This section includes suggestions intended to help sharpen surface observations for possible anomaly, plus a few highlights on the potential effects of the abnormal findings on the child or primary caregivers.

Rooting and Sucking Reflexes
A hungry infant will turn the head to the right or left when the cheek is brushed by a hand or facecloth. If a nipple is touched to the face -whether to the right or left, above or below the mouth-the lips and tongue will tend to follow in that direction. These rooting and sucking reflexes should be present in all full-term babies. As might be expected, they are more easily elicited before than after a feeding. The reflexes may be absent in small prematures. Absence among full-term infants suggests depression of the central nervous system from maternal anesthesia, hypoxia, or congenital defect.

Rooting reflex

although there may be a slight movement of flexion first. with the exception of the distal phalanges of the index finger and thumb. and finally return to the position of flexion and abduction [Mitchell. the rooting response may persist during sleep until as late as 7 or 8 months. Feeding problems are discussed later. peculiar dentition (such as double-fused teeth). While rooting and sucking reflexes are being appraised. to give a single description for all ages and all infants. The Moro Reflex The Moro reflex. Mitchell described the reflex in the infant a few days old: The initial part of the response is extension and abduction of the upper ex.. visual stimulation plays a part-babies may root for a bottle but may not respond to the touch of a finger. and gradually alters during the first few months of life with increasing maturity. attention should also be given to the possible presence of such anomalies as a particularly small chin. Sometimes there is a slight tremor or even a rhythmic shaking of the limbs.. A sudden jolting movement. 1960. If the lower extremities are extended when the stimulus is applied. Extension of the head relative to the trunk or a sudden strong stimulus appear to be the most reliable means of eliciting the reflex. is a series of movements by an infant in response to a stimulus. The movement of the lower extremities is usally less pronounced. the flexion movements may be more readily noted. warrant thorough medical evaluation. such as that produced by striking the mattress or table on both sides of the infant. Excess salivation. a face that appears unusually fat in relation to a rather small skull. will usually cause the startle response. or its reappearance later in life. Both legs tend to extend and abduct with the upper extremities. a cleft lip or palate.tremities with extension of the spine and retraction of the head. sometimes termed a "startle" reflex. therefore. or asymmetry of the nasolabial folds. The forearms are supinated and the digits tend to extend and fan out. 9]. mucus. bringing the hands towards one another in front of the body. the upper extremities describe an arc-like movement.These responses usually last until the infant is 3 or 4 months old. It is not possible. The pattern of movement varies among infants. Persistence of the response beyond the 7th month. p. However. . At later ages. Occasionally a loud noise may precipitate the reflex. which may be C-shaped . and frothing always warrant attention.

Its absence in a newborn may be due to a central nervous system disorder. but this is followed by greatly diminished intensity of the response during the ensuing weeks. it becomes less pronounced. McGraw (1937) found that most infants change at about 90 days from the newborn phase to a transitional phase in which movements become less gross. and in one infant who subsequently developed athetosis. disappear. possibly because of birth injury or general muscular weakness. . Occasionally cerebral edema or other factors may cause the reflex to be absent on the first day and gradually develop during the following 4 days. Paine did not find persistence of the Moro reflex beyond the 6th month in any of the infants in his series who had homologous retardation of psychic and motordevelopment. an infant will display the Moro reflex on the first day.Moro reflex The Moro reflex is strongest during approximately the first 8 weeks of life. But abnormal persistence was seen occasionally in the presence of spastic tetraparesis. but asymmetry usually suggests fracture of the clavicle or humerus. Thereafter. the need for medical attention is immediate and urgent. opisthotonos. injury to the brachial plexus. These variations point to the value of public health nurses following up infants who have been discharged early from the hospital after delivery. Paine (1964) points out that a defective Moro. and at about 130 days to the final "body-jerk" phase. Occasionally. the reflex may be present the first day. and the setting-sun sign of the eyes (only the upper half of the iris showing above the lower lid) are the principal and probably indispensable clinical signs of kernicterus in the first week of life. and return slowly after the 6th day. The Moro response is missing or incomplete in the younger premature but should be readily obtained in any full-term normal baby. or neonatal hemiplegia. Asymmetry of response may occasionally be noted in normal full-term infants. In some cases of cerebral hemorrhage. Persistence of the Moro reflex after the 6th month should be considered suspicious and deserves careful medical evaluation. Whenever such symptoms are noted.

