Gestational age assessment and

Neonatal Reflexes

Dr. Kalpana Malla

MD Pediatrics
Manipal Teaching Hospital

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 Gestational Age Assessment:

Estimating post-conceptual age of the neonate

• An accurate assessment of age is important
for 2 reasons
– Age and growth patterns appropriate to that age
aid in identifying neonatal risks
– Help in developing management plans
 Gestational Age
Assessment
• There are 3 general methods to determine
gestational age
– Calculation of dates based on LMP
– Evaluation of obstetrical patterns
– Physical exam of the neonate
– Assessment of neuromuscular and physical
criteria by inspection and palpation
Modified
Ballard
Plotting Weight, Length, HC
 Neuromuscular Criteria
• Posture
– Observe in the supine position
– Score is assigned based on the degree of flexion of
arms, knees and hips
– Increased flexion and hip adduction with
increased gestational age
 Neuromuscular Criteria
• Square Window
– Infants hand is flexed on the forearm between the thumb
and index finger of the examiner
– Apply enough pressure to get FULL flexion without rotating
the wrist
– Angle between the forearm and hypothenar eminence of
palm is measured
 Neuromuscular Criteria
• Arm Recoil
– Flex the neonates arms for 5 seconds while in the supine
position
– Fully extend the arms by pulling on the hands and release
– The degree of arm flexion and strength of recoil are
scored
 Neuromuscular Criteria
• Popliteal Angle
– Place infant in supine position with the pelvis on the
mattress
– Using the thumb and index finger of one hand, examiner
holds the knee adjacent to the chest and abdomen.
Gently extend the leg with the index finger
– Look at the angle between the lower leg, thigh and
posterior knee
 Neuromuscular Criteria
• Scarf sign
– Place infant in supine position with head in mid-line
position.
– Grasp the infants hand and pull the arm across the chest
and around the neck.
– Look at the relationship of elbow to mid-line of body when
arm pulls across the chest
 Neuromuscular Criteria
• Heel to ear
– Place the infant supine with pelvis flat on table.
– Grasp one foot with thumb and index finger and
draw foot as near to head as possible.
– Note the distance between the foot and head as
well as degree of knee extension
Physical Criteria
• Skin
– less transparent and tougher
with increasing gestational
age
– 36-37 weeks loses
transparency and underlying
vessels are no longer visable
– Increasing gestational age the
veins become less viable and
increasing subcutaneous
tissue
 Physical Criteria
• Lanugo
– Fine downy hair covering fetus from 20-28 weeks
– Disappears around face and anterior trunk ~28
weeks
– Term infants may have a few patches over
shoulders
Physical Criteria
• Sole creases
– 28-30 weeks appear and
cover the anterior portion of
of the plantar surface of the
foot
– Extend toward the heel as
increases gestational age
– After 12 hours sole creases
are not valid indicator of
gestational age due to drying
of the skin
Physical Criteria
• Breast tissue and
areola
– Areola is raised by 34
weeks
– A 1-2 mm nodule of
breast tissue is palpable
by 36 weeks
– By 40 weeks the nodule
is 10mm
 Physical Criteria
• Ears
– Incurving of the upper pinna begins by 34 weeks
gestation and extend entire lobe by 40 weeks
– Before 34 weeks, pinna has very little cartilage
(Stays folded on itself)
– At 36 weeks, there is some cartilage and will
spring back
Physical Criteria
• Female Genitalia
– Early gestation, clitoris
prominent and widely
separated labia
– By 40 weeks, fat
deposits have
increased in size in
labia majora so labia
minora are completely
covered
 Physical Criteria
• Male genitalia
– Testes begin to descend from abdomen around 28
weeks
– At 37 weeks, testes can be palpated high in
scrotum
– At 40 weeks, testes are completely descended and
covered with rugae
– As gestation progresses, scrotum becomes more
pendulous
 CANSCORE
Nine signs for assessing nutritional
status in term infants
• Hair • Buttocks
• Cheeks • Legs
• Chin & neck • Chest
• Arms • Skin on
• Back Abdominal
wall
 Gestational Age Assessment
• Physical Assessment
– Assessment of anterior vascular lens capsule using
opthalmoscope
• Best done on the 2nd day of life
– Assessment of neuromuscular and physical criteria
by inspection and palpation
Neonatal reflexes or primitive reflexes

• Definition – 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 three to 12 months of
postnatal life.
Neonatal reflexes or primitive reflexes

• Essential for a newborn's survival immediately

after birth -
sucking, swallowing, blinking, urinating, hiccu
pping, and defecating.

• Neonatal reflexes represent important

reactions of the nervous system
Moro reflex
• Elicited by the sudden
downward movement of the
head and release it -
symmetric extension and
abduction of the arms and
opening of the hands,
followed by flexion of the
upper extremities in an
embracing movement
• Present at birth and
disappears by 3-4 months.
 Startle reflex
Elicited - infant lying in a supine position and is stimulated by a sudden
loud noise that causes rapid or sudden movement of the head - results in
a symmetrical extension of extremities while forming a C shape with the
thumb and forefinger. This is followed by a return to a flexed position with
extremities against the body.
Disappears - third to the sixth month.

