What Are Examples of Infantile Primitive Reflexes?

Patient Presentation
A 2-month-old female came to clinic for her health supervision visit. The parents were pleased with how well she was growing. “She’s amazing,” said her dad, “She can even walk,” and he proceeded to show the pediatrician how she would lift her feet and place them slightly forward when she was held upright. The past medical history showed a full term infant without prenatal or natal problems.

The pertinent physical exam revealed normal growth parameters in the 75-90%. She had a social smile. She had good tone and strength. Cranial nerves were intact and deep tendon reflexes were normal for age. She had a positive Babinski reflex. The pediatrician also pointed out other normal primitive reflexes including the Moro reflex, Asymmetric Tonic Neck reflex, Stepping and Placing reflexes as well as Galant and Perez. The diagnosis of of a healthy infant was made. “You’ll notice some of these reflexes for a while and then they will go away as her brain matures. Right now they show that she is doing well,” the pediatrician remarked. The parents smiled approvingly.

Discussion
As part of the normal developmental process of central nervous system maturation, primitive reflexes (i.e. infantile automatisms) occur which are automatic movement patterns which can begin during fetal development and continue after birth. Some appear important for human survival such as rooting and sucking to obtain nutrition. Others may be phylogenetic remnants. Primitive reflexes are present and disappear at predictable times and therefore can assist in evaluation of infant development. There is a range of normal and some can persist to older ages in some individuals. Primitive reflexes that occur before or after predicted times or that present asymmetrically on the body can potentially show abnormalities and therefore are important to note. Children and adults with various brain injuries or diseases also may show some of these primitive reflexes.

Learning Point
Examples of primitive reflexes include:

  • Rooting reflex
    • Mouth or cheek touched and infant turns head to that side
    • Present at birth
    • Disappears around 3-4 months, but can be seen in sleeping infants until 7-8 months
  • Sucking reflex
    • Sucking begins when nipple placed in infant’s mouth, or examiner’s finger is placed at the commissure of infant’s mouth
    • Present at birth
    • Disappears around 3-4 months, but can seen in sleeping infants until 7-8 months
  • Moro or Startle reflex
    • Infant is surprised/startled and the four limbs abduct and extend then abduct and flex. Infants will also extend the spine initially and then close the fingers. Startle is elicited by striking surface on either side of infant (original method by Moro), loud noise, or lifting the infant head and shoulders above body and allowing the head to drop (of course with support).
    • Present at birth, can be seen as early as 25 weeks gestation and is elicited by 30 weeks
    • Disappears around 3-4 months but normal up until 6 months
  • Stepping reflex
    • Infant held upright and slightly forward with feet on surface will raise legs and look like stepping or walking
    • Present at birth
    • Disappears around 2-3 months
  • Placing reflex
    • Infant held upright and dorsum of foot is touched by the edge of table. Infant lifts foot and places it on the table
    • Present at birth
    • Disappears by first year
  • Palmar grasp reflex
    • Examiner’s finger placed in infant palm at base of fingers and press applied. Infants finger’s flex to grasp the examiner’s finger. There are 2 phases – the catching of the examiner’s finger and the holding of the examiner’s finger
    • Present at birth, can be seen as early as 28 weeks gestation
    • Disappears by 6 months
  • Plantar grasp reflex
    • Examiner’s finger placed in infant sole at base of toes and press applied. Infants toes flex to curl around the examiner’s finger. There are 2 phases – the catching of the examiner’s finger and the holding of the examiner’s finger.
    • Present at birth
    • Disappears by 15 months
  • Babinski reflex
    • Pressure applied to sole of foot along the lateral edge starting with the heel and curving around to the base of big toe. Normal or negative is to have downward curving of the toes or no movement. A positive Babinski reflex, that of the toes curving upward, is normal in infants because of their immature neurological status.
    • Present at birth
    • Disappears by 1-2 years
  • Landau reflex
    • Infant is placed face down on a surface or in lateral suspension and the infant lifts its head and extends its legs
    • Present starting at 3 months
    • Disappears by 2 years
  • Blinking or Glabella reflex
    • Glabella is lightly tapped and both eyes blink. Habituation occurs with multiple attempts of the tapping
    • Present at birth
    • Disappears by 1 year
  • Asymmetric tonic neck reflex
    • With infant in supine position, head is gently rotated to one side. Extension of the lateral arm and flexion of the contralateral arm occur. This position is sometimes called the Fencer’s position.
    • Present around birth
    • Disappears by about 6 months
  • Symmetric tonic neck reflex
    • With infant in supine position, head is gently flexed. Extension of the head, arms and legs occurs
    • Present around 2 months
    • Disappears about 6-9 months
  • Parachute reflex
    • Infant prone in air and brought to the surface with the head down. Infant reacts as if trying to cushion a fall with their arms abducted and extended and fingers spread.
    • Present around 8-9 months
    • Present throughout life
  • Gallant reflex
    • Infant head prone in air and one side of lower spine lightly stroked. Infant’s spine contracts on that side causing the hips to move laterally on the side stroked (e.g. spine incurves).
    • Present at birth
    • Disappears around 2-4 months, up to 6 months
  • Perez reflex
    • Infant head prone in air and both sides of lower spine lightly stroked. Infant extends hips and legs.
    • Present at birth
    • Disappears around 2-4 months

