Neuro/Reflexes

Hypotonia

The assessment of tone can be made both from observing the posture, activity of the infant when undisturbed, and by handling the baby. Infants with normal tone will not feel "floppy" when held by the examiner. The infant in the photo above is hypotonic. When this baby was lifted, the examiner had to give much more support to the head and shoulders than is usual to keep the infant from sliding out of her hands. Notice how the both arms fall back (instead of being held in flexion), and the baby's chest seems to drape over the physician's hand.

photo by Janelle Aby, MD

Hypotonia

Here is the same infant held in ventral suspension. Normally newborns do have a convex curvature of the spine in this position, but not to this degree. Here the head drops much lower than one would expect, and the examiner has the sense that the infant could easily slip out of her hand without extra support. In this case, the hypotonia was caused by trisomy 21.

photo by Janelle Aby, MD

Rooting Reflex

A rooting reflex can be elicited by stroking the cheek with a finger. The newborn responds by turning the head towards the side being stroked and by opening the mouth, as if ready to eat. Although it may sometimes seem difficult to elicit in the first few days, it becomes stronger over the first week or two.

video by Deb Steele

Rooting Reflex

Here, another newborn demonstrates the rooting reflex.

video by Deb Steele

Sucking Reflex

In this clip, the infant shows how easily the sucking reflex can be elicited. As soon as the baby feels his thumb at his lips, he begins sucking. Sucking is a self-soothing manuever for infants; an examiner can take advantage of this reflex (and its ability to soothe a fussy baby) by allowing the infant to suck on a finger or pacifier during the examination.

video by Janelle Aby, MD

Sucking Reflex

When evaluating the sucking reflex of a newborn, the examiner should note the quality and strength of the suck. Preterm infants are more likely to have a suck reflex that seems uncoordinated or weak. Other infants do more biting initially (making breastfeeding challenging!). Rubbing the infant's palate with the pad of the examiner's finger or firmly stroking in an anterior-posterior direction under the side of the chin may help stimulate a sucking reflex in an infant who is slow to start.

video by Janelle Aby, MD

Protective Reflex

Even at birth, a newborn is equipped with a protective reflex. When the eyes and nose are gently covered with a cloth, the infant arches and make efforts to push the offending item away with her hands. Babies will respond to objects that obstruct nasal breathing in a similar way. At times new mothers are concerned that their infants cannot breathe while breastfeeding because the nose appears to be blocked by the breast itself, but this reflex prevents that. An infant who cannot breathe will pull away from the breast.

video by Deb Steele

Moro Reflex

The Moro reflex (also known as the "startle reflex") is easily elicited in a newborn by pulling up gently on the arms and then suddenly letting go. The infant will extend the fingers and arms out and around and then frequently cry. There is no need to lift the infant off the bed, though sometimes the shoulders may be slightly raised. The reflex is produced by the suddenness of the stimulus, not the distance of the fall. An asymmetric or absent Moro is of concern. Brachial plexus or upper extremity injury or underlying CNS pathology should be considered in those cases.

video by Janelle Aby, MD

Grasp Reflex of the Foot

The grasp reflex is also strongly present in the feet of a newborn. Stroking up the middle of the foot will elicit the reflex -- the toes curl under and seem to grasp onto the thumb of the examiner. This is not the same as a negative Babinski reflex. This same infant would fan out the toes and have an upgoing great toe if the foot were stroked up the side. The grasp reflex is present until 2 - 3 months of age.

video by Janelle Aby, MD

Galant Reflex

The galant reflex is elicited by suspending the infant in a prone position -- the feet should not be touching the bed. The side of the back is then stroked in a cephalocaudal direction. The infant will respond by moving the hips towards the side that was stimulated.

video by Janelle Aby, MD

Asymmetric Tonic Neck Reflex

As the infant's head is turned to one side, the arms will briefly come into a "fencer's" position, with the arm on the same side as the face straight out to the side and the arm behind the head flexed at the elbow. This reflex is present until about 6 - 7 months of age. An obligatory tonic neck reflex, where the infant is "locked" in the fencer's position when the head is turned, is an abnormal finding.

video by Deb Steele

Stepping Reflex

One of the more interesting of the primitive reflexes is the stepping reflex. When the infant is suspended upright, with the feet touching the table, and then is brought to a forward-leaning position, one foot will lift up and then step forward in an apparent walking motion.

video by Janelle Aby, MD

Jittery Movements

This infant is jittery. Jitteriness most commonly occurs in an otherwise well-appearing infant on the first day of life. The most common cause is hypoglycemia, so any baby with this kind of activity on examination should have a glucose level checked. In some cases, the glucose level will be normal and the jitteriness will be a transient, idiopathic finding. It is important to remember the other medical causes of jitteriness, however. These include hypocalcemia and drug withdrawl, among others.

