Primitive reflexes

A reflex is a muscle reaction that happens automatically in response to stimulation. Certain sensations or movements produce specific muscle responses. Primitive reflexes are reflex actions originating in the central nervous system that are exhibited by normal infants but not neurologically intact adults, in response to particular stimuli. Infants are born with a number of instinctual responses to stimuli, such as light or touch, known as primitive reflexes, which gradually disappear as the baby matures. Primitive reflexes disappear or are inhibited by the frontal lobes as a child moves through normal child development. These primitive reflexes are also called infantile, infant or newborn reflexes. Infant reflexes are responses that are normal in infants, but abnormal in other age groups. The presence and strength of a reflex is an important sign of nervous system development and function ¹.

The following are some of the normal inborn reflexes you will see your baby perform during her first weeks.

Primitive reflexes include the:

1. Sucking reflex, which triggers an infant to forcibly suck on any object put in the mouth or an area around mouth is touched.
2. Grasp reflex or Palmar grasp reflex: Grasp reflex occurs if you place a finger on the infant’s open palm. The hand will close around the finger. Trying to remove the finger causes the grip to tighten. Newborn infants have strong grasps and can almost be lifted up if both hands are grasping your fingers.
3. Moro reflex or Startle reflex, which causes an infant to suddenly throw the arms out to the sides and then quickly bring them back toward the middle of the body whenever the baby has been startled by a loud noise, bright light, strong smell, sudden movement, or other stimulus
4. Step reflex or Walking reflex (stepping motions when sole of foot touches hard surface with body supported): The walking or stepping reflex is present at birth; though infants this young can not support their own weight, when the soles of their feet touch a flat surface they will attempt to ‘walk’ by placing one foot in front of the other. This reflex disappears as an automatic response and reappears as a voluntary behavior at around eight months to a year old.
5. Babinski reflex: Often confused with the plantar reflex, the Babinski reflex is also present at birth and fades around the first year. The Babinski reflex appears when the side of the foot is stroked, causing the toes to fan out and the hallux to extend. The reflex is caused by a lack of myelination in the corticospinal tract in young children. The Babinski reflex is a sign of neurological abnormality in adults.
6. Placing, leg extends when sole of foot is touched
7. Galant reflex: The galant reflex, also known as Galant’s infantile reflex, is present at birth and fades between the ages of four to six months. When the skin along the side of an infant’s back is stroked, the infant will swing towards the side that was stroked. If the reflex persists past six months of age, it is a sign of pathology.
8. Plantar grasp or Plantar reflex: The plantar reflex or plantar grasp is present at birth and fades around the infant’s first birthday. The plantar reflex causes the infant’s toes to curl up tightly when something rubs the ball of their foot.
9. Rooting reflex: Rooting reflex occurs when the baby’s cheek is stroked. The infant will turn toward the side that was stroked and begin to make sucking motions. The rooting reflex is present at birth and assists in breastfeeding, disappearing at around four months of age as it gradually comes under voluntary control. A newborn infant will turn their head toward anything that strokes their cheek or mouth, searching for the object by moving their head in steadily decreasing arcs until the object is found. After becoming used to responding in this way (if breastfed, approximately three weeks after birth), the infant will move directly to the object without searching.
10. Tonic neck reflex or asymmetrical tonic neck reflex (ATNR): Asymmetrical tonic neck reflex (ATNR) occurs when the head of a child who is relaxed and lying face up is moved to the side. The arm on the side where the head is facing reaches away from the body with the hand partly open. The arm on the side away from the face is flexed and the fist is clenched tightly. Turning the baby’s face in the other direction reverses the position. The tonic neck position is often described as the fencer’s position because it looks like a fencer’s stance.
11. Truncal incurvation or galant reflex: This reflex occurs when the side of the infant’s spine is stroked or tapped while the infant lies on the stomach. The infant will twitch their hips toward the touch in a dancing movement.