Questions for Further Discussion
1. What do decerebrate and decorticate postures look like? What do they mean?
2. What informal or formal developmental evaluations do you carry out in the office?
3. What are indications for referral to a neurologist or developmental pediatrician?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Infant and Newborn Care and Infant and Newborn Development.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Futagi Y, Toribe Y, Suzuki Y. The grasp reflex and moro reflex in infants: hierarchy of primitive reflex responses. Int J Pediatr. 2012:191562. doi:10.1155/2012/191562

Gieysztor EZ, Choinska AM, Paprocka-Borowicz M. Persistence of primitive reflexes and associated motor problems in healthy preschool children. Arch Med Sci AMS. 2018;14(1):167-173. doi:10.5114/aoms.2016.60503

Salandy S, Rai R, Gutierrez S, Ishak B, Tubbs RS. Neurological examination of the infant: A Comprehensive Review. Clin Anat N Y N. 2019;32(6):770-777. doi:10.1002/ca.23352

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Causes Bradycardia?

Patient Presentation
A 17-year-old male long-distance runner came to clinic for his health supervision visit. He had no concerns and had recently run a marathon. He had no recent athletic injuries and was doing well in school. He was looking forward final year of cross-country in high school.

The pertinent physical exam revealed a heart rate of 56 beats/minute, blood pressure of 96/60, respirations were 12/minute. Weight was 25% and height was 75%. He looked healthy and thin. Heart showed normal rhythm with no murmur. He had no bruits. His heart rate was responsive to respiration and movement. The remainder of his examination was normal.

The diagnosis of a healthy male runner with bradycardia was made. The pediatrician noted that he had a lower heart rate. Previous heart rates had been in the 60-70s in the past few visits. He had no personal or family history of chest pain, dizziness, syncope, early cardiac death or cardiac issues. He denied taking any medications other than some antihistamines for some mild seasonal allergic rhinitis. The pediatrician discussed that this most likely was because he was highly trained. He cautioned the patient to be aware and to call if he developed any problems such as dizziness, syncope or chest pain.

Discussion
Bradycardia is a heart rate below what the lowest value that is normal for age. Infants and children have higher heart rates that slowly decrease with age to adult levels. It is usually noted as an incidental finding because of increased vagal tone. Reasons for cardiology referral include associated heart murmur, syncope especially if associated with exercise or unusual triggers, other signs such as chest pain or palpitations, family history of sudden cardiac death, congenital heart disease or familial heart disease, bradycardic medication use, or unusual symptoms associated with the concern. Severe bradycardia that causes poor cardiac output is a medical emergency. Fortunately most children have mild bradycardia which may have no symptoms or can manifest as dizziness, syncope, exercise intolerance or fatigue. Evaluation includes a good history and physical examination. Electrocardiogram may determine a rhythm abnormality but often an ambulatory Holter monitoring will be needed as the bradycardia and/or rhythm may be intermittent. Echocardiogram may be appropriate if congenital heart disease is suspected. Exercise stress testing is usually not need but can determine if the heart is appropriately responsive during exercise.

