Neonatal reflexes Assessment Retained Reflexes and it's clinical Implications Refrences

1. -Karishma Sachdev
1st year MPT(Neurological and
Psychosomatic Disorders)
PRIMITIVE REFLEXES
PRIMITIVE REFLEXES 1

2. Contents
 Primitive Reflexes
 Assessment of primitive reflexes
 Retained Primitive Reflexes and its clinical manifestations
PRIMITIVE REFLEXES
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3. Primitive Reflexes
 Primitive reflexes are typically present in childhood, suppressed
during normal development, and may reappear with diseases of
the brain, particularly those affecting the frontal lobes.
 These reflex are essential for normal progressive motor
development.
 However not overcoming these primitive reflex patterns at the
right time should be definitely considered as abnormal.
 Initially lower centers such as spinal cord control these
movements but later on higher centers like midbrain and cortex
take control over them and dominate the lower ones thus
integrating them for various voluntary functional task.
 Disappearance of certain primitive reflex does not mean they are
abolished but means that they have been take over by stronger
reflexes at higher level in the CNS.
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4.  These primitive reflexes are classified according to
the level at which they are controlled. Accordingly
we have four levels at which these reflexes are
regulated:
1. Spinal cord
2. Brainstem
3. Midbrain
4. Cortex
 There is a fifth category called Automatic reflexes
under which we have Moro’s reflex, Gallants trunk
incurvatum, Landau’s reflexes and Parachute reflex.
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5. AUTOMATIC REACTIONS
 MORO’S REACTION
 Position: Supine.
 Stimulus: Drop head backwards or sudden loud noise like
clapping.
 Reaction: Sudden abduction of upper extremities with
extension followed by flexion and adduction.
 Present from birth up to 6 months.
 https://www.youtube.com/watch?time_continue=18&
v=PTz-iVI2mf4&feature=emb_title
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6.  Absence of any of these movements in any extremity can
be suggestive of LMN lesion
 In hypertonia - the full movement of the arm is prevented
 In hypotonia - arms tend to fall backwards on to the table
during the adduction phase
 It is asymmetrical if there is an Erb’s palsy, a fractured
clavicle or humerus, or a hemiplegia
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7.  THE STARTLE REFLEX
 Stimulus: obtained by a sudden loud noise or by
tapping the sternum
 Response: the elbow is flexed (not extended, as in the
Moro reflex), and the hand remains closed.
 https://www.youtube.com/watch?v=LyVpFmWxcKo
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8.  LANDAU’S REACTION
 Position: Ventral suspension.
 Stimulus: Either active or passive extension of neck.
 Response: Hyperextension of spine and lower limbs seen around
months of age, reaches its peak at 8 months.
 Beyond 10 months is pathological.
 https://www.youtube.com/watch?v=Q5pZNd93qEw
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9.  GALLANTS TRUNK INCURVATUM
 Position: Ventral suspension.
 Stimulus: Stroking paraspinally from twelfth rib
to the iliac crest.
 Reaction: Lateral flexion and curvature of
to the side of stimulus.
 It is present at birth and normal up to 6
months.
 https://www.youtube.com/watch?v=bswn56Q
_XM
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 Disappearance of this reflex suggests trunk control is
developing.
Clinical Significance:
 The spinal galant reflex is used in the birthing process by
helping the baby work its way down the birth canal
 It also enables the fetus to hear and feel the sound
vibrations in the aquatic environment in the womb

10.  PARACHUTE REFLEX
 Position: Child in prone position on plinth
and suddenly lifted either by holding ankle
or pelvis and tip downwards
 Response: Sudden extension of upper limb
which is in order to protect head.
 It appears around 6 months and remains
throughout life.
 https://www.youtube.com/watch?v=tJ1_a1F
GFs4
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11.  PLACING
 Stimulus: Bringing the anterior aspect of the tibia or ulna against the
edge of a table.
