NEONATAL REFLEXES

Presentation By DR. BANEET SHARMA (p.t)

ContentsIntroductionDefinationWhy it iz necessoryReflexesSucking reflexRooting reflexMoro reflexAsymmetrical tonic neck reflexSymmetric tonic reflexPalmar grasp reflexLandaus reflexPlantar reflexGallant reflexStepping reflexParachute reflexPupillary reflexAcoustic reflex

Primitive REFLEXES

Also known asInfantileInfant Newborn reflexes

Introduction

Period of growthPrenatal periodOvumEmbryofetus0 to 14 days14 days to 9 weeks9 weeks to birthPerinatal period22 weeks of gestation to 7 days after birthPostnatal periodNew bornInfancyToddlerPreschool childFirst 4 weeks after birthFirst year1 to 3 years3 to 6 yearsSchool age child6 to 10 years {girls}6 to 12 years{boys}Adolescence10 to 19 years

Defination

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 3 to 12 months of postnatal life.

Reflexes which are essential for a newborns survival immediately after birth

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 evaluationA normally developing newborn should respond to certain stimuli with these reflexes, which eventually become inhibited as the child matures

Why neonatal reflexes are necessary to asses

Most primitive reflexes begin to occur in utero through the early months of the childs postnatal life. These reflexes are then replaced by voluntary motor skills. When the reflexes are not inhibited, there is usually a neurological problem at hand. In those individuals with cerebral palsy and neurogenic dysphagia, the presence of primitive reflexes is a characteristic

Classification of reflexes

Automatic reflexes

Moro Reflex (Automatic reflex)

Onset - begins at 28 weeks gestationIntegration - 5-6 monthsTesting position - child in supine with head in midline, support the child's head while pulling the child to a position halfway between supine and upright sittingProcedure - support the infants head and shoulders with one hand. Allow the neck to drop back to allow the anterior neck muscles to stretchResponse observed - the shoulders abduct, the elbows, wrists and fingers extend. Subsequently, the shoulders adduct, and the elbows and fingers flexFunctional significance - asymmetry during this reaction may indicate a brain lesion or injury or peripheral nerve problems to the upper extremity

Landaus Reflex (A.R)Onset - 3 -4 monthsIntegration - 12 - 24 monthsTesting position - prone, supported in airProcedure - wait for a reaction after placementResponse observed - the head will extend and the back and hips will extend in sequence ("superman" appearance)Functional significance - breaks up the total flexion pattern seen at birth

Gallant Reflex (A.R)

Onset - begins at 32 weeks gestationIntegration - 2 months, though may persist in atypical childrenTesting position - infant placed prone in alignmentProcedure - gently stimulate along the paravertebral area from the C7 area to the buttocksResponse observed - infant will laterally flex toward the stimulated sideFunctional significance - often seen with children with athetoid CP

Parachute reflex(A.R)

occurs inslightly older infants, when you hold the child upright and then rotate his body quickly face forward (as if falling). The baby will extend his arms forward as if to break a fall, even though this reflex appears long before the baby walks.

Spinal reflexesFlexor withdrawal reflexExtensor trustCross extensorPalmar graspPlantar reflexSucking reflexRooting reflexPrimitive walking

Flexior withdrawalPosition- supine head in neutral position and legs extendedStimulus- sole of footresponse- uncontrolled flexion of stimulated extremityPresent since birth disappears- by 2 months

Extensor trustPosition- supine head neutral one leg extended and the other flexedStimulus- sole of flexed leg is given strokingResponse immediate extension ,adduction and internal rotation of flexed led with plantar flexion of footPresent at birth and integrated by 4 months

Sucking ReflexOnset - begins at 28 weeks gestationIntegration - 2-5 monthsTesting position - infant supine with the head in midlineProcedure - place a finger of nipple into the infants mouthResponse observed - rhythmical suckingFunctional significance - persistence of this reflex may inhibit voluntary sucking

Rooting reflex (Spinal ref)Onset - 28 weeks gestationIntegration - 3 monthsTesting position - with the infant supine, the head in midline and hands on chestProcedure - gently stroke the infant from the lips to the cheekNormal response - the infant should turn his head toward the stimulated side with the mouth opening and a trial of sucking the finger. May not be present if the infant is not hungry.Functional significance - persistence can interfere with sucking. Absence of this is seen in neurologically impaired infants.