Learning Point
The differential diagnosis of bradycardia includes:

  • Athletes, well trained
  • Hypervagotonia this is a sinus bradycardia
    • Apnea and bradycardia in infants
    • Breathholding spells
    • Coughing
    • Emesis
    • Gastroesophageal reflux
    • Increased intracranial pressure
    • Obstructive sleep apnea
    • Stimulation of the nasopharynx or esophagus, or the rectum or perineum
  • Cardiac
    • Congenital heart disease
      • Atrial septal defect
      • Atrioventricular canal
    • Ischemic heart disease
    • Myocarditis/pericarditis
    • Sinus node dysfunction
    • Arrhythmias
      • Atrioventricular block
      • Long QT syndrome
    • Heart surgery
  • Electrolyte abnormalities
    • Hypo or hypercalcemia
    • Hypo or hyperkalemia
    • Hypoglycemia
    • Hypomagnesemia
  • Genetic
    • Carnitine deficiency
    • Glycogen storage disease
  • Hypoxia
  • Hypothermia
  • Immunologic
    • Systemic lupus erythematosus
    • Sjorgrens syndrome
  • Infectious
    • Chagas disease
    • Diphtheria
    • HIV
    • Lyme disease
    • Mumps
    • Rocky Mountain Spotted Fever
    • Rubella
  • Malnourishment
    • Anorexia nervosa
  • Medication
    • Acetylcholinesterase inhibitors
    • Alpha-adenergic agonists
    • Beta-adrenergic blockers
    • Calcium channel blockers
    • Clonidine
    • Lithium
    • Opioids
    • Parasympatheticomimetic drugs
  • Sleep
  • Relative bradycardia – pulse lower than expected for body temperature

Questions for Further Discussion
1. What Causes Tachycardia? A review can be found here
2. What medications should be avoided in long QT syndrome? A review can be found here
3. What are causes of sudden cardiac death? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Arrhythmia

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Baruteau A-E, Perry JC, Sanatani S, Horie M, Dubin AM. Evaluation and management of bradycardia in neonates and children. Eur J Pediatr. 2016;175(2):151-161. doi:10.1007/s00431-015-2689-z

Ye F, Hatahet M, Youniss MA, Toklu HZ, Mazza JJ, Yale S. The Clinical Significance of Relative Bradycardia. WMJ Off Publ State Med Soc Wis. 2018;117(2):73-78.

Doyen B, Matelot D, Carre F. Asymptomatic bradycardia amongst endurance athletes. Phys Sportsmed. 2019;47(3):249-252. doi:10.1080/00913847.2019.1568769

Silva JN, Bradycardia in Children. UpToDate. Rev 9/3/19, accessed 4/1/20.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Causes Pyogenic Granulomas?

Patient Presentation
A 3-year-old female came to clinic with a draining lesion on her upper chest. The lesion had been noted about 4 weeks previously, was red and had grown in size until it was “about half a pea” and looked like a blister per her mother. It then “popped” and had draining fluid that was described as bloody but with also other “stuff” in it. It drained for a couple of days and then left a reddened area that was similar to a crater. There was no pain, redness around the area or fever. She denied any trauma. She lived on a farm with potential animal exposures. They had put a gauze bandage on it because of the non-fouling smelling discharge. The child picked at the bandage but did not seem to have pain, itching or burning of the lesion. No home photographs were available.

The past medical history was non-contributory. The family history was negative for dermatological problems or cancer. The review of systems was negative.

The pertinent physical exam showed a healthy female with normal vital signs. Her growth parameters were 10-50% and appropriate. Her examination was normal. On skin examination she had several bruises on her shins. She had a ~5 mm cafe-au-lait spot on her right lower back. On her right upper chest just below the clavicle she had a 5-6 mm, punched-out, crater-like lesion that was 2-3 mm in depth. The base had normal appearing pink granulation tissue with an area that was still ulcerated and wet. No vascular components were identified. The skin around it was slightly reddened.

The diagnosis of an unknown lesion but possible small skin abscess was made. The patient was treated with oral antibiotics because of age, her irritating the bandage/lesion and the non-specific diagnosis. She was treated for potential methicillin-resistant Staphylococcus as her father was a health care provider.

The patient’s clinical course revealed she returned to clinic 4 weeks later when the lesion reappeared. The patient had taken the entire antibiotic and the lesion healed according to the mother but then started to regrow and was very red. It had bled a small amount once when the child irritated it. The lesion was 4-5 mm, spherical and sitting on top of the surrounding skin but without a specific pedicle. It was non-tender and without erythema. The diagnosis of a pyogenic granuloma was made and the patient was referred to dermatology for confirmation and removal.

