Pediatric Physical

Diagnosis

Irwina M. Lazo, MD
College of Medicine
University of Northern Philippines
Physical Examination
of the Newborn

Irwina M. Lazo, MD
College of Medicine
University of Northern Philippines
 Physical Examination in the
Pediatric Age Group

❖ Neonatal period to Infancy

❖ Toddlers and Children
❖ Pre-adolescent/ pre-teens
❖ Adolescent
Physical Examination in the
Pediatric Age Group …
❖ Leave the more unpleasant or
uncomfortable parts of the PE last
❖ Techniques to examine the patient
❖ Playful interactions and distractions
❖ Carried by the parents/caregiver
❖ Uncooperative patients - immobilize
Physical Examination in the
Pediatric Age Group …
Parts of the PE :
❖ General survey
❖ Vital signs, anthropometric
measurements
❖ Skin
❖ HEENT
❖ Chest and lungs
Physical Examination in the
Pediatric Age Group …

❖ Heart
❖ Abdomen
❖ Genitourinary system
❖ Extremities
Physical Examination in the
Pediatric Age Group …
Neurologic examination:
❖ Cerebrum
❖ Cranial nerves
❖ Motor
❖ Cerebellar
❖ Sensory
❖ Reflexes
PE - Newborn
❖Deliveryroom/operating room
❖Nursery/rooming-in
❖Upon discharge
PE - Newborn
➢ Transition from fetal life to
extrauterine breathing
➢ Gestation, labor progress, delivery
➢ Anesthetics
➢ Signs of infection
➢ Metabolic diseases
➢ Congenital anomalies
Basics of Newborn Physical Exam
!!! Review the perinatal history for clues to
potential pathology
❖ Begins with conception and includes
events that occurred throughout
gestation
❖ Labor & delivery history
❖ Genetic history
Basics of Newborn Physical Exam
❖ Assess
the infant’s color for clues for
potential pathology
❖ Auscultate in a quiet environment
❖ Keep infant warm during exam
❖ Calm the infant before exam
❖ Handle gently
PE - Newborn
❖ Inspection, palpation, percussion,
auscultation (IPPA)
❖ Patience, gentleness, procedural
flexibility
❖ Disturbing manipulations done last
❖ Premies, sick, congenitally
defective neonates: changes in
approach
Neonatal Gestational Age
Assessment
Prenatal Gestational Age
Assessment
Calculation by the mother estimated date
of confinement (EDC)
Collection of prenatal data:
❖ First fetal movement (16-20 weeks)
❖ Fetal heart tones (20 weeks) (with
doppler 9-12 weeks)
❖ Fundal height (1 cm = 1 week after
18-20 weeks)
Prenatal Gestational Age
Assessment
Collection of prenatal data:

❖20 weeks (fundus normally at

umbilicus)
❖Term (fundus at xyphoid)
❖Amniotic fluid creatinine levels
❖Maternal serum and urine estriols
❖Fetal ultrasonography
Prenatal Gestational Age
Assessment
Fetal Ultrasonogram
Measurements
❖ Crown to rump length
❖ Biparietal diameter
❖ Femur length
❖ Abdominal
Circumference
❖ Head Circumference
❖ Placental grade
Classification of size for
gestational age
❖ Growth for dates can be determined by
weight, length, and head circumference
❖ Plotted on a graph appropriate for
gestation
❖ Preterm before 36 6/7 weeks
❖ Term 37 - 41 6/7 weeks
❖ Post term after 42 weeks
Classification of size for
gestational age (GA)
❖ Using the gestational age
score the weight, height
and head circumference
are plotted on the
infants growth chart
❖ This information gives
information: SGA, LGA,
or AGA
Classification of size for
gestational age (GA)
❖ SGA: small for
gestational age-weight
below 10th percentile
❖ AGA: weight between
10 and 90th percentiles
(2,500 – 3,500 grams)
❖ LGA: weight above 90th
percentile
Classification of size for
gestational age (GA)
❖ IUGR: deviation in expected fetal growth
pattern, caused by multiple adverse
conditions; not all IUGR infants are SGA,
may or may not be “head sparing”
PE - Newborn
PE - Newborn
APGAR score
❖ Immediate intervention and resuscitation
❖ Time-bound examination of the newborn
❖ 1 and 5 mins of life
❖ 0 – 10
❖ A – appearance/color
❖ P – pulse rate/cardiac rate
❖ G – grimace
❖ A – activity/movements
❖ R - respiration
Apgar Score ...
❖ 1 min score : index of necessity of
resuscitation
❖7 – 10 : at 1min vigorous
❖4 – 6 : moderately depressed
❖0 – 3 : severely depressed