12. Parachute reflex: Parachute reflex occurs in slightly older infants when the child is held upright and the baby’s body is rotated quickly to face forward (as in falling). The baby will extend his arms forward as if to break a fall, even though this reflex appears long before the baby walks.
13. Symmetrical tonic neck reflex (STNR): Symmetrical tonic neck reflex is a primitive reflex that is characterized by upper extremity extension and lower extremity flexion with neck extension, and by upper extremity flexion and lower extremity extension with neck flexion ². Symmetrical tonic neck reflex (STNR) consists of two phases: flexion (inward movement) and extension (outward movement). When the child is positioned on their hands and knees, flexion or lowering of the head causes the arms to bend and the legs to extend. When the head is extended or raised, the arms extend and the legs bend. Although often seen in children with cerebral palsy (CP), it is an uncommon finding in term neonates and infants. Symmetrical tonic neck reflex is developed after the asymmetrical tonic neck reflex (ATNR) and allows the infant to defy gravity on their hands and knees, and is a precursor to creeping ³. This reflex helps the infant learn to rise up onto the hands and knees. The symmetrical tonic neck reflex emerges between 6 and 9 months of life, and should be integrated by 9 to 12 months of life. This is a short-lived reflex that primarily helps the baby to learn to get up off the floor and onto their hands and knees. However, if this reflex is retained, the baby will not be able to move forward by crawling or creeping but will do a “bear walk”, scoot on their bottoms, or skip crawling, and just stand up and walk.
14. Glabellar reflex also known as the “glabellar tap sign”, nasopalpebral reflex or blinking reflex, is a primitive reflex elicited by repetitive light tapping on the forehead over the glabella produces a reflex blinking of both eyes ⁴. Subjects blink in response to the first several taps. If the blinking persists, this is known as Myerson’s sign and is abnormal and a sign of frontal release; it is often seen in people who have Parkinson’s disease ⁵. However, the glabella tap reflex may also be positive as a release phenomenon as a result of diffuse (probably frontal lobe) damage ⁶ and in one report was positive in 36% of patients with no intracranial pathology ⁷. As the glabella tap reflex is neither sensitive forthe presence of intracerebral pathology, nor specific for parkinsonism, its role in modern clinical practice is question-able.
15. Tonic labyrinthine reflex (TLR): Tonic labyrinthine reflex is a primitive reflex found in newborn humans. With this reflex, tilting the head back while lying on the back causes the back to stiffen and even arch backwards, the legs to straighten, stiffen, and push together, the toes to point, the arms to bend at the elbows and wrists, and the hands to become fisted or the fingers to curl. The presence of this reflex beyond the newborn stage is also referred to as abnormal extension pattern or extensor tone. The presence of the tonic labyrinthine reflex as well as other primitive reflexes such as the asymmetrical tonic neck reflex (ATNR) beyond the first six months of life may indicate that the child has developmental delays and/or neurological abnormalities ⁸. For example, in people with cerebral palsy, the reflexes may persist and even be more pronounced. As abnormal reflexes, both the tonic labyrinthine reflex and the asymmetrical tonic neck reflex can cause problems for the growing child. The tonic labyrinthine reflex and asymmetrical tonic neck reflex (ATNR) both hinder functional activities such as rolling, bringing the hands together, or even bringing the hands to the mouth. Over time, both the tonic labyrinthine reflex and asymmetrical tonic neck reflex (ATNR) can cause serious damage to the growing child’s joints and bones, causing the head of the femur to partially slip out of the acetabulum (subluxation) or completely move out of the acetabulum (dislocation).
16. Landau reflex: The landau reflex assists with posture development and technically isn’t a primitive reflex as it isn’t present at birth. It is when a baby lifts his head up causing the entire trunk to flex and typically emerges at around 3 months of age. It is fully integrated by one year. If the landau reflex persists beyond this point, children may experience short term memory problems, poor motor development and low muscle tone.

Also, due to the immaturity of their developing nervous systems, newborns’ arms, legs, and chins may tremble or shake, particularly when they’re crying or agitated.

Many infant reflexes disappear as the child grows older, although some remain through adulthood. A reflex that is still present after the age when it would normally disappear can be a sign of brain or nervous system damage.

