Prof Faten H Abdelazeim Chair of Pediatric Department

Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Introduction A reflex is an involuntary muscular response to a sensory stimulus. Certain sensations or movements are known to produce specific muscular responses. The presence and strength of a reflex is an important indication of neurological development and function. Many of the infantile reflexes disappear as the infant matures, though some remain throughout adulthood. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Motor Development: Infant Reflexes Basic REFLEXES, unlearned, organized, involuntary responses that occur automatically in the presence of certain stimuli, represent behavior that has survival value for the infant. Reflexes are innate motor responses elicited by critical stimuli Reflexes are adaptive Examples of infant reflexes: Rooting reflex: A touch on the cheek induces the infant to move its mouth toward the source of the touch (helps guide feeding) Sucking reflex: Tactile stimulation of the mouth produces rhythmic sucking. Swimming reflex. Eye blink reflex Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Motor Development : Infant Reflexes The neonate exhibits a number of reflexes "primary" "primitive" which demonstrate the activity of CNS. These reflexes provide the basis for later motor development. A reflex is an involuntary or automatic, action that your body does in response to something without you even having to think about it. You don't decide to kick your leg, it just kicks. There are many types of reflexes and every healthy person has them. In fact, we're born with most of them. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Classification of Reflexes According to their function Some reflexes are protective and have a survival value. i. e. reflex saving life. Other promote appropriate orientation for feeding. i. e. rooting reflex. Others promote postural control and balance. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

According to level of C. N. S. maturation Spinal level reflexes. i. e. crossed extension. Brain stem level reflexes. i. e. tonic neck reflexes. Mid brain level reflexes. i. e. righting reactions. Cortical level reflexes. i. e. equilibrium reactions. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

According to their relation to the normal sequence of motor development A pedal: predominance of primitive spinal and brain stem reflexes with motor development of prone or supine creature. Quadri pedal: predominance of midbrain righting reactions and motor development that a child can right himself, crawl, sit. Bi pedal: at the cortical level of development reveals equilibrium reactions with motor development that of a child who can assume standing, walking (ambulant). Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

According to their time of appearance Primitive reflexes which are present at birth and then fade on (disappear). Postural reflexes which play an important role in regulating tone. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Importance of Infant Reflexes • Reflexive movements occur during the last 4 months of prenatal life and the first 4 months after birth – Reflexes occur subcortically (below the level of the higher brain centers) – E. g. , palmer grasp Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Infant vs. Lifespan Reflexes • Most “infant” reflexes do not last beyond the first year • Reflexes that endure are called “lifespan” reflexes – Knee-jerk reflex – Flexor-withdrawal reflex Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Infant vs. Lifespan Reflexes • Many of the reflexes do not completely disappear – First, they are inhibited by the maturing nervous system – Second, they are integrated into new movement behaviors Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Role of Reflexes in Developing Future Movement Infant Reflex Future Voluntary Movement Crawling Labyrinthine Upright posture Palmar grasp Grasping Stepping Walking Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

