Primitive Reflexes in the
baby
Objectives
• After this lecture the learner should be:
– familiar with the premature reflexes present in the
baby at birth, which are included in the neurological
examination of the baby
– able to explain the role of the primitive reflexes
– 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 emerge during the late foetal period, are 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 SC
• 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 and achievement of milestones
The levels of hierarchy in motor control
CORTEX
MIDBRAIN
BRAINSTEM
SPINAL CORD
Background
• Some typical developing children continue to have persistent primitive
reflexes e.g. ATNR are strongly associated with
dyslexia(reading,writting), dyspraxia(movement,coordination) and
hyperactivity
Eliciting of the primitive reflexes
• The eliciting of these reflexes usually correlates with gestational age
and the developmental status of the neurological system
• They are elicited in the neonate to evaluate the developmental status
and the integrity of the neurological system
• In some cases e.g. Moro, the reflex can be used to evaluate symmetry
and could help identify possible obstetric brachial plexus injuries
• 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
Primitive reflexes
• Rooting Sucking Reflexes are divided into 3
• Palmar grasp groups:
• Babinski
• Plantar grab • Functional significance (help
birth process)
• Withdrawal
• Crossed extensor • Protective value e.g. flexor
• Automatic walking withdrawal, crossed extensor
• ATNR
• Moro • Early postural reactions e.g.
moro and startle
• Startle
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, hypersensitive 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
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
• 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
month 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
• difficult 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
Clinical implications of persistence ?
• over exaggerated in some children with CP, any
stimulation under foot results in flexor withdrawal.
This negatively impact locomotion
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, Co-
contraction 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 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
Clinical implications of persistence ?
• In children with myelomenigeocele
no extension of the legs might occur