 Response: The child lifts the leg up to step onto the table, or elevates
the arm to place the hand on the table.
https://www.youtube.com/watch?v=Ft-DY5SGXEg 0:38
https://www.youtube.com/watch?v=hPrAMItWWsU 0:30
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12.  PRIMITIVE WALKING (Automatic Walk: Reflex Stepping)
 Hold baby upright and tip forward, sole of foot presses
against table
 Initiates reciprocal flexion and extension of legs
 Weight bearing in development of standing
 Normal until 2 months
 https://www.youtube.com/watch?v=-ih_pCBo70o
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13. SPINAL LEVEL REFLEX OR
NOCICEPTIVE REFLEX
 FLEXOR WITHDRAWAL
 Position: Supine head in neutral position and legs extended.
 Stimulus: Sole of foot.
 Response: Uncontrolled flexion of stimulated extremity.
 This is present since birth and disappears by 2 months.
 https://www.youtube.com/watch?v=p4vM8ca8QZU
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14.  EXTENSOR THRUST
 Position: Supine head neutral one leg extended and
other flexed.
 Stimulus: Sole of flexed leg is given stroking
 Response: Immediate extension adduction and internal
rotation of flexed leg with plantar flexion of foot.
 Present at birth and integrated by 4 months.
 https://www.youtube.com/watch?v=e-yYmB_ylHc
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15.  CROSS EXTENSOR
 Position: Supine; head, mid-position; legs extended
 Stimulus: holding one leg extended at the knee and
applying firm pressure to the sole or stroking it on the
same side
 Response: Immediate flexion ,adduction and internal
rotation of flexed leg with plantar flexion of foot and
extension.
 Present since birth and integrated by 2 months.
 https://www.youtube.com/watch?v=aul0I1OOqJg
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16. PRIMITIVE REFLEXES
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17.  PLANTAR AND PALMAR GRASP
 Stimulus: Press some object on palm from ulnar side.
 Response: Grasping of the object on the ulnar side.
 Stimulus: Press object on the plantar side of toes laterally.
 Response: Clawing and clutching .
 Both these reflexes are present since birth and integrate on 10 months.
 The grasp reflex is assessed partly with regard to intensity, partly with
regard to symmetry and partly with regard to persistence after it should
have disappeared
 https://www.youtube.com/watch?v=6tPXGSxEkm0
 https://www.youtube.com/watch?v=moIUcOa0t-w
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18. PRIMITIVE REFLEXES
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 An exceptionally strong grasp reflex may be found in
the spastic form of cerebral palsy.
 It may be asymmetrical in hemiplegia and in cases of
cerebral damage.
 It should have disappeared in 2 or 3 months and
persistence may indicate the spastic form of cerebral
palsy.
 Clinical significance:
 Normal grasp and release cannot develop unless the
palmar grip is present
 Normal walking cannot develop until plantar grasp is
present.

19.  ROOTING REFLEX
 Stimulus: Touch baby’s cheek
 Response: Head turns towards stimulus
 Present at birth and integrates within 3 to 6 months.
 https://www.youtube.com/watch?v=xneStHZ0Kho
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20. THE CARDINAL POINTS REFLEXES
NORMAL STIMULUS THERAPY
2 months Touch corner of mouth The bottom lip is lowered on the same side and
the tongue moved towards the point of
stimulation. When finger slides away, the head
turns to follow it.
Centre of the
upper lip is stimulated
The lip elevates, baring the gums and the tongue
moves
towards the place stimulated. If the finger slides
along the oronasal groove, the
head extends.
Centre of the bottom lip
is stroked
The lip is lowered and
the tongue is directed to the site of stimulation. If
the finger moves towards the
chin, the mandible is lowered and the head flexes.
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21. PRIMITIVE REFLEXES
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22.  SUCKING REFLEX
 Stimulus: Introduce a finger into the mouth
 Response: Sucking action of lips and jaw
 Present at birth and integrates within 3 to 6 months.
 https://www.youtube.com/watch?v=ONjB-7u9nvM
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23.  POSITIVE SUPPORTING REACTION
 Position: Hold patient in standing position
 Stimulus: press down on soles of feet
 Response: Increase of extension in legs. Plantarflexion,
genu recurvatum may occur.