video by Janelle Aby, MD

Jittery Movements

This infant had severe, persistent jitteriness on exam. In this case the jitteriness was associated with irritability, low grade fever, and difficulty feeding. Neonatal abstinence syndrome resulting from the mother's prescription medication was the underlying etiology. Twelve hours after treatment was started for the infant, all these symptoms resolved.

video by Janelle Aby, MD

Seizure Activity

This video demonstrates the appearance of seizure activity in a newborn. In contrast to jitteriness, seizure activity cannot be stopped by holding the involved area. Any newborn with seizures requires monitoring and evaluation -- it is a pathologic physical finding.

video by Henry Lee, MD

Seizure Activity

The same newborn is shown here. Along with the arm movement, activity in the legs is also seen. This is frequently referred to as "bicycling" motion. It is one manifestation of seizure.

video by Henry Lee, MD

Seizure Activity

The sucking movements in the first portion of this video are a third manifestation of seizure activity. Seizures may be caused by a wide variety of problems in the newborn period, including ichemic injury, metabolic disorders, anatomical CNS abnormalities, or neonatal abstinence syndrome.

video by Henry Lee, MD

Facial Nerve Palsy

This newborn was delivered by forceps assisted vaginal delivery. Although not visible in this photo, there were small abrasions present on the left lateral eyelid and anterior to the right ear. The right facial nerve is affected here. In an infant who is crying, the lower lip should be pulled down by the action of the facial nerve, but in this baby, the lip is pulled down only on the left and an asymmetry results. Spontaneous resolution is expected.

photo by Janelle Aby, MD

Facial Nerve Palsy

This is the same infant as the previous photo. When the baby is quiet, asymmetry in eyelid closing can more easily be seen. In this case, the baby was resting, so both lids should have been closed. Instead, the lid on the affected side is partially open. Involvement of both the eye and lip help differentiate facial palsy from other diagnosis, such as asymmetric crying facies.

photo by Janelle Aby, MD

Facial Nerve Palsy

This infant has a facial nerve palsy on the left. Here, both the abnormal lip and eyelid positions can be seen. When the eyelid does not completely close, it is important to protect the eye with a lubricant, such as Lacri-Lube, to prevent corneal abrasions.

photo by Janelle Aby, MD

Aysmmetric Crying Facies

This infant has asymmetric crying facies. This condition can be differentiated from facial nerve palsy in that the eye and forhead muscles are unaffected. The etiology is a congenital deficiency or absence of the depressor anguli oris muscle which controls the downward motion of the lip. In this patient, the left side is affected. In rare cases, this anomaly has been associated with cardiac or renal abnormalities or 22q11 deletion, so a careful examination is warranted.

photo by Janelle Aby, MD

Erb's Palsy

When shoulder dystocia occurs during the birth, injury to the brachial plexus can occur. This photo shows how the posture of the arms is asymmetric: the left arm is at the side and the hand is medially rotated at a time when the other arm is flexed with crying. Testing the Moro (startle) reflex in this infant produces a similar result as the left arm does not raise as high as the right. Most brachial plexus injuries of this type resolve spontaneously. Improvement in movement can often be noted within the first 24 hours. If improvement does not occur, referral to a pediatric neurologist, and possibly a physical therapist, is warranted.

photo by Janelle Aby, MD

Erb's Palsy

This is another example of Erb's palsy. In this case, the infant's right arm is affected. When assessing movement of the extremity, look for movement, function, and strength of all three major joints (shoulder, elbow and wrist) as well as the hand grasp.

photo by Juin Kong, MD

Meningomyelocele

Meningomyelocele is a type of neural tube defect that results from incomplete closure of the posterior spine during early development.

The visible mass contains dysplastic spinal cord as well as meninges, nerve roots, and CSF.

As is the case with this patient, the lumbar spine is the most common location for this abnormality.

When this diagnosis is made prenatally, cesaerian section is usually recommended, and the birth is planned at a location where a pediatric neurosurgeon and level 3 NICU are available.

At delivery, the defect can be protected with sterile saline-soaked gauze, covered by plastic wrap, and the infant kept in a side-lying or prone position.

Infants with this condition frequently have associated abnormalities; Arnold Chiari malformation, dislocated hips, bowel or bladder dysfunction, and lower extremity weakness are all common co-morbidities.

To keep latex sensitivitiy from becoming a problem, only non-latex gloves and supplies should be used.

photo by Juin Kong, MD

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