Palmar Grasp spinal reflex

Onset - 10 weeks gestationIntegration - 4-6 monthsTesting position - supine, head midline, arms and hands freeProcedure - place a finger in infants hand from the ulnar to the palmar surfaceResponse observed - infants fingers will flex around the fingerFunctional significance -following the development of grasp, the infant begins to reach for objects and utilizes a crude palmer grasp to hold them

Plantar Reflex spinal reflexOnset -18 weeks in utero Integration 6 months after birthStimulated by stroking the sole of the foot:toes of the foot should fanning outthe foot itself should curl in.

Stepping reflex Onset - begins at 37 weeks gestationIntegration - 2 monthsTesting position supported in the vertical positionProcedure - support the infant upright with the feet touching a hard surface. Incline the infant forward and gently move the infant forward to accompany any steppingResponse observed - alternating, rhythmical, and coordinated stepsFunctional significance - premature infants will tend to walk in a roe-heel fashion while more mature infants will walk in a heel-toe pattern.

Brainstem level reflexSymmetrical tonic neck reflexAsymmetrical tonic neck reflexTonic labyrinthine reflexPositive supporting reaction

Symmetrical tonic reflex

Onset 0,4-6 monthsIntegration - 8 - 12 monthsTesting position - child in quadruped position on the floor or either in supine positionProcedure - passively flex the head forward and then extend it backwardsResponse observed - forward head flexion will produce flexion of the upper extremities and extension of the lower extremities; extension of the head will produce extension of the upper extremities and flexion of the lower extremitiesFunctional significance - necessary to achieve quadruped crawling

Asymmetrical tonic reflexBrain stem reflex

Onset - 0-2 monthsIntegration - 4-6 monthsTesting position - supineProcedure - gently turn the infants head to one sideResponse observed UL and UL of opposite side goes into flexion and on the same side ,limbs are extended.Functional significance - persistence of this reflex may indicate CNS damage

Tonic labyrinthine reflexPosition either supine or proneResponse: in supine extensor tone is present ,in prone flexion tone is increasedPresent from birth Integrated by 3 to 4 months

Positive supporting reactionStimulus : hold child in eract position ,lift him up and bounce up and down on plinth till sole of foot touches the plinthResponce : exaggerated extension of the lower limbsThis is present at birth and disappears within 3 to 4 months

Negative supporting reactionIt can be checked by holding the child in weight bearing position and suddenly lift him up The response is sudden flexion of the lower limb Present at birth and integrated by 4 months

Midbrain reflexOptical righting reflexNeck righting

Optical righting reflexOptical righting reflexPosition hold child from armpit in a suspended position then change position of his head from side to sideresponse: eyes will always move to same side as headAppears by 1 to 2 year and remains throughout ones life

Neck rightingPosition : supine blind folded ,rotate head to one sideResponse:body rotates to that side as a whole .Generally present at birth but a time may appear as late as 3 months

Cortical level reflexThis consists of all the equlibrium reactions Usually checked on tilt board or rocking board

Other reflex

ACOUSTIC REFLEXALSO CALLED . STAPEDIUS REFLEXIt is an involantary muscle contraction that occurs in the middle ear of mammals in responce to high intensity sound stimuli.Response in neonate ,in response of loud sound upper limb goes in to extension ,abduction followed by adduction and flexion.Functional significance to locate injury to facial nerve. as the stapedius muscle is innervated by the facial nerve

Pupillary reflexreflex 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.

ReflexStimulationResponseDurationBabinskiSole of foot strokedFans out toes and twists foot inDisappears at nine months to a yearBlinkingFlash of light or puff of airCloses eyesPermanentGraspingPalms touchedGrasps tightlyWeakens at three months; disappears at a yearMoroSudden move; loud noiseStartles; throws out arms and legs and then pulls them toward bodyDisappears at three to four months

Summary

RootingCheek stroked or side of mouth touchedTurns toward source, opens mouth and sucksDisappears at three to four monthsSteppingInfant held upright with feet touching groundMoves feet as if to walkDisappears at three to four monthsSuckingMouth touched by objectSucks on objectDisappears at three to four months

tonic neckPlaced on backMakes fists and turns head to the rightDisappears at two months

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