 Normal until 3 months
 https://www.youtube.com/watch?v=EyK93ptzkXM
 0:26
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24.  NEGATIVE SUPPORTING REACTION
 Position: Hold in weightbearing position
 Response: Child 'sinks’ , release of positive supporting
reaction
 Normal until 3-5 months
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25. EYE REFLEXES
 Blink reflexes
 Various stimuli will provoke blinking, even if the child is asleep, or
tensing of the eyelids if the eyes are closed.
 Present throughout life.
 Sharp noise – cochleopalpebral reflex
 Bright light - visuopalpebral or ‘dazzle’ reflex
 Painful touch - cutaneo-palpebral reflex
 The ciliary reflex is blinking on stroking the eyelashes.
 The corneal reflex consists of blinking when the cornea is
touched.
 McCarthy’s reflex is homolateral blinking on tapping the supraorbital
area.
https://www.youtube.com/watch?v=2rsIQpsnkt0
 Glabellar tap reflex
https://www.youtube.com/watch?v=srxh6bfKF18
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26.  THE DOLL’S EYE RESPONSE.
 Delay in the movement of the eyes after the head has
been turned. If the head is turned slowly to the right or
left, the eyes do not normally move with the head.
 The reflex is always present in the first 10 days,
disappearing thereafter as fixation develops.
 The reflex may persist beyond the first few days in
abnormal babies.
 https://www.youtube.com/watch?v=MpjR5eyu9Pc
 PUPIL REFLEXES.
 The pupil reacts to light, but in the preterm baby and
some full term babies the duration of exposure to the
light may have to be prolonged to elicit the reflex.
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27. BRAINSTEM LEVEL
 ASYMMETRICAL TONIC NECK REFLEXES
 Position: Child is supine, head neutral and limbs relaxed.
 Stimulus: Turning of head of child towards one side.
 Response: Extension of limbs on face side and flexion of the limb
on the occipital side.
 Present at 2 months of age and integrated by 4 to 6 months
 If ATNR is predominant then hand to mouth reaction is affected,
hand coordination is affected and midline activity like rolling
over doesn’t develop.
 Purpose: Prepares the body for reaching (arm extends towards
an object the baby is looking at).
 https://www.youtube.com/watch?v=0oI_yGQViXY
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28.  CLINICAL SIGNIFICANCE :
 The ATNR helps the fetus move the head from side to side while
swinging the arms and kicking the legs.
 This pattern helps develop the muscle tone and the vestibular
ear) system.
 The connection between the hand and eyes help develop
depth perception and eye-hand coordination.
 This movement pattern is the infant’s first experience in
understanding the coordination of both sides of the body
(reciprocal interweaving).
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29.  The ATNR not only supports the birth process, but is
strengthened by it.
 This reflex is also needed at birth so that the fetus can help
rotate itself through the birth canal.
 This may be one reason why some children who are born by
caesarean section or require forceps delivery are in jeopardy
of becoming developmentally delayed.
 Without experiencing the twisting they do not directly learn
the right-left and upper body-lower body coordination that
is needed for developing the interweaving patterns of
crawling, walking and skipping.
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30.  SYMMETRICAL TONIC NECK REFLEX
 Position: The child is in quadripedal position.
 Stimulus: The head is either flexed or extended.
 Response:
When the head is in flexion, the upper limb gets flexed and
lower limb extends,.
When the head is extended the upper limb goes into
extension and the lower limb goes into a flexed position.
https://www.youtube.com/watch?v=b1Ss7S-wuLg
https://www.youtube.com/watch?v=QZ4C2WjmVBI
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31.  This reflex helps the infant learn to rise up on hands and
knees and experience the force of gravity.
 VISUAL DEVELOPMENT:
Head up: bottom will sink onto ankle, and get eyes
fixed at distance
Head down : feet will rise , arms will bend bringing
vision back to near distance
 THUS, training eyes to adjust from far to near
distance
 If present then the child is unable to crawl as everytime
he will put head up hip will flex onto ankle.
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32.  TONIC LABYRINTHINE REFLEX
 Position: Either supine or prone
 Response: As the position itself is the stimulus, if the child
in supine position then there is increase in tone in the
extensor group of muscles and when the child is kept in
prone position then there is increase in tone in the flexor
group of muscles.
 This reflex is present from birth and integrates by 3 to 4
months.
https://www.youtube.com/watch?v=HZriJqf1w2I
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33. PRIMITIVE REFLEXES
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34.  It is the foundation for head control.