Images of similar lesions can be found here or here.

Discussion
Pyogenic granuloma (PG) is a benign, vascular lesion of the skin. PGs are red, small, often pedunculated nodules that can rapidly increase in size (up to 1-2 cm). They also can often ulcerate and bleed. They frequently occur on the head and neck, with back and chest being the next most common locations but can occur in other locations. They usually are solitary and do not regress. They are seen in children (mean age 6.7 years), young adults and pregnant women (5%). Treatment is electrocautery or excision.

Learning Point
PG’s cause is not fully understood. A gene has recently been identified with PG suggesting it is a benign neoplasm and simply caused by a reactive etiology.

PG is usually an acquired lesion that occurs after skin trauma, insect bites, infection, eczema, burns, oral retinoid therapy, and underlying vascular lesions. Acquired PG can be simple to diagnose if the history and physical examination are more classic or with monitoring over time to evaluate the lesion.

Deep-seated or subcutaneous PG is not common but does occur. Congenital PG is rare and often affects the mucosa. Multiple congenital PG is even less common. It may look like infantile hemangiomas or other vascular tumors. Even on biopsy, congenital or deep-seated PG can be difficult to diagnose.

Questions for Further Discussion
1. What are common congenital vascular cutaneous lesions?
2. What are common acquired vascular lesions?
3. What cutaneous zoonoses might be considered for children exposed to domestic or non-domestic animals?
4. What are indications for referral to a dermatologist?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Skin Conditions and Benign Tumors.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Johnson EF, Davis DM, Tollefson MM, Fritchie K, Gibson LE. Vascular Tumors in Infants: Case Report and Review of Clinical, Histopathologic, and Immunohistochemical Characteristics of Infantile Hemangioma, Pyogenic Granuloma, Noninvoluting Congenital Hemangioma, Tufted Angioma, and Kaposiform Hemangioendothelioma. Am J Dermatopathol. 2018;40(4):231-239. doi:10.1097/DAD.0000000000000983

Putra J, Rymeski B, Merrow AC, Dasgupta R, Gupta A. Four cases of pediatric deep-seated/subcutaneous pyogenic granuloma: Review of literature and differential diagnosis. J Cutan Pathol. 2017;44(6):516-522. doi:10.1111/cup.12923

Schneider MH, Garcia CFV, Aleixo PB, Kiszewski AE. Congenital cutaneous pyogenic granuloma: Report of two cases and review of the literature. J Cutan Pathol. 2019;46(9):691-697. doi:10.1111/cup.13496

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Causes Free Peritoneal Fluid?

Patient Presentation
A pediatric resident was telling some other residents during their continuity clinic about some of the interesting radiology cases he had seen the previous week.
“Seems like I had a lot of abdominal cases. There was a CT case with blunt abdominal trauma where the spleen was ruptured and they had to take him to the operating room.
We had a teenage girl with pelvic pain who had a ruptured ovarian follicle and free fluid. And then there was the 4-year-old with nephrotic syndrome who had bad ascites.
I have a lot of good images to show in our pediatric case conference so everyone can learn.”

Discussion
Peritoneal fluid is normal. It decreases the friction of the peritoneum covering abdominal and pelvic organs and helps to protect them and allow their movement. A normal amount of peritoneal fluid is expected on radiological evaluation. Increased peritoneal fluid is a continuum and is concerning as a wide variety of pathological causes are associated with it such as abdominal trauma and appendicitis. At the far end of the scale is ascites that is the accumulation of free fluid more than 25 ml. It is usually associated with abdominal distension but fluid must accumulate before distension can occur and therefore it may be diagnosed before distension.

One prospective study of prepubertal healthy children found the normal volume of free peritoneal fluid had a mean and standard deviation of 4.7 +/- 5.65 mL for females and 1.9 +/- 3.11 mL for males. Maximum volume was 25 mL for females and 17 mL for males. Fifteen percent of females and 3% of males had more than 10 mL of fluid. There are also normal variations with menstrual cycles in women.

Abdominal trauma is an obvious cause of increased free peritoneal fluid and can include blood or other abdominal organ fluids. Usually there is a trauma history, but some intra-abdominal injuries can be difficult to diagnose and may occur after the acute injury and therefore are unrecognized immediately. There is a mortality rate as high as 8.5% with abdominal trauma. With blunt trauma, the spleen is the most common organ injured followed by the liver and pancreas. Bowel perforation can occur acutely or a few days later due to bowel compression and possible devascularization of the mesentery. Seat belt injuries are common causes of small bowel injuries particularly the jejunum. Free fluid and free air on radiologic studies are red flags for a surgical abdomen.

