Course:KIN366/ConceptLibrary/NeonatalMotorDevelopment

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Movement Experiences for Children
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KIN 366
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Instructor: Dr. Shannon S.D. Bredin
Email: shannon.bredin@ubc.ca
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A neonate is a newborn child less than 4 weeks old (Connelly, 1985). Motor development can be broken down into gross motor development (i.e. gaining of independent and voluntary movement) and fine motor development (i.e. use of upper extremities to manipulate environment) (Gerber, Wilks, & Erdie-Lalena, 2010). Motor activity during the neonatal period is crucial to the latter motor development of the child as infant reflexes appear and become integrated (Futagi, Toribe, & Suzuki, 2012; Sohn, Ahn, & Lee, 2011). Aside from reflexes, rhythmical stereotypies and spontaneous movements also play a large role in preparing the child for future voluntary movements as these movements help to develop muscles and joints (Robertson, 1984). In addition, neonatal motor activity provides an insight on the health of a child’s nervous system development (Robertson, 1984; Futagi et al., 2012) and may have significance in the diagnosis of certain disorders (Futagi et al., 2012; Zafeiriou, 2004; Goldman et al., 2009).

Reflexes

A reflex is a stereotyped, involuntary movement triggered by a specific external stimulus (Blasco, 1994). The presence and absence of reflexes may have important clinical implications on the health and development of the child (Futagi et al., 2012; Sohn, Ahn, & Lee, 2011).

Primitive reflexes are those which are mediated by the brainstem and may begin during gestation (Sohn et al., 2011; Blasco, 1994). The disappearance or “integration” of primitive reflexes is a sign of central nervous system maturity and sparks the beginning of certain voluntary motor activities (Sohn et al., 2011; Blasco, 1994; Shapiro et al., 1981).

Palmar Grasp Reflex

The palmar grasp reflex can be elicited during the neonatal period. This reflex is elicited when the palm of the newborn is applied with light pressure in which the newborn should respond by flexing his or her fingers to a close (Futagi et al., 2012). An abnormal response (i.e. diminished or asymmetrical) or an absence of the reflex may have significant clinical implications. According to Futagi et al., a newborn’s failure to elicit the palmar grasp reflex may reflect a problem with the spinal cord or its peripheral nerves (2012). The disappearance of the palmar grasp reflex is crucial to the initiation of the voluntary use of hands and usually occurs past the neonatal period at 3 to 6 months (Futagi et al., 2012). For instance, if the newborn fails to integrate the palmar grasp reflex, he or she will have great difficulty with manual control, such as grasping and releasing.

Plantar Grasp Reflex

The plantar grasp reflex is elicited when the sole of the newborn’s foot is pressed. In response, the newborn would flex his or her toes (Futagi et al., 2012). Abnormal responses of the plantar grasp reflex have been correlated to the later development of spasticity and several neurodevelopmental disorders such as Down’s syndrome and cerebral palsy (Futagi, et al., 2012). Similar to the disappearance of the palmar grasp reflex, the disappearance of the plantar grasp reflex precedes the voluntary use of the feet; therefore, this reflex must be integrated before the infant is able to come to a stand (Futagi et al., 2012). For example, the task of standing and walking would be nearly impossible if the infant reflexively flexes the toes whenever his or her feet come in contact with a surface.

Asymmetrical Tonic Neck Reflex

The asymmetric tonic neck reflex occurs when the newborn’s head is turned to one side. The stereotyped response includes an extension of the limbs on the side the newborn is facing and flexion on the opposite (Zafeiriou, 2004). An abnormal response of this primitive reflex is associated with cerebral palsy (Paine, 1964; Zafeiriou, 2004), the delayed ability for the newborn to roll from prone position to supine position (Zafeirious, 2004) and the delayed maturation of the central nervous system (Shapiro et al., 1981). In addition, the asymmetric tonic neck reflex aids in early visual inspection of the hands; therefore, this reflex is thought to play a large role in the development of hand-eye coordination (Clopton, Duvall, Ellis, Musser, & Varghese, 2000).

Moro Reflex

The Moro reflex is tested by introducing head extension to the newborn with a sudden light drop of the head. In response to this, the newborn will first abduct, then adduct and flex his or her upper limbs (Zafeirious, 2004). Like the asymmetric tonic neck reflex, absences or abnormalities of the Moro reflex in the first months of life are also related to cerebral palsy (Paine, 1964; Zafeirious, 2004).

Babkin Reflex

The Babkin reflex occurs when both palms of the newborn are pressed and the newborn responds by opening the mouth, flexing the arms and head, and closing the eyes (Futagi, Yanagihara, Mogami, Ikeda, & Suzuki, 2013). In typically developing newborns, this reflex can be elicited from birth and becomes integrated by 3 to 5 months of age (Futagi et al., 2013). Failure to demonstrate this reflex may be a sign of circulatory insufficiency in the brainstem and should be monitored for further neurological abnormalities (Futagi et al. 2013).

