Pediatric: Reflexes

Rooting

baby turns towards the direction of the corner of the mouth, lip, or cheek that is stimulated/touched; functionally for finding food (why it’s also called the “searching reflex”)

• birth-3 months

  • onset: 28 weeks gestation

  • integration: 3 months

• “roots” growing “towards” the water

Galant

elicited by holding the newborn face down (prone) and stroking 1 side of the spine; baby’s trunk laterally flexes towards the stimulated side

• important for facilitating (1) lateral trunk movements/trunk stabilization, (2) hip movement, and (3) ROM in preparation for crawling and walking

• birth-3 months

  • onset: 32 weeks gestation

  • integration: 2 months

• mnemonic:

  • going to a “gala” and “posing”

  • ga”L”ant (L pose when the trunk “L”aterally flexes)

Suck-swallow

elicited by a finger, nipple, or bottle in the mouth, resulting in baby rhythmic sucking-swallowing; important for eating food/ingestion for nourishment

• birth-6 months

  • onset: 28 weeks gestation

  • integration: 2-5 months

Palmar grasp

fingers grasp (flex) when baby’s palm is stimulated; important for increasing tactile input in the palms + facilitating reflexive grasp

• if the reflex doesn’t integrate, there will be…

  • poor fine motor coordination

  • poor motor development, like grasping, releasing, and hand manipulation (which can impact handwriting)

• birth-6 months

  • onset: 37 weeks gestation

  • integration: 4-6 months

Plantar grasp

similar to palmar, but for the feet; when the sole is stroked/pressured, the toes curl in flexion

• importance: increases tactile input to the sole of the foot —> assisting in positioning of feet when standing, walking, running

• if this reflex is retained, foot positioning will be more difficult, as the child may experience (1) hypersensitivity to touch and (2) gravitational insecurity when standing (which will make it hard to walk, run, and maintain balance in motion)

• birth-9 months

  • onset: 28 weeks gestation

  • integration: 9 months

Traction

elicited by pulling the baby up by their forearms into sitting (pull-to-sit), resulting in (1) head lag, then —> (2) baby flexing their head, *UEs, and *hands —> and (3) ending in a sitting position; importance is the enhanced *momentary reflexive grasp, preparing baby for voluntary control of grasping

• birth-6 months

  • onset: 28 weeks gestation

  • integration: 2-5 months

• “pulling” is a form of “traction”; “traction of the neck” resulting in it —> “following the body into flexion”

Moro

elicited by a sudden noise, rapid movement, or sudden change in movement (e.g., by raising the baby’s head and allowing it to drop); baby (1) extends + abducts their arms, legs, and neck, and then (2) rapidly brings their arms together with flexion + adduction

• importance: development of a protective response; an alarm system or “fight or flight” response triggered with a sudden loss of support

• birth-6 months

  • onset: 28 weeks gestation

  • integration: 4-6 months

• also called the startle reflex

• baby got “scared” from a “moro”n playing loud music in the nursery

TLR (Tonic Labyrinthine Reflex)

elicited by changes in the position of the head and body in relation to gravity; causes a tonic extension of the limbs when the head is tilted backwards + a tonic flexion of the limbs when the head is tilted forward

• image

  • TLR prone (baby in prone) —> response: body in flexor tone

  • TLR supine (baby in supine) —> response: body in extensor tone

• if reflex isn’t integrated: profound functional limitations in movement

  • you will have difficulty extending the head in prone

  • you will have difficulty flexing your head to sit up from supine + roll over

  • —> poor posture, muscle tone, coordination, etc.