❖ 5 min score : predicting mortality and

neurologic deficits of the surviving
infant at 1 year of age
Apgar Score
Parameter 0 1 2

Appearance Blue, pale Body pink, Completely pink

extremities blue

Pulse Absent < 100 >100

Grimace No response Grimace Cry, sneeze,

cough

Activity Limp Some flexion of Active motion

extremities

Respiration Absent Slow, irregular Good strong cry

PE – Newborn…
Patterns of Activity – birth to stability
First 15 – 30 mins :
1. immediate tachycardia 160-180/min then
gradual drop to 100-120/min
2. irregular respirations, tachypnea 60-80/min,
brief moments of apnea
3. moist-sounding lung fields, transient
grunting and retractions
4. awake, moving, alert, easily startled, crying,
transient tremors /jitteriness
PE - Newborn …
Patterns of Activity – birth to stability
60 – 90 minutes :
1. sleepy or sleeping, somewhat
responsive
2. HR: 120-160/min
3. RR: 50-60/min, transient tachypnea
4. passage of meconium
PE - Newborn
Patterns of Activity – birth to stability
Next several hours:
Awake, alert, easily startled, crying,
easily stimulated and reactive
Ballard’s scoring - PA
Neonatal Gestational Age -
Ballard Exam
❖ The physical maturity part of the examination
should be done in the first two hours of birth
❖ The neuromuscular maturity examination
should be completed with 24 hours after
delivery
❖ Derived to look at various stages in an infants
gestational maturity and observe how
physical characteristics change with
gestational age
Neonatal Gestational Age -
Ballard Exam

❖ Neonates who are more physically mature

normally have higher scores than
premature infants
❖ Points are awarded in each area -2 for
extreme prematurity to 5 for post-mature
infants
Ballard’s scoring - PA
As soon as possible after initial
stabilization or by 12 hours after birth
2 parts : neuromuscular and physical
12 scores : weeks of gestation

Avoid eliciting the primitive reflexes

Done with head midline, without
grasping the palms and soles
Neonatal Gestational Age
Assessment
Neuromuscular Maturity
❖ Posture & Tone
❖ Square Window
❖ Arm Recoil
❖ Popliteal Angle
❖ Scarf Sign
❖ Heel to Ear
Ballard’s scoring - PA
Neonatal Gestational Age
Assessment
• Neuromuscular Maturity
• Posture/Tone-Total body muscle tone is
reflected in the infants preferred
posture at rest and resistance to
stretch of individual muscle groups
• Make sure infant is quiet
• The more mature an infant is the
greater their tone will be
•A more flexed position indicated
greater tone
Neonatal Gestational Age Assessment

Posture & Tone

❖ Before 30 weeks-
hypotonic, little or no
flexion seen
❖ 30-38 weeks-varying
degrees of flexed
extremities
❖ 38-42weeks-may
appear hypertonic
Posture
Ballard’s scoring - PA
Neuromuscular maturity
b. Square window
→ exert gentle pressure on the head of the
3rd metacarpal; the angle between the
hypothenar eminence and anterior aspect of
the forearm is measured
Neonatal Gestational Age
Assessment
Neuromuscular Maturity
Square Window-
wrist flexibility and/or
resistance to extensor
stretching resulting in angle
or flexion at wrist
Flex hand down to wrist-
measure the angle
between the forearm &
palm
Before 26 weeks-wrist
can’t be flexed more
than 90 degrees
Before 30 weeks-wrist
can be flexed no more
than 90 degrees
Square window
Ballard’s scoring - PA
c. Arm recoil
→ with infant supine, head in midline,
grasp the sides of the wrist, flex the
forearm for 3-5 seconds, extend the elbow
fully but momentarily, and release
Neonatal Gestational Age
Assessment
Neuromuscular Maturity
 Arm Recoil-measures the angle of recoil following
a brief extension of the upper extremity
 For 5 seconds flex the arms while infant is in the
supine position, pulling the hands fully extend the
arms to the side, then release-measure the
degree of arm flexion & strength (recoil)
 Before 28 weeks-no recoil
 28-32 weeks-slight recoil
 32-36 weeks-recoil does not pass 90 degrees
 36-40 weeks-recoils to 90 degrees
 After 40 weeks-rapid full recoil
Arm recoil
Ballard’s scoring - PA
 Neuromuscular maturity
d. Popliteal angle
→ with infant supine and pelvis flat on the
examining surface, grasp the sides of the ankle, flex
the hip to appose the anterior surface of the thigh
 Neonatal Gestational Age
Assessment
 Neuromuscular Maturity
 Popliteal Angle-assesses
maturation of passive flexor tone
about the knee joint by testing
resistance to extension of the leg
 The angle decreases with
advancing gestational age
 Before 26 weeks-angle 180
degrees
 26-28 weeks-angle 160 degrees
 28-32 weeks-angle 140 degrees
 32-36 weeks angle 120 degrees
Popliteal angle
Ballard’s scoring - PA
 Neuromuscular maturity
e. scarf sign
→ assesses by pulling the arm towards the
opposite shoulder to encircle the neck as scarf
 Neonatal Gestational Age
Assessment
 Neuromuscular Maturity
 Scarf Sign-tests the passive tone of
the flexors about the shoulder girdle
 Increased resistance to this
maneuver with advancing gestational
age
 Before 28 weeks-elbow passes torso
 28-34 weeks-elbow passes opposite
nipple line
 34-36 weeks-elbow can be pulled
past midline, no resistance
 36-40 weeks-elbow to midline with
some resistance
 After 40 weeks-doesn’t reach
midline
Scarf sign
Ballard’s scoring - PA
 Neuromuscular maturity
f. Heel to ear
→ with hip flexed and knee extended
with the leg beside the thorax, grasp the
sides of the ankle and draw the heel to
the infant’s face
 Neonatal Gestational Age
Assessment
 Neuromuscular Maturity
 Heel to Ear-measures
passive flexor tone about
the pelvic girdle by
testing passive flexion or
resistance to extension
of the posterior hip
flexor muscles
 Breech infants will score
lower than normal
 Before 34 weeks-no
resistance
 40 weeks-great
resistance may be
difficult to perform
Heel to ear
Ballard’s Physical Maturity Scoring
Physical Maturity
❖ Skin
❖ Lanugo
❖ Plantar surface
❖ Breast
❖ Eyes & Ears
❖ Genitalia: male & female
Physical Maturity-Skin

 Examine the texture, color and

opacity
 As the infant matures:
▪ More subcutaneous tissue develops
▪ Veins become less visible and the skin
becomes more opaque
 Neonatal Gestational Age
Assessment
 Physical Maturity
 Skin
 Before 28 weeks-
gelatinous red, friable
 28-37 weeks-skin over
abdomen thin,
translucent, pink with
visible veins
 37-39 weeks smooth,
pink, increased
thickness, rare veins
over abdominal wall
 Neonatal Gestational Age
Assessment
 Physical Maturity
 Skin
40 Weeks-
vessels have
now
appeared,
skin may be
leathery with
deep cracking
Ballard’s scoring - PA

 Physical maturity
2. lanugo – lumbosacral area to
the scapular area
-- “sparse” : lanugo over the
lumbosacral area, but none over
the scapular
-- “thinning” : lanugo over the
scapular area but none over the
lumbosacral area
 Neonatal Gestational Age
Assessment
• Physical Maturity
• Lanugo
• After 20 weeks - begins to
appear
• 28 weeks-abundant
• After 28 weeks - thinning,
starts to disappear from the
face first
• 38 weeks - bald areas slight
amount may be present on
shoulders
Lanugo
 Neonatal Gestational Age
Assessment
 Vernix caseosa
 Before 34 weeks: vernix thick
and covers entire body
 34-38 weeks: vernix is
absorbed gradually, portions
over shoulder and neck is the
last to be absorbed
 38-40 weeks: vernix only
present in folds of skin
 After 40 weeks: no vernix
present
Ballard’s scoring - PA

Physical maturity
3. plantar surface
→ deep transverse creases
4. breast
→ breast tissue
5. eye/ear
→ eyelid fusion
 Neonatal Gestational Age
Assessment
 Plantar Surface
 Before 28 weeks-no creases
 28-32 weeks-virtually no
sole creases, faint thin red
lines over anterior aspect
of foot
 34-37 weeks-1/2 anterior
creases
 37-39 weeks-creases now
over the anterior 2/3 of the
sole
Plantar creases
Neonatal Gestational Age
Assessment

 Physical Maturity
 Breast
 Before 28 weeks-nipples imperceptible
 28-32 weeks-nipple barely visible, no areola
 32-37 weeks-well defined nipple areola
 38-40 weeks-well defined nipple raised
areola
Neonatal Gestational Age
Assessment
 Physical Maturity
 Eyes
 Eyes are evaluated as either fused as seen in
extremely premature infants or open
 Before 26 weeks eyes are fused
 Neonatal Gestational Age
Assessment
 Physical Maturity
 Ears
 Before 34 weeks: pinna
is very immature,
cartilage not present,
lies flat, remains folded
 34-37 weeks: pinna
curved with soft recoil
 37-40 weeks: formed,
firm instant recoil
 After 40 weeks: thick
cartilage ear stiff
Ear recoil
Ballard’s scoring - PA

 Physicalmaturity
f. genitalia
male: scrotum touches the
examining surface (4)
 Neonatal Gestational Age
Assessment
 Physical Maturity  Genitalia-Female
 Genitalia-Male • Before 28 weeks-clitoris
 Before 28 weeks-scrotum prominent labia flat
empty and flat • 28-32 weeks-prominent
 28-30 weeks-testes clitoris, enlarging labia
undescended into scrotal minora
sac • 33-36 weeks-labia majora
widely spaced with equally
 30-36 weeks testes
prominent labia minora
descending with a few
rugae over the scrotum • 33-39 weeks-labia extends
over the labia minora but
 36-39 weeks-testes have not over the clitoris
descended into scrotum
which is now pendulous • 39 weeks-labia majora
and complete with rugae completely covers the
labia minora and clitoris
Genitalia
Pediatric aging
Muito obrigado pela atenção
Physical Examination
of the Newborn

