To help a clinician quickly identify disease and know how to manage the very disease

1. PAEDIATRICS AND CHILD HEALTH
• NEONATOLOGY
• Primitive Reflexes and Stereotypies
Dr. Chongo Shapi.
- Bsc.HB, MBChB
2/21/2013 Dr. Chongo Shapi, BSc.HB, MBChB, CUZ. 1

2. Objectives
• Explain the primitive reflexes and their importance.
• Pinpoint and explain the number of infant reflexes.
• Describe the primitive reflexes.
• List and explain some stereotypies.
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3. What are primitive reflexes?
• Definition: Are reflex actions originating in the
CNS that are exhibited by normal infants, but not
neurologically intact adults in response to a
particular stimuli
• Hence, are involuntary stereotyped movement
responses to a particular stimuli
• Appear and disappear in sequence during specific
periods of development
• These primitive reflexes are also called infantile,
infant or newborn reflexes.
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4. • Dominant movement form during the last 4
months of prenatal life and first 4 months
postnatally.
• Occur subcortically (below the level of the higher
brain centers)
• Older children and adults with atypical neurology
(e.g., people with cerebral palsy) may retain these
reflexes and primitive reflexes may reappear in
adults.
• Reappearance may be attributed to certain
neurological conditions including, but not limited
to, dementia, traumatic lesions, and strokes
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5. Examples
1. Moro reflex (startle
reflex)
2. Tonic neck reflex
(asymmetric/symmetric)
3. Parashute reflex
4. Babinski reflex
5. Palmar grasp
6. Rooting reflex (search
reflex)
7. Suckling reflex
8. Walking/stepping reflex
9. Swimming reflex
10. Babkin reflex (Palmar
Mandibular Reflex)
11. Galant reflex
12. Plantar reflex
13. Labyrithine reflex
15. Palmar mental
16. Crawling reflex
17. Pull up reflex
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6. Infant reflexes and
stereotypies are very
important in the process of
development.
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7. What is the importance of primitive reflexes?
1. Are the dominant form of movement for last 4
months prenatally and first 4 months postnatally
2. Are critical for human survival
3. Postural reflexes believed to be foundation for
later voluntary movements
4. Appearance and disappearance helpful in
diagnosing neurological disorders
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Dr. Chongo Shapi, BSc.HB, MBChB, CUZ.
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8. Role of Primitive Reflexes in Survival
• Human infants essentially helpless.
– Highly dependent on their caretakers and reflexes for
protection and survival.
• Primitive reflexes occur during gestation or at birth
and most are repressed by 6 months of age
• Primitive reflexes are important for protection,
nutrition, and survival
• For example, the rooting reflex:
- Helps a breastfed infant find the mother's nipple
- Babies display the rooting reflex only when they are
hungry and touched by another person, not when
they touch themselves
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Dr. Chongo Shapi, BSc.HB, MBChB, CUZ.
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9. • There are a few reflexes that likely assisted in the
survival of babies during human evolutionary past
(i.e., the Moro reflex)
• Other reflexes such as sucking and grabbing help
establish gratifying interaction between parents and
infants
• They can encourage a parent to respond with love
and affection, and to feed their child more
competently
• In addition, it helps parents to comfort their infant
while allowing the baby to control distress and the
amount of stimulation they receive
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Dr. Chongo Shapi, BSc.HB, MBChB, CUZ.
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10. Role of Reflexes in Developing Future Movement
• Postural reflexes are related to the development
of later voluntary movement.
– Reflexes integrated, modified, and incorporated into
more complex patterns to form voluntary
movements.
– Automatic movement is “practice” for future
voluntary movements.
– Some believe reflexes may not be related to future
motor development.
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11. Infant Reflex Future Voluntary
Movement
Crawling Crawling
Labyrinthine Upright posture
Palmar grasp Grasping
Stepping Walking
Role of Reflexes in Developing Future Movement
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12. Reflexes as Diagnostic Tools
• Reflexes can determine level of neurological maturation.
– Reflexes are age-specific in normal, healthy infants
– Severe deviations from normal time frame may indicate
neurological immaturity or dysfunction.
• Reflexes should be tested carefully and only by trained
professionals.
– Need state of quiet.
– If baby restless, crying, sleepy, or distracted, may not respond
to applied stimulus.
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13. Reflex Concern
Moro reflex May signify cerebral birth
injury if lacking or
asymmetric.
Asymmetric
tonic reflex
May indicate cerebral palsy or
other neurological problem if
persists past normal time.
Reflexes as Diagnostic Tools
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14. Pinpointing the Number of Infant
Reflexes
• Different terminologies used for same reflex
by experts
– Rooting reflex = search reflex; cardinal points
reflex
• Reflexes are often poorly defined and more
complex than once thought
– Palmar grasp vs. traction response
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Dr. Chongo Shapi, BSc.HB, MBChB, CUZ.
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15. Stimulus /
Response
S: place infant in a semi-upright position, then
voluntarily allow the head to fall backward with
immediate re-support with the examiners 'hand
R: symmetrical abduction and extension of arms
and flexion of thumbs. This is then followed by
adduction of upper extremities
Onset/
Duration
Onset: 28-32 wks GA, fully developed at
37wks. Duration: 5-6 months
Concerns May signify CNS dysfunction if lacking
May signify sensory motor problem if persists
May delay sitting & head control if persists
May indicate fratured clavicle, injury to brachial plexus or
hemiparesis if asymmetrical
Other Reaction time increases with age
Moro reflex (Startle Reflex)
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16. 16
Discovered by an Austrian paediatrician: Ernst Moro (1874-1951)