 This reflex prepares the baby for movements of rolling
over, crawling on all fours, standing and walking.
 With the disappearance of this reflex head control will
begin.
 If it is present in supine then lifting of head, kicking is
not possible but midline activity is possible.
 However if it is present in prone position then head
raising and reaching over is not possible.
 If you put such a child in sitting position he will be
sitting on the sacrum or if the head is allowed to extend
there will be extension of the entire body and the child
will fall backward
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35. MIDBRAIN LEVEL REFLEX
 OPTICAL RIGHTING REFLEX
 Position: Hold child from armpit in a suspended
position supine or prone then change position of his
head from side to side.( 2 to 6 months)
 Hold patient in space and tilt from side to side. (6
months)
 Response: Head rights itself to normal position face
vertical mouth horizontal.
 It appears by 1 to 2 years and remains throughout one’s
life.
 https://www.youtube.com/watch?v=nFdrp_p51zU
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36. PRIMITIVE REFLEXES
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37.  LABYRINTHINE REFLEX
 Position: Blind fold child, same position as in optical reflex.
 Response: Head comes to neutral and rights itself to
position.
 Seen by 2 to 3 months, reaches peak by 5 to 6 months.
 https://www.youtube.com/watch?v=Ttt1upF3nQY
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38.  NECK RIGHTING
 Position: Supine blind folded.
 Stimulus: Rotate head to one side.
 Response: Body rotates to that side as a whole.
 Generally present at birth but a time may appear as
as 3 months.
 https://www.youtube.com/watch?v=r1pZWHJPKg0
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39.  BODY ON NECK
 Position: Supine Blind folded.
 Stimulus: Rotate body to one side.
 Response: Head turns in line of body.
 Present since 6 months and remains throughout one's
life.
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40.  BODY ON BODY
 Position: Blind folded.
 Stimulus: Rotation of pelvis to one side..
 Response: The trunk and shoulder follow direction of
pelvis. It is called as segmental rolling.
 These reflexes present from 6 months onward and
remains throughout one's life.
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41. Cortical Level Reflex
 This consists of all the EQUILIBRIUM REACTIONS.
 It is usually checked on tilt board or rocking board.
 Look for extension of upper or lower extremities in direction
of tilt (prevent any injuries).
 Equilibrium reaction in supine and in prone position is
present from 6 months onwards.
 Equilibrium reaction in quadrupedal position is present
from 8 months.
 Equilibrium in sitting starts normally from 10-12 months.
 Kneeling equilibrium occurs from 15 months onwards
 Equilibrium reactions in standing occur from 18 months
onwards.
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42.  ABNORMAL MANIFESTATIONS
• A patient with spinal cord dominance will not be able to walk
and carry out ADL and therefore he will be bedridden throughout
his life. The condition gives rise to lot of contractures. Hence
the treatment aims primarily at preventing secondary complication
due to lack of ambulation like preventing tightness or
contractures, respiratory complication, etc. need to be taken care
of.
• Child with brainstem dominance will also be bedridden and
unable to walk. Aim of the treatment will be similar to the above
situation where all secondary complications due to lack of
ambulation need to be prevented.
• Midbrain dominance children will have a relatively better
prognosis. Such a child can ambulate but due to and or absent
equilibrium reactions some walking aids are required.
• Cortical dominance children will have a near normal development.
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43.  What Happens If Primitive Reflexes Don't Go Away?
 If the primitive reflexes are retained they can interfere with
social, academic, and motor learning.
 Basically, the perception of our inner and outer environment and
our response to it may be disturbed; that is, conscious life may
be disturbed.
 Children with learning disorders, ADHD, Autism Spectrum,
and various other neurodevelopmental disorders are known to
have retained primitive reflexes contributing to their symptoms
and level of dysfunction.
 Each reflex is associated with one or more of the Sensory
Processing System: Auditory, Taste, Tactile, Smell, visual,
Vestibular, Proprioceptive and/or Interoceptive.
 Therefore, if retained, a child/person may experience
dysfunction within one or several of the sensory processing
systems. This can lead to what is known as a Sensory
Processing Disorder.