this behavior may be due to elicitation of the Moro by lack of ability to maintain the head erect so that it drops back unexpectedly. the nurse can observe if and when the Moro appears and the characteristics of the response. However. the reflex will be elicited several times in any 24-hour period in a hospital nursery. The public health nurse should look for the Moro reflex as she puts the infant down just before or after demonstrating how to bathe the infant. may be interpreted by the caregiver or "behavior shaper" as due to volitional. In fact. turns the head to one side or if the head is passively rotated to one side. or during the infant's visits to a well-child conference. when checking vital signs. and they should receive more constant and consistent medical surveillance. . while the other arm flexes at the elbow. the hospital nurse should be alert for the Moro response when she rolls the bassinet to display the infant at the nursery window or when she replaces the infant in the bassinet after changing the crib sheet. Nevertheless. the sudden extension of the arms and opening of the hands. and in other circumstances when the infant is subjected to slight movements. or a loud noise or unexpected jostle of the chair or table. a sudden flash of sunlight on the spoon. no matter how gently the infant is handled. These authors assert that it is present in practically all infants during the first 12 weeks of life. maladaptive behavior. causing the spoon to fly off in one direction and perhaps the food in the other. The lower limbs respond in a similar manner. If the infant's limbs are free to move. The asymmetrical tonic neck reflex appears "when the infant. In the course of routine nursing functions. the older child with a persistent Moro is at risk of having this resemblance overlooked. lying on the back. The Asymmetrical Tonic Neck Reflex Articles by Gesell (1938) and Gesell and Ames (1960) contain descriptions of the asymmetrical tonic neck reflex." The infant tends to assume a "fencing" position-with his face toward the extended arm.Touwen (1976) points out that it may be hard to differentiate the Moro reflex from a fright response occurring later in life. Or it may be ascribed to the possibility that the child is too retarded to understand what is expected of him. during the appraisal and demonstration bath carried out in the home by the public health nurse. Extreme care should be exercised at all times in handling distressed or premature infants. while feeding. in teaching the child self-feeding. often spontaneously manifested by the quiescent baby in the supine position as well as during general postural activity. As an example.

. Prechtl and Beintema (1964). however.. A persistent asymmetrical tonic neck reflex is potentially a very handicapping disability. (1960) have pointed out. The child is prevented from seeing both hands simultaneously unless measures are instituted to position the head and hands in midline. Paine (1964). persistence of the response after the 7th month constitutes an index of suspicion.Asymmetrical tonic neck reflex Paine (1960). being replaced by symmetrical head and arm positions (when the baby is in supine position) by the time the infant is 5 or 6 months old. The response tends to be most noticeable between 2 and 4 months of age. The influence of the pattern on the legs obviously poses severe restriction on the ability to achieve standing and walking. A study of 66 normal infants during their first year of life found that a few infants under 3 months of age could sustain the asymmetrical tonic neck pattern for more than 30 seconds. sustained response (Paine et al. but none demonstrated an imposable. and Andre-Thomas et al. and Vassella and Karlsson (1962) agree that. Responses that are completely obligatory or unusually strong on one side or the other deserve medical attention at any age. The effort to bring food or any object to the mouth is also inhibited. The studies indicate that while the asymmetrical tonic neck posture may be apparent from time to time during the first few months of life. that there is no constant asymmetrical tonic neck pattern among newborns. 1964). while the tonic neck pattern may be partially imposed on a normal infant by passive rotation of the head. Prechtl and Beintema (1964). this is not a consistent response.