• birth-6 months

  • onset: 37 weeks gestation

  • integration: 6 months

• so named because it is influenced by the orientation of the “labyrinth”, which is the “part of the inner ear that helps with balance and spatial orientation”; all extremities follow the neck:

  • neck flexion —> extremity flexion

  • neck extension —> extremity extension

• believed to help with the development of postural control and balance; as the reflex integrates and disappears, the infant begins to develop more advanced motor skills, such as rolling over, sitting up, and crawling

ATNR

elicited by head turning to 1 side (while baby is in supine); face side | arm extension, skull side | arm flexion

• importance: precursor to hand-eye coordination, promoting visual and hand movement in regard; if it doesn’t get integrated…

  • e.g., poor reading comprehension 2/2 poor visual tracking and eye pursuit associated with difficulty crossing midline + losing place while reading

  • e.g., poor FM skills + handwriting 2/2 head rotation dictates arm movement —> arm extension on face side (i.e., with every slight head turn, the arm/hand will want to open and extend)

  • e.g., poor hand-eye coordination; because movement of arms is dependent on head position, it can cause asymetrical movment/positioning of the arms, making it

    • difficult to bring both hands to midline

    • difficult to hold an object with both hands

    • difficult to bring objects to mouth

    • difficult to reach for objects in front

• birth-6 months

  • onset: 37 weeks gestation

  • integration: 4-6 months

• also known as the fencing reflex, as it resembles a fencer

  • A= asymmetric (arms are different)

  • T= tonic (involves a sustained muscle tone or contraction in the neck muscles)

  • N= neck (neck turns towards the same side as the head)

  • R= reflex

Landau

elicited when the infant is held horizontally in the prone position (facing down), and the head is lifted; results in a curve-like shape, with the legs and arms extending and the head lifting up

• importance: to break up flexor tone and facilitate prone extension, which is important for posture development

• 3 months-2 years

  • onset: 3-4 months

  • integration: 12-24 months

• considered an important milestone in the development of motor skills, as it helps the infant to develop postural control, balance, and coordination

• as the reflex integrates and disappears, the infant gains more control over their body and is able to perform more complex movements, such as crawling, standing, and walking

• resembles an airplane “landing”

Parachute

elicited when the baby (or adult) is suspended in mid-air and suddenly moves towards the ground, as if falling; they will automatically extend their arms and legs forward, as if trying to catch themselves, even if they are not actually falling (helps to protect the body in the event of sudden fall or loss of balance)

• infancy-lifetime

• baby folds like a “parachute” with the “top of the parachute being the mid-section of the body” and the “bottom of the parachute being all the extremities”

STNR (Symmetric Tonic Neck Reflex)

• 6 months-12 months

  • onset: 4-6 months

    • *notice this is not primitive/newborn and begins at 6 months

  • integration: 8-12 months

i.e., the “crawling reflex”, as it functions to “help the baby get onto their hands and knees for crawling”; a transitional reflex, precursor to crawling

• symmetrical extension of the arms and flexion of the legs (underneath the butt) when the head is extended (in crawling position)

• symmetrical flexion of the arms and extension of the legs when the head is flexed (in crawling position)

mnemonic: S= symmetric

• “arms follow the neck” in flexion/extension, as the “arms are closer to the head than the legs are”; the legs do the opposite

• the “left/right of the upper or lower extremities” are “symmetric,” NOT the upper AND lower extremities are symmetric

also remember the “function”

• the baby has different movement patterns for upper vs lower extremities because this helps facilitate movement in “crawling”; if the upper and lower extremities were in the same flexion or extension position, they would be in prone/quadruped pattern instead of the unique STNR pattern

• poor integration of STNR would result in:

  • difficulty sitting up from supine 2/2 sitting up requires neck flexion, but in STNR, head flexion would result in hip/leg extension (which gets in the way of sitting up)

  • poor muscle tone and posture

    • e.g., when arms are bent, the legs will extend, resulting in a slouch backwards (imagine when a child is sitting at their desk writing); the same vice versa

    • e.g., when legs are bent, the arms will extend, resulting in a slouch forward (imagine when a child is sitting at their desk writing)

Gag and cough

a combination of 2 different reflexes (gag + cough) that protect the airway and prevent foreign objects from entering the lungs

• birth-continue throughout life, although their sensitivity and strength may change over time

TLR vs STNR

lack of integration of both would result in difficulty sitting up, but the mechanisms are different

• TLR

  • supine position —> increase in extensor tone —> difficulty flexing the neck to sit up

• STNR

  • neck flexion —> hip and leg extension —> resists movement to sit up

righting reactions

a reflex that develops after birth that helps us assume a position, by maintaining alignment (head-trunk + trunk-limbs); in babies it helps to initiate…