Not all infants acquire and lose these reflexes at exactly the same time, but this table will give you a general idea of what to expect.

Examples of reflexes that last into adulthood are:

• Blinking reflex: blinking the eyes when they are touched or when a sudden bright light appears
• Cough reflex: coughing when the airway is stimulated
• Gag reflex: gagging when the throat or back of the mouth is stimulated
• Sneeze reflex: sneezing when the nasal passages are irritated
• Yawn reflex: yawning when the body needs more oxygen

Older children and adults with atypical neurology (for instance, people with cerebral palsy) may retain these reflexes and primitive reflexes may re-appear in adults due to certain neurological conditions including, but not limited to, dementia, traumatic brain lesions, and strokes ¹⁰. An individual with cerebral palsy and typical intelligence can learn to suppress these reflexes, but the reflex might resurface under certain conditions such as during an extreme startle reaction. Reflexes may also be limited to those areas affected by the atypical neurology, such as individuals whose cerebral palsy affects only their legs retaining the Babinski reflex but having normal speech in individuals with hemiplegia, the reflex might be seen in the foot on the affected side only.

Primitive reflexes are also tested with suspected brain injury to test the functioning of the frontal lobe ¹. If they are not being suppressed properly they are called frontal release signs. Atypical primitive reflexes are also being researched as potential early warning signs of autistic spectrum disorders (Asperger’s syndrome) ¹¹.

Retained primitive reflexes

Primitive reflexes should only remain active for the first few months of life. There have been links identified between the inhibition of primary reflexes and the attainment of gross-motor milestones. As such, reflexes are often utilized as a form of measurement for central nervous system (CNS) maturity. They play a vital role in survival for crucial periods but should then undergo inhibition or transformation. A number primitive reflexes are important for child birth, and in typical development, these reflexes naturally inhibit during the first year, and are replaced by postural reflexes. Postural reflexes are more mature patterns of response that control balance, coordination and sensory motor development.

Retention of primitive reflexes can be caused by a variety of factors. The birth process is a key factor in the integration of these reflexes. Therefore a traumatic birth experience or birth by c-section may lead to retained reflexes. Additional causes can include: falls, traumas, lack of tummy time, delayed or skipped creeping or crawling, chronic ear infections, head trauma and vertebral subluxations. Brain injury can cause reoccurring primitive reflex reactions. They can be observed in cerebral palsy patients or people who have suffered a stroke. There are many studies associated with the role of primitive reflexes in development of cerebral palsy ¹². Retained primitive reflexes can disturb natural development and involve difficulties in social and educational children’s life ¹³. Retained primitive reflexes can also impact on psychomotor development. Mature responses in a child’s psychomotor progress can only occur if the central nervous system itself has reached maturity. The process consist the transition made from brain stem reflex response to cortically controlled response.

If primitive reflexes are retained beyond 6-12 months of life, they suggest evidence of a structural weakness or immaturity of the central nervous system (CNS). This presence of primitive reflexes is often found in combination with an absence or under-developed set of postural reflexes (above 3.5 years of age). As mentioned, retention of a reflex may impact the development of postural reflexes, which are required to support child maturation and gross motor development to effectively engage with their surroundings.

There are few studies about asymmetrical tonic neck reflex (ATNR), symmetrical tonic neck reflex (STNR) or tonic labyrinthine reflex (TLR) in the healthy population, and they are mainly focused on adults ¹⁴.

The asymmetrical tonic neck reflex (ATNR), symmetrical tonic neck reflex (STNR) and tonic labyrinthine reflex (TLR), along with the plantar reflex, palmar reflex, rooting reflex and spinal Galant reflex, if retained, play a great role in decreasing the brain’s ability and efficiency in processing sensory information. The asymmetrical tonic neck reflex (ATNR) emerges 18 weeks in utero and diminishes completely 3–9 months after birth. The effect of the retained asymmetrical tonic neck reflex (ATNR) can be poor eye tracking and difficulty crossing the visual midline. The occurrence of the reflex can cause difficulties in learning to read, telling the time and left-right confusion as well. In the posture we can observe spinal deformities caused by the asymmetrical tonic neck reflex (ATNR), which is not only a health problem of the person but also represents a high cost to society ¹⁵.