Free fluid is very common in appendicitis and occurs in up to 90% in some studies.

Ascites usually is caused by chronic diseases especially of the hepatic system, but also the cardiac and renal system or multiple organ systems. Ascites is less common in the pediatric age group as cardiac and liver disease are less common. However, nephrotic syndrome is a common cause of ascites.

A history of trauma, abdominal or pelvic pain, and abdominal distension are common reasons for radiographic evaluation. Computed tomography and/or abdominal ultrasound are used to assess for intra-abdominal pathology, free peritoneal fluid and free air. Management obviously depends on the history and cause. Blunt abdominal trauma is often treated conservatively but patients who are hemodynamically unstable or have free air are usually surgically explored as well as these with penetrating trauma. Patients with appendicitis or intra-abdominal abscess may be treated surgically. Management of medical pathology depends on the acute or chronic cause and secondary problems.

Learning Point
The differential diagnosis of free peritoneal fluid includes:

  • Appendicitis
  • Trauma – Solid organ
    • Spleen
    • Liver
    • Pancreatic injuries
    • Renal
  • Trauma – hollow viscous
    • Appendix
    • Bowel
    • Gall bladder
    • Meckel’s diverticulum
  • Genitourinary
    • Ectopic pregnancy
    • Tubo-ovarian abscess rupture
    • Follicular cyst rupture
    • Ovarian torsion
  • Infectious/inflammatory
    • Perihepatitis
    • Pelvic inflammatory disease
  • Mid-gut torsion

The differential diagnosis of ascites includes:

  • Liver
    • Presinusoidal
      • Portal vein thrombosis
    • Sinusoidal
      • Cirrhosis
      • Liver failure
      • Vitamin A toxicity
    • Post sinusoidal
      • Budd-Chiari syndrome
      • Cardiac
    • Cardiac
      • Congestive heart failure
      • Pericarditis
      • Venoocclusive disease
    • Renal
      • Hepatorenal syndrome
      • Nephrotic syndrome
      • Dialysis
    • Neoplasms
      • Hepatocellular cancer
      • Lymphoma
      • Others
    • Infectious Disease
      • Tuberculosis
      • Viral hepatitis
      • Sepsis
      • Whipple disease
    • Inflammatory
      • Allergic
        • Eosinophilic gastroenteritis
      • Chemical
      • Systemic lupus erythematosus
      • Vasculitis
    • Miscellaneous
      • Protein losing enteropathy
      • Thoracic duct obstruction
    • Fetal ascites
      • Hydrops fetalis
      • Genetic disorders
      • Prune Belly syndrome

Questions for Further Discussion
1. What are the causes of abdominal pain? A review can be found here
2. What is the ROME criteria? A review can be found here
3. What causes pelvic pain? A review can be found here
4. What causes abdominal distension? A review can be found here
5. What are indications for computed tomography or ultrasound for potential abdominal pathology?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Peritoneal Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Hou W, Sanyal AJ. Ascites: diagnosis and management. Med Clin North Am. 2009;93(4):801-817, vii. doi:10.1016/j.mcna.2009.03.007

Lynch T, Kilgar J, Al Shibli A. Pediatric Abdominal Trauma. Curr Pediatr Rev. 2018;14(1):59-63. doi:10.2174/1573396313666170815100547

Held JM, McEvoy CS, Auten JD, Foster SL, Ricca RL. The non-visualized appendix and secondary signs on ultrasound for pediatric appendicitis in the community hospital setting. Pediatr Surg Int. 2018;34(12):1287-1292. doi:10.1007/s00383-018-4350-1

Stengel D, Leisterer J, Ferrada P, Ekkernkamp A, Mutze S, Hoenning A. Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma. Cochrane Database Syst Rev. 2018;12:CD012669. doi:10.1002/14651858.CD012669.pub2

Tadayoni A, Farhadi F, Mirmomen SM, et al. Evaluation of incidental pelvic fluid in relation to physiological changes in healthy pubescent children using pelvic magnetic resonance imaging. Pediatr Radiol. 2019;49(6):784-790. doi:10.1007/s00247-019-04355-y

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa