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Primitive Reflexes and Postural Reactions inthe Neurodevelopmental Examination
Dimitrios I. Zafeiriou, MD, PhD
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he primitive reflexes and the postural reactions com-rise one of the earliest, simplest, and most frequentlysed tools among child neurologists to assess the cen-ral nervous system integrity of infants and younghildren. Infants with cerebral palsy have been knowno manifest persistence or delay in the disappearance ofrimitive reflexes and pathologic or absent posturaleactions. The clinical significance of asymmetric toniceck reflex, Moro, palmar grasp, plantar grasp, Ga-
ant, Babinski, Rossolimo, crossed extensor, suprapu-ic extensor, and heel reflex, alone or in combination,s well as their contribution to the early diagnosis andifferential diagnosis of cerebral palsy, have beenemonstrated in a number of studies. Moreover, in-ants with 5 or more abnormal postural reactions haveeveloped either cerebral palsy or developmentaletardation as reported in a number of studies. Al-hough a comprehensive neurologic examination inhe context of a motor assessment instrument is pref-rable to an informal list of items, the combinedxamination of primitive reflexes and postural reac-ions should be considered by the child neurologist, as
simple but predictive screening test for the earlydentification of infants at risk for cerebral palsy. It isuick and easy to perform, both in nonhospital envi-onments and in underdeveloped countries, where timend specific recourses are limited. The combined ex-mination is also useful in developed countries becauseany developmental disorders such as cerebral palsy
ppear in nonrisk groups whereas others are notetected by metabolic screening programs. © 2004 bylsevier Inc. All rights reserved.
afeiriou DI. Primitive reflexes and postural reactions inhe neurodevelopmental examination. Pediatr Neurol004;31:1-8.
rom the Neurodevelopmental Center “A Fokas”, First Department ofediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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2004 by Elsevier Inc. All rights reserved.oi:10.1016/j.pediatrneurol.2004.01.012 ● 0887-8994/04/$—see front matter
ntroduction
The primitive reflexes and the postural reactions con-titute one of the earliest, simplest, and most frequentlysed tools among child neurologists, as well as develop-ental and general pediatricians all over the world to
ssess the central nervous system integrity of infants andoung children [1]. On the other hand, there are aonsiderable number of developmental scales [2-8], devel-pmental screening tests [9-15], and motor assessmentnstruments [16-20] which more or less cope with thevaluation of motor development in either term or pretermnfants and young children and include a variable numberf primitive reflexes or postural reactions as items [21]Table 1). The reliability, sensitivity, and validity of somef these motor assessment instruments vary greatly, andach one’s predictive power increases with the age of thenfant or young child [22]. Moreover, in a critical reviewy Majnemer and Mazer, none of the instruments testedas effective in the early diagnosis of infants younger than2 months of age [23]. Although a comprehensive neuro-ogic examination is preferable than an informal list oftems, either in the busy neuropediatric daily practice orven at the hospital, it is crucial to obtain as muchnformation as possible within a small time frame.
The purpose of the current article is to review andritically discuss the major primitive reflexes and posturaleactions as an integral part of the neurologic examinationf the infant. This review will also summarize the diag-ostic relevance of specific primitive reflexes or posturaleactions, alone or in combination, regarding an earlyiagnosis of cerebral palsy and developmental retardation.urthermore, the diagnostic utility of the presence ofrimitive reflex patterns in adults with various neurologicisorders will be outlined. Finally, the assessment ofeneral movements, a promising new diagnostic tool forhe neurologic examination of high-risk infants based on
ommunications should be addressed to:r. Zafeiriou, Child Neurologist; Egnatia St. 106;4622 Thessaloniki, Greece.