You Think Reflex can be classified According to "method of elicitation" or "type of stimulus" Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Reflexes response to "light touch“ Grasp reflex Palmar ………. . Planter – Stimulus: light touch of the palm or sole "slide pencil or finger across the lateral border". – Response: reflexion of fingers or toes. – Age: birth to 3: 4 months. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Reflexes response to "light touch“ Grasp reflex (Palmar) – Function of palmar grasp: it has a survival value by enabling the infant to cling to the mother's cloth "strong reflex grasping". – Persistence of palmar reflex interferes with ability to A. grasp and release objects voluntarily B. bear weight or open hand for propping, crawling and protective responses. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Reflexes response to "light touch“ Grasp reflex (Planter) Persistence of planter reflex interferes with the ability to: – Stand with feet flat on surface. – Balance reactions and weight shifting in standing. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Reflexes response to "light touch“ Placing reflex of lower limbs – Stimulus: let the dorsum of the foot touch the lower side of the edge of table "from upright". – Response: the infant flexes the leg and appears to do so to place foot on the table. – Age: birth to 1 month. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Reflexes response to "light touch“ Placing reflex of Upper limbs Test position: ventral suspension. Stimulus: let the dorsum of hand touch the lower side of edge of the table. Response: the infant flexes the stimulated arm with placing hand on top of the table. Age: birth to 6 months "early months of life" Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Reflexes response to "light touch“ Rooting reflex: • Stimulus: light touch of the check or stimulation of edge of mouth. • Response: turning of the head in the direction of the stimulus with simultaneous opening of mouth, extension of tongue. • Age: birth to early months "newborn period". Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Reflexes response to "light touch“ Rooting reflex • Function of rooting reflex: • It has an adaptive and survival function "utilization of the reflex during feeding ensures that the infant takes the nipple well into its widely opend mouth, so avoids painful pressure upon the end". Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Reflexes response to "light touch“ • • Rooting reflex Persistence of rooting reflex interferes with: Oral motor development. Development of midline control of head. Optical righting. Visual tracking. Social interaction. It also call "cardinal points" Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to "Pressure" and "Pain" • • • Galant's reflex Test position: infant is held upright and trunk movement is unrestricted. Stimulus: firm sharp stimulation alongside the spine with the finger nails or a pin. Response: contraction of the underlying muscles and curving of back. Age: in the neonatal period. Persistence of galant reflex interferes with: Development of sitting balance can lead to scoliosis. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to "Pressure" and "Pain" • • Withdrawal reflex Test position: supine. Stimulus: a pinprick or other sharp painful stimulus to sole of foot. Response: flexion and withdrawal of the stimulated leg. Age: birth to 2 months. Function of flexor withdrawal reflex: It has protection and diagnostic values. Persistence of the flexor withdrawal reflex indicates delayed reflexive maturation Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to "Pressure" and "Pain" • • Crossed extension reflex Test position: supine. Stimulus: a pinprick or other sharp painful stimulus to sole of foot. Response: flexion and withdrawal of the stimulated leg. Age: birth to 2 months. Function of flexor withdrawal reflex: It has protection and diagnostic values. Persistence of the flexor withdrawal reflex indicates delayed reflexive maturation Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to "Pressure" and "Pain" Babinski Reflex • Test stimulus: firm painful stroke along the lateral border of the sole of foot from heel to toe. Used in path • Response: movement (flexion or extension) of big toe and sometimes fanning of other toes. • Predominates in 1 st year, • N. B. after 2 years flexion of big toe becomes normal response. • Age: throughout life. N. B. • In first 2 years "stimulus area & motor response" are quite extensive. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to "Pressure" and "Pain" Babinski Reflex • After this age "both" become more controlled restricted. • Function: it is great diagnostic value. • Persistence of reflex: "after age of 2 years" indicates a lesion in pyramidal tract and appear as extension of big toe after 2 years. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Reflexes response to "Pressure" and "Pain" • • Magnet (traction) reflex Test position: supine with limb flexed. Stimulus: steady firm pressure is applied to sole of foot or hand then gently withdrawn. Response: extension of the limb as if being drawn forwards by a magnet. Age: early months Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Reflexes response to "Pressure" and "Pain" • • • Stepping reflex Test position: the infant is held upright with head in mid position. Stimulus: pressure against firm surface upon the sole of the foot (with weight leaning forwards). Response: the neonate causes first flexion then extension of the leg "alternate stepping“"Walking reflex“ an impression of "automatic walking or stepping", it is not true walking because there is no trunk support or pelvic stability. Age: birth to 2 months. Interfere with , standing, walking, weight shift in standing and development of smooth coordinated alternative movements. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to "Pressure" and "Pain" • • Support reflex: "Legs" Test position: the infant is held vertically. Stimulus: the soles of feet allowed to come into contact with a table or floor, then pressure is allowed on them. Response: reflex extension of legs"secondary stiffening of legs". N. B. : A chain response producing follows the initial reaction and makes the leg strong supporting pillars. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to "Pressure" and "Pain" Support reflex: "Legs" • Age of supporting reaction: 3 to 8 months. • Function of support reflex (legs): • It is important for the development of upright posture. Persistence of the support reflex interferes with: • Standing. • Walking. • Balance reactions, can lead to "abnormal gait patterns“ and Weight shift in standing. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to "Pressure" and "Pain" • • • Support reflex: “ARMs" Test position: ventral suspension. Stimulus: tilt the infant's body forward & sideways. Response: extension of arms. Stimulus: contact of palms of open hands with a firm surface with pressure on palms. Response: extension of arms with support on palms. Age: several months later than that of legs. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Reflexes response to "Kinaesthetic stim. " • • • Moro reflex Stimulus: "several ways". sudden movement of head on shoulders, allow the head drop about 25 mm (1 in) into palm of hand. raise the supine baby a short way from the couch by pulling upon the hands and then relasing them suddenly. Response: "2 phases" "symmetrical" phase (1) – wide abduction of the arms & opening of hands. phase (2) – the arms come together again Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Reflexes response to "Kinaesthetic stim. " Moro reflex Consider • tensing of back muscles. • Flexion of legs. • Crying. • Age: birth to 4 : 6 months. Function: • it has a diagnostic value. • it has a therapeutic value. • Response should be symmetrical – any asymmetry indicates: a central or peripheral nervous lesion. Fractures of bones, injuries of the muscles of affected arm. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Reflexes response to "Kinaesthetic stim. " • • Moro reflex Persistence of moro reflex interferes with: sitting reaction protective responses eye – hand co-ordination and visual tracking Persistence of startle reaction interferes with: social interaction and attention (startle) N. B. it is the most useful of all neonatal reflexes. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to "Kinaesthetic stim. " Asymmetrical tonic neck reflex "ATNR" • Test position: supine, head in midline. • Stimulus: sideways turning of the head either passively or actively by using toys or his mother to fellow her. • Response: extension of the arm on side to which the head turns flexion of the opposite arm. • Similar response occur in legs "less obvious". • Age: birth to 4 : 6 months. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to "Kinaesthetic stim. " Asymmetrical tonic neck reflex "ATNR" • Function: it plays an important role in visumotor development. • it is present during the time that visual fixation upon nearby objects is developing "eye – hand coordination". • Persistence of ATNR interferes with: • Feeding, visual tracking, midline use of hands. • bilat. hand use, rolling, crawling, may be leading to skeletal deformities , e. g. scoliosis, hip sublaxation or dislocation. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Reflexes response to "Kinaesthetic stim. " Symmetrical tonic neck reflex "ATNR" • Test position: prone on lab with arms, legs free, head in mid position. • Stimulus: two different stimuli: • Flexion of head OR Extension of head. Response: • Stimulation by flexion of head causes flexion of UL's‘ extension of LL's'. • Stimulation by extension of causes extension of UL's‘ flexion of LL's'. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to "Kinaesthetic stim. " Symmetrical tonic neck reflex "ATNR" • Age: birth to 4 : 6 months. Persistence of STNR interferes with: Assuming quadrepid posture. • Propping an arms from prone. • Crawling reciprocally. • Sitting balance when looking around. • Hand manipulative skills when looking at object in hands in sitting position. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to "Kinaesthetic stim. " Head body Body head righting reflexes • Orientation of head in relation to body and vise versa. Neck righting: • Test position: supine, head in mid position arms & legs extended. • Stimulus: head is turned sideways actively or passively. • Response: trunk realigns itself so as to remain in normal relationship to head "rotates as a whale". • Age: birth to 6 months. • Function: it facilitates rolling from supine to prone and vice versa. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to "Kinaesthetic stim. " • Head body Body head righting reflexes Orientation of head in relation to body and vise versa. Neck righting: • Test position: supine, head in mid position arms & legs extended. • Stimulus: head is turned sideways passively or actively. • Response: passively or actively rotate upper or lower trunk. • segmental rotation of the trunk, so that the body rotates at shoulder then trunk then pelvis. Reorientation of head position. • Age: it starts at 4 to 6 months. • it becomes mature at 8 to 10 months. • it is controlled at 18 months. • Function: it provides the basis for voluntary rolling Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to " Visual & Auditory stimuli" As our visual and auditory senses are able to receive stimuli from a distance, they are well equipped to act as warning mechanisms. They have a protective and survival value. Blink reflex • • • Stimulus: Bright light suddenly shone into eyes. A puff of air upon cornea, Sudden loud noise. Response: immediate blinking of eyes, it may be associated with: tensing neck muscles, turning head away from stimulus, grimacing. Age: seen in neonatal period and continue throughout life. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to " Visual & Auditory stimuli" – Visual (optical) righting • Once some visual awareness of orientation has developed, infants do not readily tolerate distorted views and reflexly attempt to right their head position in order to correct the view. • These visual righting reflex develops in close association with labyrinthine righting reflexes. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to " Visual & Auditory stimuli" – Visual (optical) righting • Once some visual awareness of orientation has developed, infants do not readily tolerate distorted views and reflexly attempt to right their head position in order to correct the view. • These visual righting reflex develops in close association with labyrinthine righting reflexes. • Stimulus: quieter sounds. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to " Visual & Auditory stimuli" – Visual (optical) righting • Response: reflex eye and head turning to side of sound as if locate it. • Age: starts at 4 months – becomes mature – "accuracy of localization of sounds by turning had completely towards the sound stimulus" by age of 9 -10 months. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to " Labyrinthine stimuli" Labyrinthine head righting • • Test position: Different position in space with blind fold. supine position, prone position, vertical position, ventral suspension. held by the feet with the trunk & head down. Stimulus: position itself. Response: the infant's head is always moved into a position of which the vertex is uppermost and mouth is horizontal whatever the position of child. Age: it is not present at birth but develops during early months, it continues throughout life. Function of labyrinthine head righting: it important for development of antigravity postures and balance. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Response to " Labyrinthine stimuli" Tonic labyrinthine reflexes • • Birth to 6 months supine extensor tone prone flexor tone • The labyrinths are thought to Exert tonic influence upon the distribution of the muscle tone throughout the body. • Control the balance between the extensor and flexor muscles. • It is very difficult to isolate these tonic reflexes and to study their effects in normal infants, but the effects of disturbances of these tonic reflexes are very obvious in neurologically damaged infants – dystonic syndromes. Persistence of tonic labyrinthine interferes with: • ability to initiate rolling. • ability to prop on elbows with extended hips when prone. • ability to flex trunk and hips to come to sitting position from supine. • Balance in sitting and standing. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