and pelvis in the same direction. it is of interest to note that the early and normal tendency of the infant to extend the "face arm" places the hand in an excellent position to be viewed without effort. there is a momentary delay between the head rotation and the following of the shoulders. and whether it is compulsory or persistent. An observant nurse can discern whether the asymmetrical tonic neck reflex is present. Even during the first few days and weeks of life. If the body response seems dependent on the head position in serial observations of an infant over 6 months of age. Observation for the asymmetrical tonic neck reflex pattern provides opportunity for carefully examining the child's neck to note the possible presence of torticollis or webbing. . A particularly short neck in relation to the rest of the body is also worth noting. and area around the ears several times in a 24-hour period. sudden. and complete body rotation in immediate response to a passive turn of the head that may occur in some abnormal states. trunk. The Neck-Righting Reflex As the asymmetrical tonic neck response is "lost." it is replaced with a neck-righting reflex. "Learning" that the hand is there. Finally. is a first step toward later learning what can be done with a hand. the nurse has many opportunities to watch for the asymmetrical tonic neck response as she rotates the head of the infant in supine to cleanse first one side of the face and then the other. neck. at the end of the arm. in which passive or active rotation of the head to one side is followed by rotation of the shoulders. whether the response is stronger on one side than the other. With young infants it is a bit easier to use a passive head rotation maneuver. the nurse should ascertain whether the reflex has persisted. Waving a bright toy first to the right and then to the left of the child is an effective way to elicit active rotation of the head. many normal infants may be observed maintaining attentive eye contact for minutes at a time with the hand they are facing while in this position.Since the newborn needs gentle cleansing of the face. In the true neckrighting response. as opposed to the automatic.

As the newborn infant is turned to prone. Public health nurses may assess tone as they weigh and measure the baby at well-child clinics or while bathing the child at home. nor should the response at any age be so completely invariable that the baby can be rolled over and over. The nurse may observe this when the baby is turned to prone during the nursery admission cleansing procedure. before undertaking the more complicated series of maneuvers by which he rolls over and achieves sitting (and/or rises from the floor in the quadrupedal manner). First. as he voluntarily gets up to a sitting position from the supine. they point out that a neck-righting reflex in which the response is much stronger with the head to one side than to the other is not seen in normal infants. the legs should be flexed. Posture in Ventral Suspension and the Landau Reflex All normal neonates display some evidence of tone when suspended in the prone position. and pelvis. (1964) found that the neck-righting reflex was obtainable in all normal infants by 10 months of age and was gradually covered up by voluntary activity. the infant should not be completely limp and collapse into an inverted U. It also is relevant to note that infants with low muscle tone (hypotonicity) or with considerable excess of tone (hypertonicity) and infants with an obligatory asymmetrical tonic neck reflex would be impeded from demonstrating a normal neckrighting reflex. then the shoulders. making the age of its disappearance difficult to gauge. . However. While the head may sag below the horizontal and the spine be slightly convex. Stereotyped reflexes of this type are considered pathologic and are often found in infants with cerebral palsy.Neck-righting reflex The nurse may observe the two-step righting response in the normal child of 1 or 2 years. with the trunk or abdomen supported. trunk. he turns the head. Paine et al.

the nurse then passively flexes the head forward. 1976). Many physicians designate this posture. If the child is plunged sideward as well as downward to the flat surface. In any event. as a "positive Landau" (Touwen. The Landau reflex is tested in a different way by others. but concavity was noted universally at 10 months. While holding the infant in ventral suspension with the head. when the child can anticipate visually that he is going down to a flat surface. Paine et al. In general. while the spine remains straight. the nurse's report to the physicians should describe exactly what was done and the infant's response. In each instance. Under these circumstances. Since the older infant tends to smile or chuckle under anticipatory circumstances but may be frightened when unexpectedly plunged. with the back slightly arched. Still later. Dissolution of the reflex is difficult to ascertain since it is gradually covered up by struggling or other voluntary activity. the former is usually the method of choice by the nurse in eliciting the presence of the reflex. The spine was at least slightly concave in approximately half of the 8-month-olds. and legs extended. there is elevation of the head well above the horizontal and arching of the spine in a concave position. spine. There is a gradual increase in the tendency to elevate the head as if to look up. the nurse will find that holding the infant in ventral suspension provides more useful information than elicitation of the Landau by means of passive flexion of the head. Touwen (1976) suggests that the earlier appearance of the positive response. Under these circumstances the parachute response may not be seen until about 6 or even 9 months of age. the maneuver is the same but the child's visual attention is first attracted to a bright toy displayed in front of and a little above him and he is then suddenly plunged downward. Whatever the infant's age. The normal positive response is a forward extension of both arms and dorsiflexion of the infant's hands during the movement. the influence of the optical factors is reduced. the infant is held in vertical suspension and suddenly lowered toward a flat surface. the infant is permitted to see where he is going. the head and spine are maintained in a more nearly horizontal plane. partial . The reflex is considered present if the whole body then flexes. The difference between the two is that. The Parachute Reflex and Optical Placing of the Hands There is a tendency to refer to the parachute reflex when the behaviors being elicited and the reactions being described are actually those associated with the optical placing reaction of the hands. his limp collapse into an inverted U when held in ventral suspension should be called to immediate medical attention. In the true test for the parachute response. in the optical placing reaction.As the baby becomes a little older. (1964) found that the head was above the horizontal in 55 percent of their series at 4 months and in 95 percent at 6 months. The reflex may be seen as early as 3 to 4 months but should be present after 7 months of age. Touwen (1976) calls attention to and describes the difference between the two. This response may be noted as early as 3 months of age. illustrates the reinforcing effect of visual on vestibular input.

