2 Localizes 1 Withdraws limb 0 - No response or inappropriate response Best verbal response 2 Cries appropriately 1 Moan or 0 - No vocal response to pain

with

or

follows

painful from

pain, abnormal

painful

or,

if cry

verbal, with

stimulus stimulus

speaks pain

Neonatal reflexes or primitive reflexes are the inborn behavioral patterns that develop during uterine life. They should be fully present at birth and are gradually inhibited by higher centers in the brain during the first three to 12 months of postnatal life. These reflexes, which are essential for a newborn's survival immediately after birth, include sucking, swallowing, blinking, urinating, hiccupping, and defecating. These typical reflexes are not learned; they are involuntary and necessary for survival.

Description A normal birth is considered full term if the delivery occurs during the thirty-seventh to fortieth week after conception. Developmentally, the baby is considered a neonate for the first 28 days of life. At birth, the neonate must immediately make five major adjustments: • • • • •

Transition from an aquatic environment to a world of air. The first breath begins even before the umbilical cord is cut. Eat and digest his or her own food since the circulatory relationship between mother and baby stops with the severance of the umbilical cord. Excrete his or her own wastes. Maintain his or her own body temperature. Adjust to intermittent feeding since food is now only available at certain intervals.

Under normal developmental conditions, these neonatal reflexes represent important reactions of the nervous system and are only observable within a specific period of time over the first few months of life. The following reflexes are normally present from birth and are part of a normal newborn evaluation: •

• •

•

• •

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The Moro reflex (or startle reflex) occurs when an infant is lying in a supine position and is stimulated by a sudden loud noise that causes rapid or sudden movement of the infant's head. This stimulus results in a symmetrical extension of the infant's extremities while forming a C shape with the thumb and forefinger. This is followed by a return to a flexed position with extremities against the body. Inhibition of this reflex occurs from the third to the sixth month. An asymmetrical response with this reflex may indicate a fractured clavicle or a birth injury to the nerves of the arm. Absence of this reflex in the neonate is an ominous implication of underlying neurological damage. . Grasping reflex occurs as the palmar reflex when a finger is placed in the neonate's palm and the neonate grasps the finger. The palmar reflex disappears around the sixth month. Similarly, the plantar reflex occurs by placing a finger against the base of the neonate's toes and the toes curl downward to grasp the finger. This reflex becomes inhibited around the ninth to tenth month. Rooting reflex is stimulated by touching a finger to the infant's cheek or the corner of the mouth. The neonate responds by turning the head toward the stimulus, opening the mouth and searching for the stimulus. This is a necessary reflex triggered by the mother's nipple during breastfeeding. It is usually inhibited by the third to fourth month. Sucking reflex is triggered by placing a finger or the mother's nipple in the infant's mouth. The neonate will suck on the finger or nipple forcefully and rhythmically and the sucking is coordinated with swallowing. Like the rooting reflex, it is inhibited by the third to fourth month. Babinski or plantar reflex is triggered by stroking one side of the infant's foot upward from the heel and across the ball of the foot. (The infant responds by hyperextending the toes; the great toe flexes toward the top of the foot and the other toes fan outward.) It generally becomes inhibited from the sixth to ninth month of post natal life. Blink reflex is stimulated by momentarily shining a bright light directly into the neonate's eyes causing him or her to blink. This reflex should not become inhibited. Pupillary reflex occurs with darkening the room and shining a penlight directly into the neonate's eye for several seconds. The pupils should both constrict equally; this reflex should not disappear. Galant reflex is stimulated by placing the infant on the stomach or lightly supporting him or her under the abdomen with a hand and, using a fingernail, gently stroking one side of the neonate's spinal column from the head to the buttocks. The response occurs with the neonate's trunk curving toward the stimulated side. This reflex can become inhibited at any time between the first and third month. Stepping reflex is observed by holding the infant in an upright position and touching one foot lightly to a flat Reflex Stimulation Response Duration SOURCE: Table after Child Development, 6th ed. Wm. C. Brown Communications, Inc., 1994. Babinski

Sole of foot stroked

Fans out toes and twists foot in

Blinking

Flash of light or puff of Closes eyes air

Permanent

Grasping

Palms touched

Weakens at three months; disappears at a year

Moro

Sudden move; loud noise Startles; throws out arms and legs Disappears at three to four and then pulls them toward body months

Rooting

Cheek stroked or side of Turns toward source, opens mouth Disappears at three to four mouth touched and sucks months

Stepping

Infant held upright with Moves feet as if to walk

Grasps tightly

Disappears at nine months to a year

Disappears at three to four

Reflex Sucking

Stimulation

months

Mouth touched by object Sucks on object

Disappears at three to four months

face

Tonic neck Placed on back

• •

Duration

feet touching ground

Swimming Placed water

•

Response

down

in Makes coordinated movements

swimming Disappears at six to seven months

Makes fists and turns head to the Disappears at two months right

surface, such as the bed. The infant responds by making walking motions with both feet. This reflex will disappear at approximately two months of age. Prone crawl reflex can be stimulated by placing the neonate prone (face down) on a flat surface. The neonate will attempt to crawl forward using the arms and legs. This reflex will be inhibited by three to four months of age. Doll's eye reflex can be noted with the infant supine (lying on the back) and slowly turning the head to either side. The infant's eyes will remain stationary. This reflex should disappear between three to four months of age.

Common Problems The presence and strength of a reflex is an important indication of neurological functioning. Within the first 24 hours after birth, a healthcare provider evaluates an infant's neurological functioning and development by testing and observing these reflexes. If a reflex is absent or abnormal in an infant, this may suggest significant neurological problems. In normal development, the primary reflex system is inhibited or transformed in the first year of life and a secondary or postural reflex system emerges. The secondary system forms the basis for later adult coordinated movement. Absence or presence of a reflex is a symptom, not a disorder. Severe persistence of primary reflexes indicates predominantly persistent physical problems. Relatively milder persistence, however, is associated with less severe disorders that include specific reading difficulties. The process of inhibition of these reflexes in the earliest months of life remains unknown but it has been assumed that this process cannot occur after early childhood because neonatal movement is largely stereotypical and follows the patterns of the primary reflex system. Thus, the early movements of the fetus and newborn were previously viewed as passive byproducts of the central nervous system. They are viewed as interactive and having a reciprocal effect on the underlying central nervous system structure and functioning. This implies that the actual rehearsal and repetition of primary reflex movements play a role in the inhibition process itself. Parental Concerns An evaluation of neonatal reflexes is performed during well-baby examinations. The abnormal presence of infantile reflexes in an older child can be discovered during a neurological examination. Assessment of neonatal reflexes is a screening tool for at-risk children with neurological difficulties. Primary reflexes may persist for certain children beyond their normal time span causing a disruption in subsequent development. Children with neurological damage will have a common denominator of prolonged neonatal reflexes. Since recent studies have demonstrated that repetition of these reflexes seems to eventually inhibit them, parents can work with the infant by assisting with the repetition of persistent reflexes. When to Call the Doctor

Persistence of neonatal reflexes is not threatening to life and, therefore, can be discussed with the pediatrician during normal well-baby visits.