17. Stimulus /
Response
S: Place a finger or object in the open
palm of each hand
R: infant grasp the object and with
attempted removal, the grip is reinforced
Onset/
Duration
Onset: 28 wks GA, fully developed by 32
wks. Duration: 2-3 months
Concerns No palmer grasp may indicate
neurological problems (spasticity)
Other One of the most noticeable reflexes
May lead to voluntary reaching / grasping
May predict handedness in adulthood
Palmar Grasp
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18. Palmar Grasp
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19. 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
Sucking Reflex
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20. Stimulus /
Response
S: touch cheek
R: head moves toward stimuli
Duration Weeks prenatal - 3 months postpartum
Concerns No reflex problematic for nutrition
No 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.
Search or Rooting Reflex
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21. Stimulus /
Response
S: Prone/supine position, turn head to one side
R: Extension of the arm occurs at the side of the body
corresponding to the direction of the face, while flexion
develops in the contra-lateral extremities
Onset/
Duration
Onset: 35 wks GA. Duration: 6-7 months
Concerns Facilitates bilateral body awareness
Facilitates hand-eye coordination
Other Also called ‘bow and arrow’ or ‘fencer’s’
position
Asymmetric Tonic Neck
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22. Asymmetric Tonic Neck Reflex
• An obligatory tonic neck response by which the
infant remains “locked” in the fencer’s position is
always abnormal and implies a CNS disorder
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Dr. Chongo Shapi, BSc.HB, MBChB, CUZ.
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23. 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
Symmetric Tonic Neck
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24. Stimulus /
Response
S: stroke the lateral portion of foot
R: Dorsi-flexion (extension) of the great toe
and fanning of the other toes
Duration Onset: 34-36 weeks GA
Well-established: 38 weeks
Disappearance: At 1 year
Concern Test of the pyramidal tract (i.e. ability to
perform conscious / voluntary movement)
Babinski Reflex
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25. Stimulus /
Response
S: Touching the ball of foot
R: Toes grasp
Duration Birth – 1 year
Other Must disappear before the baby can stand
or walk.
Issue of shoes versus no shoes?
Plantar Grasp
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26. Stimulus /
Response
S: Pressure to both palms
R: Mouth opens, head flexes (which tilts
the head forward) or head rotation
Duration Birth – 3 months
Other Also called the Babkin reflex
Palmar Mandibular (Babkin Reflex)
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27. Stimulus /
Response
S: Scratch base of palm
R: Lower jaw opens and closes
Duration Birth – 3 months
Palmar Mental
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28. Primitive but postural Reflexes
• Stepping
• Crawling
• Swimming
• Head and Body Righting
• Parachuting
• Labyrinthine
• Pull Up
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Dr. Chongo Shapi, BSc.HB, MBChB, CUZ.
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29. 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 reflex
Developmental changes in reflex over time
Stepping Reflex
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30. 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
Crawling Reflex
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31. 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
Swimming Reflex
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32. 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.
Head and Body Righting
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33. Stimulus /
Response
S: Suspend the baby by the trunk
R: Sudden forward flexion as if the baby were to fall. The
baby spontaneously extends the upper extremities as a
protective mechanism in the direction of fall
Duration 4 months – 1 year
Concerns Assessed in preterm babies as markers of
neurological development
Related to upright posture
Other Also called propping reflex
Parachute Reflex
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34. 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
Labyrinthine Reflex
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35. Stimulus /
Response
S: Sitting/standing, hold hands, tip in one
direction
R: Arms flex or extend to maintain upright
position
Duration 3 months – 1 year
Concerns Related to upright posture
Pull Up
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36. Galant (Trunk incurvation)
• Onset: 28 weeks GA
• Well-established: 40 weeks GA
• Disappearance: 3-4 months
- S: hold the baby in ventral suspension
with the chest in the palm of the
examiner’s hand. Firm pressure is
applied to the infant’s side parallel to
the spine in the thoracic area
- R: flexion of the pelvis toward the
side of the stimulus.
• If the reflex persists past six months
of age, it is a sign of pathology
• The reflex is named after the Russian
neurologist Johann Susman Galan
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37. Stereotypies
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Dr. Chongo Shapi, BSc.HB, MBChB, CUZ.
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38. Stereotypies
• Reflexes are most studied form of human
movement during first few months.
• Stereotypies are another form of movement
observable during infancy.
• Characterized by patterned, stereotyped, highly
intrinsic, and involuntary movements of the body
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Dr. Chongo Shapi, BSc.HB, MBChB, CUZ.
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39. Stereotypies
• Lourie (1949)
– Unusual movements are inherent and crucial to life of
a healthy child
– Decrease tension and anxiety
– Provide stimulation for development of later
voluntary movements
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Dr. Chongo Shapi, BSc.HB, MBChB, CUZ.
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40. Stereotypies
• Thelen (1979)
– Serve no purpose
– Not regulated by the nervous system
– Infants spend up to 40% of time exhibiting
stereotypies (peaks at 24-42 weeks).
– Grouped stereotypies by body region
• Legs and feet
• Hands and arms
• Fingers
• Torso
• Head and face
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Dr. Chongo Shapi, BSc.HB, MBChB, CUZ.
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41. Stereotypies
• Common stereotypies
– Single leg kick
– Two-leg kick
– Alternate leg kick
– Arm wave
– Arm wave with object
– Arm banging against a surface
– Finger flexion
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Dr. Chongo Shapi, BSc.HB, MBChB, CUZ.
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42. The End!
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Dr. Chongo Shapi, BSc.HB, MBChB, CUZ.
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