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44.  Causes of Retained Primitive Reflexes
 Children born via cesarean section, birth trauma,
toxicity exposure, anesthetics, etc. are more at risk for
having retained primitive reflexes.
 Subtle spinal shifts can also contribute to retained
reflexes.
 Other causes may be: insufficient tummy time as an
infant; lack of, or little, creeping or crawling; early
walkers; head injuries; excessive falls; and chronic ear
infections.
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45. RETAINED REFLEXES
 1. MORO’S REFLEX
 If Moro's reflex remain active beyond 3-4 months child will
remain hypersensitive.
 The child will experience heightened arousal and awareness.
 His world maybe full of bright, loud and abrasive stimuli.
 Over activity of the Sympathetic nervous system and the
Adrenal Glands
 Overstimulation causes secretion of cortisol and adrenaline for
constant ‘fight or flight’.
 Chronic stress can also affect the glandular functions and
digestive system.
 So, Moro reflex can cause biochemical and nutritional imbalances.
 A persistent Moro reflex depletes energy and can cause fatigue
and mood swings
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46.  Child/person may suffer with allergies, asthma, depressed
immune system, and chronic illnesses.
 Overreacts
 Impulsive and aggressive
 Emotional immaturity
 Withdrawn or timid and shy
 Easily Distracted
 Anger or Emotional Outbursts
 Poor Balance and Coordination
 Poor Digestion and Food Sensitivities
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47.  2. TONIC LABRYNTHINE REFLEX
 This reflex emerges at 16 weeks in utero. It should
be integrated at approximately 4 months
postnatally.
 There is a gradual progression of integration from
6 weeks up to 3 years after birth. The TLR is
stimulated by the vestibular system.
 Retained Tonic Labyrinthine Reflex Symptoms:
Poor balance and spatial awareness
Difficulty in judging space , distance and velocity
Tense muscles and toe walking
Difficulty holding still and concentrating
Muscle tone issues
Poor posture
Difficulty paying attention when head is down (at a
desk or reading)
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48. Lacking secure refrence point in space-sense of
direction is lost.
Dyslexia-reverse numbers letters, right to left
righting
Dyspraxia
Poor sense of rhythm and timing
Gets motion sickness easily
Speech and Auditory difficulty
Bumps into things and people more than normal.
It will prevent development of oculo and
labrynthine righting reflex-> disturbing the brain-
oculo-vestibular reflex arc.
Binocular vision is impared
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49.  3. Asymmetrical Tonic Neck Reflex (ATNR)
 The reflex develops at 18 weeks in utero and is postnatally
integrated by 6 months of life.
 If weak in utero, it may lead to the baby becoming stuck in the
birth canal.
 It will act as an invisible barrier to crossing midline, body will
execute the tasks using one side at a time.
 If the ATNR is retained the child will have difficulty walking
normally when turning his head or problems writing and reading
when head movement is needed, which is always.
 Every time the head turns, the arm may follow it and the
fingers open. Therefore, it takes a lot of effort and
concentration to try and hold the hand still while writing
when the head has to move to look at another paper or
the white board.
 The older child or adult may complain of chronic or
recurrent shoulder or neck injury/pain; often times always
on the same side.
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50.  Eye tracking or pursuit movements will be impared as eyes
cannot move independent of the head.
 Head rotation could lead in object being followed momentarily
disappearing causing missing objects or fragments of words.
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WRITING
=
HEAD
EYE
HAND
• Looks different
from 1st to 2nd
glance.
• Slope of
handwriting
changes

51.  Asymmetrical Tonic Neck Reflex Symptoms:
Reading Difficulties
Hand eye coordination problems
Awkward walk or gait
Difficulty in school
Immature handwriting
Poor balance
Eye, ear, foot, and hand dominance will not be on the same side
Difficulty in things that require crossing over the midline of the
body
Poor depth perception
Shoulder, neck and hip problems
Difficulty in sports
Math and reading issues
Possible scoliosis
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52.  4. Symmetrical Tonic Neck Reflex (STNR)
 The STNR reflex presents at 6-9 months of life.
 It should be integrated at 9-11 months postnatally.