• head control

• rolling

• crawling

• eventually standing

types

• neck righting

• body righting

• optical head righting

• labyrinthine righting

righting reactions

• neck righting

test: place baby in supine and rotate head to 1 side; results: *log rolling of the body in the direction of the head to maintain alignment

• importance: allows baby to roll and serves as a transition reflex that facilitates rolling supine to side-lying + is a precursor to crawling

• onset: 3-6 months

• integration: 6 months

*less mature form of rolling than segmental rolling, involving body moving as ONE unit

righting reactions

• body righting

test: place baby in supine and flex 1 hip/knee towards the chest; result: *segmental rolling of the upper trunk and spine in order to maintain head-body alignment

• importance: facilitates rolling through spinal/trunk rotation + supine > side-lying position

• onset: 3-6 months

• integration: 6 months

*more mature form of rolling than log rolling

righting reactions

• *optical head righting

test: hold baby suspended vertically and slowly tilt off-center by moving it side-to-side/forward-backwards; result: upright positioning of the head + orienting the head in space

• importance: what allows us to correct the orientation of our head in space (i.e., alignment of the head vertically + in the upright position)

• onset: birth-2 months

• integration: persists

*called “optical” head righting, as the baby is using its “VISUAL” system to mediate

righting reactions

• labyrinthine righting

tests: WITH BABY’S EYES CLOSED, hold baby suspended vertically and slowly tilt off-center by moving it side-to-side/forward-backwards; result: upright positioning of the head + orienting the head in space (same outcome as optical head righting reflex, but this time it is mediated by the **VESTIBULAR system)

• importance: to orient the head in space (i.e., alignment of the head vertically + in the upright position)

• onset: birth-2 months

• integration: persists

*baby will not be able to use visual cues or information in the environment for orientation

**2/2 the labyrinth, a structure in the inner ear that helps maintain and regain balance

reflexes that emerge before birth

• observed within the 1st year

• integrated within the 1st year

• may recur after injury to the brain

• important for survival, posture, and alignment of head with body

• reflexes

  • rooting

  • suck-swallow

  • galant

  • moro

  • traction

  • palmar

  • plantar

  • ATNR

  • TLR

reflexes that emerge from birth to ~6 months

• STNR

• Landau

lifetime reflexes that persist

• optical head righting

• labyrinthine righting

• protective reactions

  • downward parachute

  • forward parachute

  • sideward parachute

  • backward parachute

• equilibrium reactions

  • prone tilting

  • supine tilting

  • quadruped tilting

  • standing tilting

protective reactions

• downward parachute

test: lower baby toward a surface while vertically suspended; result: extension of the *lower extremities

• importance: protective defense against a fall + facilitates accurate placerment of feet

• onset: 4 months

• integration: persists

*the only protective reaction that involves lower extremity extention

protective reactions

• forward parachute

test: rapidly tip a baby forward while vertically suspended; result: extension of upper extremities + hand opens

• importance: protective defense against a fall

• onset: 6-9 months

• integration: persists

protective reactions

• sideward parachute

test: tip a baby off to the side while in a sitting position; result: arm extension and abduction to the side

• importance: protective defense against a fall

• onset: 7 months

• integration: persists

protective reactions

• backward parachute

test: tip a baby off balance backwards while sitting; result: arm extension backward + arm extension to 1 side w/ spinal rotation

• importance: protective defense against a fall

• onset: 9-10 months

• integration: persists

equilibrium reactions (4)

responses

• the spine will curve on the raised side

• both arms and legs will extend and abduct

importance= FIRST line of defense against falling (protective reactions are the SECOND line of defense)

• maintain equilibrium without arm support

• ability to make postural adjustments

types

• prone tilting

  • onset: 5 months

  • position baby in prone on a tilt board and raise 1 side of the surface

• supine tilting

  • onset: 7-8 months

  • position the baby in supine or sitting on a tilt board and raise 1 side

• quadruped tilting

  • onset: 9-12 months

  • position the baby on all 4 on a tilt board and raise 1 side

• standing tilting

  • onset: 12-21 months

  • position the baby in standing on a tilt board and raise 1 side