eceived September 9, 2003; accepted January 23, 2004.1Zafeiriou: Primitive Reflexes and Postural Reactions
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rimitive Reflexes
Primitive reflexes are brainstem-mediated, complex,utomatic movement patterns that commence as early ashe twenty-fifth week of gestation, are fully present at birthn term infants, and with central nervous system matura-ion become more and more difficult to elicit after the firstalf of the first year of life, when voluntary motor activitynd thus cortical inhibition emerges and takes over24-26]. They are considered part of the motor repertoiref the specific age. Primitive reflexes are highly stereo-ypical patterns and are elicited by specific sensory stim-li.The major primitive motor reflexes or patterns that have
een described include Moro, palmar and plantar grasp,ooting, sucking, placing, Moro, Galant (or truncal incur-ation), asymmetric tonic neck reflex, crossed extensor,onic labyrinthine reflex, and others [21]. Some authorsake no distinction between primitive reflexes and pos-
ural reactions (i.e., primitive and postural behaviors);here is an ongoing controversy concerning the ones that,lone or in combination, have the greatest predictivelinical significance. For example, Capute [27], in aong-term follow-up study, regards the Galant reflexmong the major predictive primitive reflexes being ex-ensively evaluated. Dargassies [13], on the other hand,elieves the crossed extensor reflex to be most critical forentral nervous system maturation. Gupta [28] selectslantar, palmar, rooting, Moro, crossed extensor, tonicabyrinthine reflex, Landau, placing, and positive support
able 1. Most commonly used motor performance toolsReferences for each are given in brackets)
. Developmental Scalesmiel-Tison [2]ayley [3]razelton [4]ubowitz [5]aataja [6]eabody [7]rechtl [8]
. Developmental Screening Testsenver Developmental Screening Test (Denver II) [9]attelle Screening Test [10]linical Adaptive Test (CAT)/Clinical Linguistic and AuditoryMilestone Scale (CLAMS) [11]
nobloch Revised Screening Inventory [12]eneral Movements (GMs) Assessment [13-15]
. Motor Assessment Instrumentslberta Infant Motor Scale (AIMS) [16]arly Motor Pattern Profile (EMPP) [17]ross Motor Function Measure (GMFM) [18]ovement Assessment Inventory (MAI) [19]
est of Infant Motor Performance (TIMP) [20]
ithout a clear distinction between reflexes and reactions. o
PEDIATRIC NEUROLOGY Vol. 31 No. 1
he revised Dubowitz scale [5] uses the palmar andlantar grasp, Moro, suck, and placing reflex. Scherzergain finds more clinically relevant the Moro, palmar andlantar grasp, asymmetric tonic neck reflex, rooting anducking reflex [21]. Mandich et al. [29] compiled aevelopmental test (not listed in Table 1) extrapolatingata from the Denver Developmental Screening Test andhe Bayley scales, which mixed primitive reflexes withostural reactions and developmental milestones and in-luded plantar grasp reflex, asymmetric tonic neck reflex,onic labyrinthine reflex, neck righting reflex, Landaueaction, and parachute reaction. Futagi et al. [30] andafeiriou et al. [31], both drawing on the work of Vojta
32], place greater emphasis on the following eight re-lexes: palmar and plantar grasp response, crossed exten-or, suprapubic extensor, Galant, asymmetric tonic neckeflex, heel, and Rossolimo reflex. Moreover, Zafeiriou etl. [33] underscore the importance of eliciting a trueabinski response by eliciting the plantar response in
nfancy, as well as the importance of the Moro reflex [34].lmost all of these investigators used the same method of
liciting reflexes, thus indicating the validity of theethod used (Table 2). This consistency in terminology
nd concept (especially method of elicitation but alsorading) was already evident in the work of Paine [35] andowen [36], but was systematically advocated by Capute
27], thus avoiding oversimplifications or even discrepan-ies in method of elicitation. Simultaneously with Holt37] and Molnar [38], Capute introduced the concept ofobligatory reflexes” (or 4� primitive reflex) [39]. Theatter is defined as a fixed response or posture when thetimulus is initiated and for as long as the stimulusersists, until it is removed.Special emphasis should be placed on the plantar
esponse of the infant, which is a polysynaptic responselicited by stroking along the lateral aspect of the footrom heel to toe [40]. Different types of responses haveeen elicited in infants, varying from flexor to extensorccording to the intensity of the stimulus used [33]. It isenerally accepted [41,42] that extensor plantar responseatures to flexor by the end of the first year in most
ormal infants. The Babinski sign refers to the extensoroe response observed in diseases involving the cortico-pinal tract in older children and adults, and is consideredy many authorities as the single most useful clinicaleflex in neurology [43]. However, there is an ongoingontroversy whether a true Babinski sign (dorsiflexion ofhe great toe and fanning of the remaining toes) obtainedy eliciting the plantar response is present in infants in theontext of a primitive reflex. According to some authors,
true Babinski response denotes dysfunction of theyramidal tract and should be clearly distinguished fromxtensor toes that do not belong to the flexion synergy ofhe leg [43] and constitute a primitive reflex of the infant.n the same context, Fenichel [44] uses the withdrawaleflex, which is produced by a noxious stimulus to the sole
f one foot and causes flexion of the stimulated limb and
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xtension of the contralateral limb. The flexion part of theithdrawal reflex can be demonstrated in a considerableumber of infants while trying to elicit the plantar re-ponse.