According to "level of CNS maturation" Spinal level reflexes • • • Flexor withdrawal. Extension thrust. Crossed extension. They are mediated by areas of the CNS Deiters nucleus which is the lower 1/3 of pons. They are "phasic" or "movement" reflexes which coordinate muscles of extremities in patterns of either total flexion or extension. Complete domination of these primitive spinal reflexes results in an apedal (prone – supine - lying) creature. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

According to "level of CNS maturation" Brain stem level reflexes • • ATNR STNR Tonic labyrinthine Associated reactions +ve supporting reactions -ve supporting reactions They are mediated by areas from the Deiters nucleus to the red nucleus which is at the most caudal level of basal ganglia. They are "static" "postural reflexes". Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

According to "level of CNS maturation" Brain stem level reflexes • • They effect the distribution of m. tone either in response to change position of head & body in space (labyrinths stim) or in response to change of head in relation to the body (proprioceptive stim). Complete domination of these primitive brain stem reflexes results in an apedal (prone – supine - lying) creature. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

According to "level of CNS maturation" Midbrain level reflexes • • Neck righting acting on body Body righting acting on body Labyrinthine righting acting on head (different position) Optical righting ((different position) Amphibian reaction. They are integrated at the midbrain level above the red nucleus, not including cortex. They interact with each other and work toward establishment of normal head and body relationship in space as well as in relation to each other. Their combined actions enable the child to roll over, sit up, get on hands and knees, and make him a quadripedal creater Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

According to "level of CNS maturation" Automatic movement reactions – Moro reflex – Landu reflex – Parachute reaction "protective extensor thrust" – They are group of reflexes observed in infants and young children which are not strictly righting reflexes, but reaction produced by changes in position of head, including semicircular canals, labyrinths or neck proprioceptor. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

According to "level of CNS maturation" Cortical level reflexes • From various positions – Supine – Prone – Four – foot kneeling – Sitting – Kneel sitting – Hopping – Standing – Squatting Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

The Asymmetrical Tonic Neck Reflex Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