The symmetrical tonic neck reflex (STNR) emerges 6–9 months after birth and integrates into the central nervous system 9–11 months after birth. The retained symmetrical tonic neck reflex (STNR) can be characterized by poor posture, poor eye-hand co-ordination and focusing difficulties. Children with a retained symmetrical tonic neck reflex (STNR) may have problems with sitting still at a desk or learning to swim, and usually they do not feel comfortable with ball games.

The tonic labyrinthine reflex is a reflex that emerges at birth and disappears completely in 2–4 months after birth. It results in poor balance, disorientation and problems with re-establishing the emotional and physical balance. The tonic labyrinthine reflex can entail binocular vision leading to a poor sense of timing and frequent careless mistakes ¹⁶.

Psychomotor development encompasses changing abilities from the beginning of life, from fetal and neonatal periods through infancy and childhood to adolescence. Estimating the degree of psychomotor development can lead to finding a way of potential help for better growing up. It can also indicate that a child has great potential and requires a specific, individual program to reach his/her full potential.

Measurement of psychomotor abilities

Children were also examined by the Motor Proficiency Test for children between 4 and 6 years (MOT 4–6) ¹⁷. The test includes 18 tasks. Tasks to perform by children are shown in Table 1. They are divided into four areas:

1. Stability,
2. Locomotion,
3. Object control
4. Fine movement skills.

The tasks were classified on a three-point rating scale, where 0 means skill not mastered and 2 means skill mastered. All task scores were added up to generate a score out of a possible total of 34. The higher the movement skill level, the higher the children scored in the Motor Proficiency Test 4–6 assessment protocol.

Table 1. Motor Proficiency Test 4–6 test – description of items

Footnote: * The first item not rated because it was use to accustom the child to the test situation.

Primitive reflex integration

Primitive reflexes are automatic movement patterns that commence during pregnancy and are fully present at birth in term infants. They are natural reactions that start a developmental process which releases a neural circuit for a specific function. Primitive reflexes should integrate and impede reflex reactions to allow development of natural motoric action ¹⁸. Primitive reflexes play a developmental role, preparing the neonate to move against gravity, gradually leading to voluntary movement by the process of integration during the first months of life ¹³. Mature responses in a child’s psychomotor progress can only occur if the central nervous system itself has reached maturity. The process consists of the transition from a brain stem reflex response to a cortically controlled response ¹⁹. If the process has not progressed properly, the child may demonstrate poor motor ability, which can manifest itself in difficulties in running, cycling and balance, and the child may be clumsy. There may also be problems with throwing and catching, and the child might avoid games involving physical movement. Psychomotor disturbances, also known as minimal brain disorders, can modify and hinder a child’s spontaneous development process. The first signs can be seen in early childhood, but many of them are seen later, i.e. learning and behaviour difficulties during the pre-school years. Reflex retention and academic or behaviour difficulties experienced by children when they reach school age may be linked ¹⁶.

In a research by Gieysztor et al. ¹³ over 60% of children demonstrated at least one primitive reflex at level 1–2 and 25% of them at levels 3 and 4. It means that most of the examined pre-school children have non-integrated reflexes. This leads to the conclusion that large scale testing should be considered, helping to conduct early therapy before the disorders are revealed by the child’s inadequate behaviour at school age. Grzywniak ²⁰ conducted research comparing the level of primitive reflexes in two groups of healthy school age children, one from an orphanage and the second one comprising children during therapy having learning difficulties. Grzywniak ²⁰ noted that 55% of healthy children had retained the primitive reflexes at levels 1 and 2. The research did not show any children with reflexes at level 3 or 4. The results can be explained by higher age of examined children and cannot be directly compared. The difference noted above can encourage further research on the dynamics of primitive reflexes in healthy children.