 If present then the child is unable to crawl as every time
he will put head up hip will flex onto ankle.
 There is a strong co relation between creeping and
ability to use written language.
 Creeping helps in developing near point vision.
 Creeping is an essential aspect of visual
development as it helps the eyes to cross midline
on the body
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53. • Poor posture standing ,Sits with slumpy posture
• Low muscle tone
• Ape-like walk
• Problems with attention especially in stressful situations
• Vision accommodation and tracking problems
• Difficulty learning to swim
• Difficulty reading
• Usually skips crawling
• Sits with legs in a W position
• Hyper activity or fidgety
• Poor hand eye coordination
• Problems looking between near and far sighted objects, like copying
from a chalkboard
• Sloppy eater
• Rotated Pelvis
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54.  5. Spinal Galant Reflex
 This reflex is first seen at 20 weeks in utero. It should be
integrated postnatally by nine months
 A persistent Spinal Galant Reflex competes for the child’s
attention and short-term memory because the child is
distracted by movement initiated by the reflex.
 This reflex can also interfere with the development of one’s
orientation.
 Retained Spinal Galant Reflex Symptoms:
• Fidgety, Hyper Activity, especially if clothes or chair brush their
back.
• If active down only one side, can cause scoliosis, rotated pelvis and
lower back pain.
• Poor concentration
• Attention problems
• Bedwetting long after potty training
• Short term memory issues
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55. • Fidgeting and wiggly “ants in the pants”
• Posture problems
• Hip rotation on one side/possibly scoliosis
• Low endurance
• Chronic digestion problems like IBS is common.
• Children with a persistent spinal gallant reflexl don’t like
clothing to fit tightly around the waist
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56.  6. Landau Reflex
 The Landau Reflex is one that develops a few months
after birth and remains until about 12 months old.
 Symptoms of Retained Landau Reflex
• Low Muscle Tone
• Poor Posture
• Poor Motor Development
• Short Term Memory Difficulty.
• Tension in the back of legs, toe walker.
• Lack of Stimulation in the pre frontal cortex causing
attention, organization and concentration problems.
• Weak upper body
• Difficulty swimming the breast stroke.
• Struggles to do a summersault. Knees buckle when
head tucks under.
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57.  7. Palmar Reflex or Grasp Reflex
 The Palmar Reflex develops in the third month of gestation and
should disappear at around 3-6 months of age as they gain hand
control.
 Retained Palmar Reflex Symptoms
• Poor handwriting
• Poor pencil grip
• Poor fine muscle control
• Poor dexterity
• Poor fine motor skills
• Poor vision coordination
• Slump posture when using hands
• Back aches when sitting
• Sticks tongue out when using hands
• Poor pencil grip
• Poor ability to put thoughts to paper
• Dysgraphia
• Speech and language problems
• Anger control issues
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58.  8. The Rooting Reflex
 It develops during pregnancy and continues until the
baby is about 4 months old.
 Retained Rooting Reflex Symptoms
• Tongue lies too far forward
• Hyper sensitive around mouth
• Difficulty with textures and solid foods
• Thumb sucking
• Speech and articulation problems
• Difficulty swallowing and chewing
• Dribbling
• Hormone imbalance
• Thyroid problems and autoimmune tendency
• Dexterity problems when talking
• Messy eaters
• Constant urge to have something in their mouth
PRIMITIVE REFLEXES
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59. REFRENCES
 Schott, JM; Rossor, MN (2003). "The grasp and other primitive
reflexes". J. Neurol. Neurosurg. Psychiatry. 74 (5): 558-
60. doi:10.1136/jnnp.74.5.558. PMC 1738455. PMID 12700289.
 Physiotherapy in Neuro-conditions -Glady Samuel Raj
 The Development of the Infant and Young Child: Normal and
Abnormal-TENTH EDITION Ronald S Illingworth
 Treatment of Cerebral Palsy and Motor Delay-Fourth edition
Sophie Levitt
 The role of primitive survival reflexes in Development of Visual
System- Sally Goldard
 Berne SA. The primitive reflexes: Treatment considerations in the
infant. Optom Vis Dev 2006:37(3):139-145.
PRIMITIVE REFLEXES
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