Rooting Reflex

The rooting reflex is the first primitive reflex that appears in a newborn and its function is to help the newborn search for food (Sosa, Eiben, & Cohn, 2004). By gently stroking the newborn’s cheek, the newborn is expected to turn his or her head towards the stroke (Sosa et al., 2004). This process is significant as it helps with breastfeeding.

Stepping Reflex

The stepping reflex happens when neonates are held in an upright position with their feet slightly touching a surface. As the name suggests, the child will respond with movements that look similar to walking (Thelen & Fisher, 1982). This response occurs in the first few weeks of life and disappears when the newborn reaches about 2 months of age but will reappear near the end of 1 year (Thelen & Fisher, 1982). The appearance of this reflex is important as the reflex is theorized to be incorporated into latter attempts of upright, bipedal locomotion (Thelen & Fisher, 1982; Paine, 1964).

Rhythmical Stereotypies

Stereotypies are spontaneous and repetitive movements that occur without a specific stimulus and is thought to be the result of central nervous system activity (Thelen, 1981). These movements appear to be random and do not have a specific functional role but are commonly seen in newborns within 1 year of age. Examples of such movements include kicking, arm waving, bouncing, rocking, swaying and banging (Thelen, 1981). Retention and an excessive expression of stereotypies are linked to certain developmental disorders such as autism (Goldman et al., 2009) and blindness (Thelen, 1981); however, normal presence of stereotypies are a precursor to more complex and coordinated movements. This suggests that stereotypies can be seen as a preparation to future voluntary movement by aiding in the development and maturation of the nervous and muscular system (Thelen, 1981).

Assessing Development

One method in assessing a newborn’s development is by observing its posture. Posture provides information on the muscle tone and reflex state of the infant (Connolly, 1985). Normal flexion indicates good muscle tone while hypertonicity and hypotonicity indicates increased flexion and lack of flexion, respectively (Connolly, 1985). Passive muscle tone is determined by measuring extensibility (i.e. amount of elongation a muscle allows) and passivity (i.e. amplitude of movement in hand and foot flapping) (Connolly, 1985). On the other hand, active muscle tone is determined by moving the infant while examining muscle groups (Connolly, 1985). Muscle tone is significant as it has implications on how well a newborn may engage in a certain movement. For instance, a newborn with good muscle tone can attempt to right his or her head when oriented in an upright position; however, a newborn with too much tone will be stiff and hyperextend the neck (Connolly, 1985). In addition to muscle tone, rhythmic spontaneous movements are also observed in newborns, as discussed previously as “stereotypies”. A lack of these stereotypies may be an indicator of significant lethargy or hypotonicity (Connolly, 1985).

Neonatal Behavioural Assessment Scale

The Brazelton Neonatal Behavioural Assessment Scale is used as a traditional examination to assess a newborn’s ability to manage behaviour in several states. In addition, inferences regarding the newborn’s nervous system and motor abilities can be made from this assessment (Anderson, 1986). In relation to motor development, the newborn’s motor maturity is observed during testing. Motor maturity is tested by making observations in regards to the newborn’s muscle tone (i.e. flaccid to hypertonic) while the baby is pulled from a supine position into a sitting position (Anderson, 1986). To further, motor maturity is also determined by examining the newborn’s ability to remove a cloth placed over their face (Anderson, 1986). Primitive reflexes, as mentioned above, as well as additional reflexes and movements are also examined during the Brazelton Neonatal Behavioural Assessment Scale to test for autonomic nervous system regulation. Each response is rated on a 3 point scale: 1 = hypoactive, 2 = normal, and 3 = hyperactive (Anderson, 1986) and as discussed previously, abnormalities in such responses may have major clinical implications.

Practical Applications

With knowledge regarding the possible implications that reflexes and stereotypies play in the role of a healthy developing child, neonatal reflexes should be assessed from birth. Noting abnormalities in the onset and offset of the reflex, the strength of the reflex and the symmetry of the reflex can help to monitor the maturity of the nervous system (Robertson, 1984; Futagi et al., 2012), and aid in the early diagnosis of certain clinical conditions (Futagi et al., 2012; Zafeiriou, 2004; Goldman et al., 2009). For instance, if a reflex persists past the appropriate age or does not occur at all, consultation from a pediatrician may be required.


For parents, recognizing that motor development begins at such an early age and that these reflexes and stereotypies are typical and necessary for development is an important tool. For instance, parents should not constrain their children from eliciting these behaviours. Certain stereotypies (i.e. kicking, waving of arms and banging) may be seen as restlessness or inappropriate behaviour from the child that may prompt parents to restrict or stop the child from acting this way. Inhibiting a child from naturally exercising these stereotypies may impair their motor development and have an impact on the child’s latter voluntary movements (Thelen, 1981). To further, the practice of swaddling, which is the wrapping of a blanket or cloth around a baby to reduce limb movement (Dodwell, 2013), may need to be reconsidered for better motor development of the child. Swaddling of a newborn results in lower arousal and increased hours of sleep (Sleuwen et al., 2007) which may effectively decrease the time the newborn has to exercise certain reflexes and stereotypies.