Screening studies can help preschool children with those difficulties by repeating mimic movement patterns from the first year of life. The therapy could involve movements based on early brain development sequences. As a result, children’s brains can have a “second chance” to pass through the stages which have been missing ²¹.

Bruijn et al. ²² studied whether the asymmetrical tonic neck reflex (ATNR) or symmetrical tonic neck reflex (STNR) can still appear in healthy adults. Ten subjects were measured, and primitive reflexes were found to exist in adults.

Studies on motor abilities in children measured by Motor Proficiency Test for children between 4 and 6 years (MOT 4–6) were conducted by Cools et al. ²³. The children’s MOT 4–6 mean performance in the research was 19. Distribution of children’s performance was as follows: over 4% were classified in the category “altered development”, nearly 19% in “delayed development”, 75% in “normal development”, about 1% in “very good development” and none in “accelerated development”. Our study showed almost the same tendency. Nine percent of children were in the category “altered development”, 29% in “delayed development”, 59% in “normal” and 3% in “very good development”. Nowak et al. ²⁴ has nearly the same results. They show the need for stimulating 21% of 4-year-old children ²⁵.

A study ¹³ shows that without training of primitive reflexes integration, it may be impossible to correct motoric functions and help clumsy children to reach the degree of psychomotor level as their compeers. In order to prevent psychomotor delays of elder children, it is necessary to conduct an examination of the degree of reflexes integration in pre-schoolers and, as a result, if necessary, apply reflex therapy. The tests are a handy tool for qualified physiotherapists or physicians, and thus might be applied during standard periodical medical evaluation of each child. If the staff know the impact of the primitive reflexes on development of healthy children, not only would they have a faster reaction to their persistence, but they could also prevent subsequent disorders. The use of reflex tests will allow determination of the degree of psychomotor skills of a healthy child. Additionally, if performed at an early age, they will allow one to adjust the treatment according to the true source of disorders, not just the results. The integration of these reflexes essentially aims to maturate the CNS.

Exercises that may inhibit primitive reflexes

• Face Stroking for Root and Suck Reflex: Stroke the child’s face until the reflex stops, which usually takes five to six times in a row. Do this at least twice a day until you can no longer elicit the reflex. Chewing gum can also be helpful to inhibit this reflex.
• Moro Reflex Integration Exercise – Starfish Exercise: Have your child sit in a chair in a fetal position, with the right wrist crossed over the left and the right ankle crossed over the left ankle. Fists should be closed. Ask your child to inhale and make like a starfish by swinging his arms up and out and thrusting his legs out while extending the head back and opening hands. Have him hold this position for 5 to 7 seconds while holding his breath. Then tell him to exhale and return to the same position, crossing the left wrist and ankle over the right wrist and ankle. Repeat this again until they are back to the original position Do this 6 times in a row a few times a day until the reflex is inhibited fully.
• Snow Angels for Galant Reflex: Have your child lie face-up on a mat or flat surface with his legs extended and arms at the sides. have him breathe in an simultaneously spread his legs outward and raise his arms out along the flour and overhead, with the hands touching. The hands should touch at the same time the legs are fully extended. Exhale and return to the original position. The key is to get the child to move all four limbs slowly at the same time. Do this 5 times several times a day until you can no longer elicit the reflex.
• Ball Squeezes for Palmer Grasp Reflex: Have child squeeze a small ball, such as a tennis ball, several times in a row. Or you can just stroke the palm of the hand with a light brush until the reflex is suppressed.
• Fencer Exercise for Asymmetric Tonic Neck Reflex: This one may take some practice to get right, so be patient. Have your child sit in a chair and turn his head to both sides or to the one side that still elicits the reflex. As your child is turning his head, have him extend the foot and arm of the same side outward from the body and look at his hand. The opposite hand should also open, the arm should flex, and the other leg should bend. Have the child return to starting position and repeat until the reflex fatigues. Repeat three times in a row.

Key things to remember

• Exercises should be repeated in succession 5 to 10 times until the reflex fatigues.
• Frequency is more important than intensity.
• Movement must be slow and purposeful.
• Proper mind-set is crucial: stay motivated and positive!
• Give it time.

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