The Spinal Galant Reflex Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

The Head Righting Reflexes Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

The Landau Reflex Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

According to "level of CNS maturation" Cortical level reflexes • These reactions are mediated by the efficient interaction of cortex and basal ganglia and cerebellum. • Maturation of equilibrium reactions bring the individual to human bipedal stage of motor development. • They occur when muscle tone is normalized. • They provide body adaptation in response to change of center of gravity (COG) in the body. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Primitive Reflexes: Palmar Grasp • The palmar grasp reflex is one of the most noticeable reflexes to emerge • Appears in utero • Endures through the 4 th month postpartum • Negative palmer grasp: neurological problems; spasticity • Leads to voluntary reaching and grasping Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Primitive Reflexes : Sucking • Occurs pre-and postnatally – Babies are born with blisters on lips • Stimulated by touching the lips Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Primitive Reflexes: Search • Helps the baby locate nourishment • Baby turns head toward the food • Usually works in conjunctions with sucking reflex • Contributes to headand body-righting reflexes Stimulus : touching the cheek Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Primitive Reflexes: Moro Reflex • Palm of hand lifts back of head • Hand is removed suddenly so that head begins to fall – Head is supported • Moro reflex precedes the startle reflex and causes the arms and legs to extend immediately rather than flex • Disappears at 4 -6 months. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Primitive Reflexes Startle • Similar to the Moro reflex • May not appear until 2 -3 months after Moro disappears • Elicited by a rapid change of head position, by striking the surface that supports the baby, loud noise • Causes the arms and legs to flex immediately Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Primitive Reflexes Asymmetric Tonic Neck Reflex • Causes flexion on one side and extension on the other • Not always seen in newborn • Facilitates the development of bilateral body awareness Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Primitive Reflexes Symmetric Tonic Neck Reflex • Limbs respond symmetrically • Its persistence may impede other motor milestones Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Primitive Reflexes Symmetric. Tonic Neck Reflex Place baby in a sitting position : tip forward Place baby in a sitting position : tip backward Neck flexes Arms flex Legs extend Neck extend s Arms extend Legs flex Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Primitive Reflexes Plantar Grasp • The toes appear to be grasping • Stimulus is touching the ball of the foot • This reflex must disappear before the baby can stand or walk Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Primitive Reflexes Babinski Reflex • Elicited by a stimulus similar to plantar grasp, but response is different • Test of the pyramidal tract activity for later motor movement. Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Primitive Reflexes Palmar Mandibular Reflex • Makes the eyes close, the mouth open, and/or neck flexes which tilts the head forward • Also called the Babkin reflex • Stimulus is pressure to both palms Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Primitive Reflexes Palmer Mental Reflex • Elicits a facial response when the base of the palm is scratched • Lower jaw opens and closes Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Postural Reflexes Stepping reflex is a forerunner to walking Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Postural Reflexes Crawling • Believed to be essential to the voluntary creeping movement • Observed from birth to 3 -4 months Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Postural Reflexes Swimming • Characterized by the baby’s swimming-like movements when held in a horizontal position Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Postural Reflexes Head-and-Body Righting • The head “rights” itself with the body when the body is turned to one side – Body follows head • Precursor to rolling movements • Body righting may not be evident before month 5 Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Postural Reflexes Parachuting Reflexes • Propping reflexes • Related to upright posture • This reflex is a conscious attempt to break a potential fall Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Postural Reflexes Labyrinthine • This reflex endures throughout most of the first year • Related to upright posture • Head tilts in the opposite direction of body tilt Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Postural Reflexes Pull-up Reflex When the baby is tipped backward, supporting arms flex in an effort to maintain the upright position Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Stereotypies • Another form of movement observable during infancy • Characterized by patterned, stereotyped, highly intrinsic, and involuntary movements of the body • Believed to precede more complex voluntary movements Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Stereotypies • Ester Thelen (1979) studied stereotypies • Thelen grouped stereotypies by body – Stereotypies are intrinsic region – They serve no purpose – Not regulated by the nervous system – Repetitive, patterned movements – Evidence of functional maturation – – – Legs and feet Hands and arms Fingers Torso Head and face Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Stereotypies • Common stereotypies – Single leg kick – Two-leg kick – Alternate leg kick – Arm wave with object – Arm banging against a surface – Finger flexion Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

There are three major Brainstem descending pathways • Vestibulospinal pathway • Extensor tone • Reticulospinal pathway • Flexor tone; extensor tone & inhibition – Both involved in posture and balance • Tectospinal pathway – Controls head and eye movements Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Some reflexes are dependent on the integrity of the brainstem and its connection to motor neurons • Vestibular and neck reflexes – Neck control, Limb control, posture and balance** **The control/suppression of certain brainstem reflexes are dependent on the integrity of the connections to the brainstem, from higher levels Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Tonic Neck Reflex • Elicited in newborns • Elicited in patients with major cerebral lesions Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

What are the patterns of reflex response produced by stimulation of these neck receptors? • Asymmetrical tonic neck reflexes • Symmetrical tonic neck reflexes – Neck flexed – Neck extended Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

When are dominant tonic neck reflexes normal and when are they a sign of a possible abnormality? • Normal: To about 4 months of age One sign of possible developmental abnormality: Persist as dominant pattern after 4 months of age • May reappear in adults with head injury in the midbrain or above that disrupts some fibers descending from the cerebral cortex Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010

Prof. Faten H. Abdelazeim Chair of Pediatric Department, Faculty of physical Therapy 2 n term 2009 -2010