- An asymmetrical reflex may indicate- fractured clavicle or a birth injury

to the nerves of the arm. Absence of this reflex - underlying neurological
damage.
Rooting reflex
• Elicited by applying light
tactile stimulation in the
perioral area- responds by
turning the head toward
the stimulus, opening the
mouth and searching for
the stimulus.
• Inhibited by the third to
fourth month.
 Sucking
• Elicited by placing a gloved finger or a nipple
in the infant's mouth. The normal term infant
has a strong, coordinated, and symmetric
suck.
• Disappears at three to four months
 Grasping reflex
palmar reflex -when a finger is placed in the
neonate's palm and the neonate grasps the
finger plantar reflex -
Palmar grasp
• Elicited by stroking or
applying pressure to the
infant's palm with the
examiner's finger - The grasp
tighten with attempts to
remove the finger
• Weakens at three months;
disappears around the sixth
month
Plantar grasp

- Elicited by placing a finger

against the base of the
neonate's toes and the toes curl
downward to grasp the finger.
- - Disappear by 9-12 months
 Stepping reflex / Walking

• Elicited by holding the infant in an upright

vertical position and gently touching the feet
to a flat surface - infant's feet move in an
alternating stepping motion
• Disappears by 2-3 months, until it reappears
as he learns to walk at around 10-15 months
 Placing reflex
- Elicited by contact of the dorsum of the foot
with the edge of a table -
• the foot is lifted and placed on a table's
surface
Asymmetrical tonic neck reflex / fencer
response
Also called- tonic labyrinthine reflex
Elicited by turning the head to one side. As
the head is turned, the arm and leg on the
same side will extend while the opposite limbs
bend
Present at birth and disappears by six months
 Symmetrical tonic neck reflex
Occurs with either the extension or flexion of
the infant's head. Extension of the head
results in extension of the arms and flexion of
the legs, and a flexion of the head causes
flexion of the arms and an extension of the
legs.
- Inhibited by the sixth month to enable
crawling
 Babinski or plantar
• Reflex is triggered by stroking one side of the
infant's foot upward from the heel and across
the ball of the foot - responds by
hyperextending the toes; and the other toes
fan outward
• Disappears at nine months to a year
 Blink reflex
Is stimulated by momentarily shining a bright
light directly into the neonate's eyes - blink.
This reflex should not become inhibited -
Permanent
 Pupillary reflex
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- permanent
 Galant reflex
Elicited by placing the infant on the stomach
and you stroke neck to the spinal cord
(paravertebral area) on his middle to lower
back, it will cause his back to curve towards
the side that you are stroking.

Present at birth and disappears by 3-6

months.
 Positive Support Reflex

• Like the stepping reflex, if the baby is held

under his arms, support his head, and allow
his feet to bounce on a flat surface, he will
extend (straighten) his legs for about 20-30
seconds to support himself, before he flexes
his legs again and goes to a sitting position
• Disappears by 2-4 months
 Prone crawl reflex
Elicited by placing the neonate prone (face
down) on a flat surface. The neonate will
attempt to crawl forward using the arms and
legs.
- Inhibited by three to four months of age.
 Doll's eye reflex
Elicited by infant supine (lying on the back)
and slowly turning the head to either side. The
infant's eyes will remain stationary

- Disappear between three to four months of

age.
 Common Problems

• Presence and strength of a reflex - indication of neurological functioning

• Absent or abnormal reflex - suggest significant neurological problems
• The primary reflex system is inhibited or transformed in the first year of
life and a secondary or postural reflex system emerges
• The secondary system forms the basis for later adult coordinated
movement
• Severe persistence of primary reflexes - predominantly persistent physical
problems.
• The process of inhibition of these reflexes in the earliest months of life
remains unknown.
 Postural reactions
• Usually begin later in the first year of life.
These postural reactions include:

Derotational Righting

Parachute Response
Propping
 Derotational Righting

• This reaction usually appears by 4-5

months, and involves your infant's body
turning to follow the direction of his head
when it turns, helping him learn to roll over.
 Parachute Response

• This is a protective response that protects

your infant if he falls. Beginning at about 5-6
months, if an infant falls, he will extend his
arms to try and 'catch' himself.
 Propping

• This responses help a child learn to sit

• Anterior propping response - begins at 4-5 months, and
involves the infant extending his arms when he is held in a
sitting position, allowing him to assume a tripod position
• Lateral propping - appearing at 6-7 months, causes him to
extend his arm to the side if he is tilted
• Posterior propping, causing him to extend his arms backwards
if he is titled backward
 Thank you
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