.response may be noted as early as 3 months. Parachute reflex Public health nurses are alerted to watch fathers at play with their children. 1964). the nurse should describe in her report exactly the way in which the parachute was elicited. The complete response begins a little later. as well as for extensor tone in ventral suspension.. Nurses who have developed a warm rapport with the child and family may themselves play with the infant in this fashion. it will be noted in most infants by 9 months and in all normal infants by 12 months (Paine et al. In any event. An asymmetrical or absent response warrants medical appraisal. as the game of "so high" or "airplane" may provide the opportunities to observe for the presence and character of the parachute reflex. since most infants respond with great glee.

While there is a tendency to fisting in the neonate.Palmar grasp AND Planter grasp "Palmar and Plantar Grasp Palmar and plantar grasp are strong automatic reflexes in full-term newborns. usually during or right after feeding. and possible malformations of the hands and feet. Turner's syndrome). Serial observation of infants in the nursery should reveal relaxation of both hands at some point. as it may signal the presence of a chromosomal abnormality (X. merging. 0. simian palm crease (a straight line rather than an M-shape across the palm). or perhaps when asleep. Possible abnormality may be suspected in asymmetry of response. edema. Persistent edema of the feet is always worth noting. though it may persist during sleep for a while thereafter. These appraisals provide additional opportunities for detecting abnormalities of color such as cyanosis of the extremities. The palmar grasp response weakens as the hand becomes less continuously fisted. this should not be evident at all times. . The plantar response disappears at about 8 or 9 months. particularly if occurring in a female child. sometime after 2 months. into the voluntary ability to release an object held in the hand. They are elicited by the observer placing a finger firmly in the child's palm or at the base of the child's toes.

in order to note the presence. or asymmetry of response. Supporting Reaction The supporting reaction is elicited by holding the infant vertically and allowing his feet to make firm contact with a table top or other firm surface. Even in the newborn period. The nurse in testing the neonate may gently raise the infant from supine in this way. . which causes the head to drop forward suddenly. but she should avoid reaching the midline point. there should be sufficient head control to bring it back upright. Normally. this is followed by increase in support. During the first 4 months of life. Automatic stepping may also be observed when the newborn is inclined forward while being supported in this position.tion of their weight by 10 months (Paine. absence. assistance by the shoulder muscles can be felt and seen. so that normal infants will usually support a substantial propor. The "standing" posture includes some flexion of the hip and knee. 1964).Simian palm crease Traction Response Physicians test the traction response by placing the infant in supine. then drawing him up by the hands to a sitting position. and greater control is expected with age. the crouching position gradually diminishes. The newborn's head lags behind and drops forward suddenly when the upright posture is reached. however.

it is difficult to distinguish from voluntary standing. By the age of 6 months.Supporting reaction and stepping In this supported standing position. A club foot or a deformity at the knee or hip may also become apparent while the supporting reaction is being appraised. However. consistent standing on the tips of the toes or scissoring of the legs after 4 months of age may be considered an index of suspicion warranting medical attention. . the supporting reaction is less easily demonstrable. and by 10 or 11 months. it is to be expected that a few infants will stand on their toes from time to time or occasionally cross or "scissor" their legs.

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