In addition to knowledge regarding reflexes and stereotypies, when demonstrated to parents, the Brazelton Neonatal Behavioural Assessment Scale can act as a teaching tool. From this assessment, parents will gain relevant information on the capabilities of their children which will allow them to better raise and protect the child for optimal development (Anderson, 1986). For instance, parents will gain a better understanding of what is considered “normal” for their newborn to do and can be alerted if abnormalities arise.


Overall, given knowledge about the functional role and possible consequences of reflexes and stereotypies, parents can apply this information to aid in the working process of these neonatal movement patterns by limiting restraint time and maximizing time for activity. In addition, parents and health care providers can utilize measurements of reflexes and stereotypies as an added indicator for increased awareness for certain conditions such as autism (Goldman et al., 2009).

References

Anderson, C.J. (1986). Integration of the Brazelton neonatal behavioural assessment scale into routine neonatal nursing care. Comprehensive Pediatric Nursing,

9, 341-351. Retrieved from: http://informahealthcare.com/doi/abs/10.3109/01460868609009060?journalCode=cpn


Blasco, P. (1994). Primitive reflexes: their contribution to the early detection of cerebral palsy. Clinical Pediatrics, 33, 388-397; doi:

10.1177/000992289403300703


Clopton, N.A., Duvall, T., Ellis, B., Musser, M., & Varghese, S. (2000). Investigation of trunk and extremity movement associated with passive head turning in

newborns. Clinical Pediatrics, 22, 544-546; doi: 10.1177/000992288302200804


Connolly, B.H. (1985). Neonatal assessment: an overview. Journal of the American Physical Therapy Association and Physical Therapy, 65, 1505-1513.

Retrieved from: http://ptjournal.apta.org/content/65/10/1505.full.pdf+html


Dodwell, E. (2013). Swaddling. Pediatrics for Parents, 29, 13-13. Retrieved from: http://connection.ebscohost.com/c/articles/96532065/swaddling


Futagi, Y., Toribe, Y., & Suzuki, Y. (2012). The grasp reflex and moro reflex in infants: hierarchy of primitive reflex responses. International Journal of Pediatrics,

2012, 191562-191572; doi: 10.1155/2012/191562


Gerber, J., Wilks, T., & Erdie-Lalena, C. (2010). Developmental milestones: motor development. Pediatrics in Review, 31, 267-277; doi: 10.1542/pir.31-7-267


Goldman, S., Wang, C., Greene, P.E., Kim, M., & Rapin, I. (2009). Motor stereotypies in children with autism and other developmental disorders. Developmental

Medicine & Child Neurology, 51, 30-38; doi: 10.1111/j.1469-8749.2008.03178.x


Robertson, S. (1984). The prenatal development of neonatal motor rhythms. Pediatric Research, 18, 343A-343A; doi: 10.1203/00006450-198404001-01502


Shapiro, B.K., Palmer, F.B., Machtel, R., Accardo, P.J., Ross, A., Capute, A.J., & Batshaw, M. (1981). The asymmetrical tonic neck reflex (ATNR): infant

indicator of later development. Pediatric Research, 15, 711-711; doi: 10.1203/00006450-198104001-01627


Sleuwen, B.E., Engelberts, A.C., Boere-Boonekamp, M.M., Kuis, W., Schulpen, T.W.J., & L’Hoir, M.P. (2007). Swaddling: a systematic review. Pediatrics, 120,

e1097-e1106; doi: 10.1542/peds.2006-2083


Sohn, M., Ahn, Y., & Lee, S. (2011). Assessment of primitive reflexes in high-risk newborns. Journal of Clinical Medicine Research, 3, 285-290; doi:

10.4021/jocmr706w


Sosa, C., Eiben, R., & Cohn, R. (2004). A new newborn reflex? Clinical Pediatrics, 43, 475-478; doi: 10.1177000992280404300510


Futagi, Y., Yanagihara, K., Mogami, Y., Ikeda, T., & Suzuki, Y. (2013). The Babkin reflex in infants: clinical significance and neural mechanism. Pediatric

Neurology, 49, 149-155; doi: 10.1016/j.pediatrneurol.2013.04.005


Thelen, E. (1981). Kicking, rocking, and waving: contextual analysis of rhythmical stereotypies in normal human infants. Animal Behaviour, 29, 3-11; doi:

10.1016/S0003-3472(81)80146-7


Thelen, E., & Fisher, D.M. (1982). Newborn stepping: an explanation for a “disappearing” reflex. Developmental Psychology, 18, 760-775. Retrieved from:

http://psycnet.apa.org/psycinfo/1983-00760-001


Zafeiriou, D.I., (2004). Primitive reflexes and postural reactions in the neurodevelopmental examination. Pediatric Neurology, 31, 1-8; doi:

10.1016/j.pediatrneurol.2004.01.012