Irwina M. Lazo, MD
College of Medicine
University of Northern Philippines
PE – Newborn…
General survey/appearance
❖ Maturity rating – pediatric
aging
❖ Naked but avoid hypothermia!
❖ Posture, skin color, muscle
tone, gross congenital
anomalies
Vital signs
1. Temperature
-- per rectum
2. Respiratory rate
-- 40-60 breaths/min, full min
3. Cardiac rate
-- 120-160 beats/min
-- varies with activity
Vital signs
4. Anthropometric measurements
a. weight (2,500 – 3,500 grams)
-- SGA, AGA, LGA
b. length (50 cms)
-- recumbent length
c. head circumference
-- occipito-frontal circumference
-- 35 cms at birth
d. chest and abdominal circumferences
Skin
-- general color : pinkish
a. vernix caseosa – greasy white
substance until term; moisture barrier
b. mongolian spots – dark-blue, or
purpluish macular spots located in the
sacrum; birthmark
c. plethora - deep, rosy red color;
overoxygenated infant
Skin
d. jaundice
e. pallor – anemia, birth asphyxia,
shock or PDA
f. cyanosis
--central cyanosis: bluish skin
including tongue and lips; low oxygen
saturation in the blood
Skin
--acrocyanosis: bluish feet and
hands only; maybe normal in
infants due to vasomotor
instability and peripheral
circulatory sluggishness
g. mottling – lacy red pattern;
maybe normal
-- cutis marmorata: persistent
mottling in trisomy 13, 18, 21
Skin
h. milia – tiny, sebaceous retention
cyst with pin-sized concretions, on
the chin, nose, forehead and cheeks

i. erythema toxicum – numerous,

small areas of red skin with a
yellow-white papule in the center;
2-10 days of life
Skin
j. macular hemangioma – vascular nevus
seen on the occipital area, eyelids, and
glabella; disappears spontaneously
within the 1st – 2nd yr of life
Head
-- general shape
-- varies with age, sex, and ethnicity
-- macrocephaly, microcephaly
-- fontanel
a. anterior : diamond-shaped fontanel
located in the midline at the junction of
the coronal and sagittal sutures; closes
at around 18-20 months
 Head

b. posterior fontanel :
triangular-shape
located between
intersection of the
occipital and parietal
bone; closes bet 3-4
months
Mass on the head
Head
-- caput succedaneum – soft tissue
swelling that crosses suture lines
-- cephalhematoma – due to
rupture of blood vessels that
traverse skull to periosteum;
fluctuant swelling that does not
cross suture lines; 2 wks – 3 mos
Caput succedaneum vs.
Cephalhematoma
Face
-- general shape of the nose,
mouth and chin
-- palsy
-- Mobius syndrome : symmetric
palsy caused by absence or
hypoplasia of the 7th nerve
nucleus
Eyes
--Red orange reflex (ROR)
--leukocoria: white pupillary reflex
--subconjunctival hemorrhages
Eyes
--Red orange reflex (ROR)
--leukocoria: white pupillary reflex
--subconjunctival hemorrhages
Ears
--shape, size, position,
presence of canal, tags or
pits
Nose
-- shape, size, and patency
--choanal atresia: non-passage of
NGT
Mouth
--palatal clefts, deciduous teeth
--tongue, buccal surface, back of the mouth and
palate
a. Epstein pearls – keratin containing cysts
which are normal, located on the hard and
soft palate
b. natal teeth – usually lower central incisors
Cleft palate & Cleft lip
Neck
-- thyroid enlargement
-- vascular malformations, cystic
hygromas, dermoid cysts, taratomas
Chest
-- symmetry of the chest
-- tachypnea, retractions
-- breast – 1 cm diameter
-- “witch milk” : white milky discharge,
secondary to the effects of maternal estrogens
Chest
-- newborn’s lung sounds are more
bronchial than vesicular because
of transmission of large airway
sounds across a thin chest
Heart
-- precordial activity, rate, rhythm, quality of
heart sounds, murmur
-- 120-160 beats/min
-- a murmur does not always signify the presence
of heart disease, nor does the absence of a
murmur provide reassurance of normalcy
 Abdomen
-- listen for bowel sounds
-- inactive bowel sounds on the first
days of life
--palpate for distention, tenderness
or masses
Abdomen
--obvious defects; normally the abdomen are
globular
-- omphalocoele: intestines are covered with
peritoneum and umbilicus is centrally located
-- gastroschisis: intestines are not covered with
peritoneum
-- scaphoid abdomen: congenital diaphragmatic
hernia
 Abdomen
--umbilicus: signs of
bleeding, infection,
abnormal communication
with intra-abdominal
organs
--2 arteries and 1 vein
-- cord should be
translucent, greenish-
yellow color suggests
meconium staining, due to
fetal distress
 Genitalia
Male
- abnormal urethral
opening
- bilateral descended testis
- hydrocoeles
Female
- discharges
- pseudomenses : maternal
estrogen
Ambiguous gnitalia
Extremities
-- arms, legs, digits and creases; palpate for pulses
a. syndactyly – fusion of the digits
b. polydactyly – supernumerary digits
c. simian crease – single transverse palmar crease
d. talipes equinovarus (club foot) – foot turned
downward and inward, sole is medially directed
Trunk and Spine
-- gross defects of the
spine
-- spina bifida
Anus and rectum
-- patency of anus
 Basic Neonatal
Neurologic Examination

Irwina M. lazo, MD
College of Medicine
University of Northern Philippines
Basic Neonatal
Neurologic Examination
Necessary in the following scenario :
 low APGAR score
 prematurity
 hypotonia
 diminished alertness
 seizures
 CNS infections
 palsies
 trauma
 evidence of dysmorphism or congenital anomalies
Basic Neonatal
Neurologic Examination

Important data:
1. Gestational age
2. APGAR score
3. Maternal & obstetric history
Basic Neonatal
Neurologic Examination
Data from PE:
Head examination
shape & size, sutures, fontanels
Skin lesions
location, color, hyper/hypo pigmentation
Masses
encephalocoeles, tumors
Dysmorphisms & congenital anomalies
Basic Neonatal
Neurologic Examination

1. Level of alertness
2. Cranial nerve examination
3. Motor examination
a. posture
b. tone
c. motor strength
4. Developmental reflexes
Basic Neonatal
Neurologic Examination
Level of alertness

 2 clinical states: sleep and wakefulness

 term infant is often sleep but can be
easily aroused
 periods of attention to visual, auditory
and tactile stimulation and crying
vigorously
Basic Neonatal
Neurologic Examination
Cranial nerves

1.Olfactory nerve(CN I)
-- can neonates discriminate odors? how?
-- changes in respiratory rates and
movements, but rarely tested
-- functional by 5-7 months of age
 Basic Neonatal
Neurologic Examination
2. Optic nerve (CN II)
-- visual fixation on the human face
-- light perception (glare response) – blinking
with bright light
-- pupillary response
-- visual tracking may be present

 Fundoscopy : optic disc is normally light pink

or pale gray; check for retinal hemorrhages
Basic Neonatal
Neurologic Examination
3. Oculomotor, Abducens, Trochlear nerves
(CN III, IV, VI)
-- eye movements maybe disconjugate at
birth
-- observe for spontaneous eye movements in
all directions
-- check for ptosis (CN III)
-- pupillary size, reactivity and symmetry
(present in neonates > 32 weeks AOG)
-- may do Doll’s eye movement (to check for
conjugate eye movement)
Basic Neonatal
Neurologic Examination
4. Trigeminal nerve (CN V)
-- facial sensation with rooting reflex
-- corneal reflexes (presence and
symmetry)
-- grimace or any movements, change in
respiratory or cardiac rate with tactile
stimulation over the forehead, cheeks
and mandibular area
Basic Neonatal
Neurologic Examination
5. Facial nerve (CN VII)
-- symmetry of the face at rest and
movement (crying)
-- check the size and symmetry of palpebral
fissures, nasolabial folds, position of the
corners of the mouth

6. Vestibulocochlear nerve (CN VIII)

-- hearing is normally present in term babies
-- neonates blink or startle with loud noise
Basic Neonatal
Neurologic Examination
7. Glossopharyngeal, Vagus, Hypoglossal nerves
(CN IX, X, XII)
-- normal and intact in the following:
a. sucking: CN V, VII, XII
b. swallowing: CN IX, X (observe coordination)
c. gag reflex: CN IX, X (use small tongue blade
covered with gauze); normal response is active
contraction of the soft palate with upward
movement of the uvula and of the posterior
pharyngeal muscles
d. tongue movement and loss of bulk: CN XII
Basic Neonatal
Neurologic Examination
8. Spinal accessory nerve (CN XI)
-- term newborns: passive rotation
of the head will show the bulk of
the neck muscles
-- not done on sick neonates
Basic Neonatal
Neurologic Examination
Motor examination
a. Posture
-- normal term newborns have “flexor”
attitude
-- coupled with spontaneous movement
indicates good muscle tone and power
-- preterm newborns lie in extension
position
Basic Neonatal
Neurologic Examination
Motor examination
b. tone
-- passive tone is tested to determine the
degree of resistance to passive movements of
the joint with an awake infant (not crying);
done by gentle flapping of the hands and feet
-- active tone is tested by observing for
response to gentle pulling from supine to prone
position (traction response); hypotonic or floppy
infant will show head lag
Basic Neonatal
Neurologic Examination
Motor examination
3. Motor strength
-- spontaneous movements and
movements against resistance
-- note symmetry of movements;
preferential movements may
suggest hemiparesis
Basic Neonatal
Neurologic Examination
Motor examination
4. Deep tendon reflexes
-- examiner’s index or middle finger may be
used instead of the hammer
-- knee jerks and biceps reflexes are tested
in older infants and children
-- ankle clonus (rapid rhythmic plantar
flexion in response to ankle dorsiflexion) up
to 10 beats is normal
Basic Neonatal
Neurologic Examination
Sensory testing
-- rarely needed in newborn
-- gross resposes to stroking, pin prick,
crying, arousal, facial grimace and
changes in sucking rates maybe used
as behavioral cues
-- in general, tests for pain and sensation
are imprecise
Basic Neonatal
Neurologic Examination
Developmental reflexes
-- primitive reflexes that reflect the
integrity of the brainstem and spinal
cord
-- disappearance indicates maturation of
the cerebral hemispheres
-- persistence beyond the expected date
suggests a maturational lag or impaired
CNS function
 Developmental Reflexes
Moro reflex
-- carry baby by his back and “drop” the baby
onto your hands
-- extension followed by flexion of upper limbs
-- birth, disappears at 5 months old
-- absence: young preterm, severe systemic disease,
kernicterus
-- asymmetric: brachial plexus palsy, clavicular fracture
and/or humeral fracture; congenital hemiplegia
-- persistence: CP, neurodegenerative disease
Moro reflex
Developmental reflexes
Grasping reflexes (palmar, plantar grasp)
-- stroke the ulnar side of the palm; apply
pressure on the ball of the foot
-- hand grasps stimulus; toe “grasps” stimulus
-- birth; palmar – 6 months;
plantar – 9 to 10 months
-- absence: young preterms, severe systemic
disease, general CNS depression
-- asymmetry: brachial plexus injury,
congenital hemiplegia
-- persistence: spastic CP, neurodegenerative
disease
Grasping reflex – palmar grasp
Grasping reflex – plantar grasp
Developmental reflexes
Rooting and sucking reflex
-- stroke angle of the mouth; insert clean
fingers
-- “search to suck” stimulus
-- birth – 3 months
-- absence: young preterm, depressed babies,
recent feeding
-- persistence: CP, neurodegenerative diseases
Rooting & sucking reflexes
Developmental reflexes
Tonic neck reflex
-- obligatory; always abnormal
-- turn head sidewise
-- “fencing posture”
-- present at birth, fully developed at 1
month of life; disappears bet 5 – 6 months
-- absence: young preterm, first few days
of life
-- persistence: CP
Tonic neck reflex
Parachute reflex
-- carry the baby by the abdomen,
pretend to drop against a flat surface
-- arms extend, palms open as if to
“break the fall”
-- onset: 8 – 9 months, persists
-- absence: CP
-- asymmetric: Brachial plexus injury,
congenital or acquired hemiplegia
Parachute reflex
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