ostural Reactions
A number of postural reactions (i.e., motor patterns)ave been identified and repeatedly described as diagnos-ically relevant. Both Capute et al. [45] in the Englishiterature and Vojta [32] in the German literature empha-ized the distinction between primitive reflexes and pos-ural reactions. Blasco [26,46] and the Kennedy groupCapute et al. from the John F. Kennedy Institute inaltimore) [45] suggested that postural mechanisms areot true reflexes, but rather are based on multiple inputodalities, usually acting as a whole; they further sug-
ested that postural mechanisms require cortical integritynd thus are not present in the neonate, but instead developostnatally, being considered mature postural responseshat persist as a basis for normal motor behavior.
It was Vojta [32] who first underlined the theory thatostural reactions are present at birth and follow the stagesf postural ontogenesis. Their mature response is elicitedt the age that Capute et al. [45] and other investigators26,46] describe and is qualitatively equivalent to theatter. Vojta slightly modified six already known postural
able 2. Eliciting the primitive reflexes according to references [3
Reflex Position Method
almar grasp Supine Placing the index finger in tinfant
lantar grasp Supine Pressing a thumb against thebehind the toes in the foo
alant Prone Scratching the skin of the infrom the shoulder downwlateral to the spinous proc
symmetric tonic neckreflex
Supine Rotation of the infant’s headfor 15 s
uprapubic extensor Supine Pressing the skin over the puthe fingers
rossed extensor Supine Passive total flexion of oneextremity
ossolimo Supine Light tapping of the 2nd-4thplantar surface
eel Supine Tapping on the heel with a hthe hip and knee joint flexankle joint in neutral posi
oro Supine Sudden head extension prodlight drop of the head
abinski Supine Striking along the lateral aspextending from the heel tothe fifth metatarsal
eactions and, together with a new one that he first e
escribed, used them as a set of seven items which coulderve as a motor screening test [32]. According to Vojta,ostural responses represent complex motor responses to alurality of afferences such as the joints, the tendons, theuscles, the skin, the inner organs, telereceptors (eye) and
toreceptors (ear), and of course the labyrinth. They areharacterized by a certain stereotyped posture of the trunk,ead, and extremities (i.e., the entire body), when thexaminer attempts a strictly defined sudden change ofosition (Table 3, Fig 1). The response at each chronolog-cal age is different and expresses the central nervousystem stage of maturation.
Regarding postural reactions, limited data are availablen their evolution in early infancy, and they concernostly the three righting reflexes in prone position: the
onic labyrinthine reflex, symmetric tonic neck righting,nd the Landau reaction (vertical suspension) [45]. How-ver, from Capute’s study, it was clear that there areifferences of opinion concerning whether the posturaleactions are all absent in the infant period and appearradually later, simultaneously with the diminution of therimitive reflexes. For example, the Landau reaction wasonsidered not present at birth, the tonic labyrinthineeflex was present in 80% of normal infants by 2 weeks ofge, and symmetric tonic neck righting appeared later thanhe infant period and disappeared in a 3- to 6-montheriod. Again, different postural reactions are used pref-
nd [54]
ResponseAge at
Disappearance
of the Flexion of fingers, fist making 6 months
st Flexion of toes 15 months
ack3 cm
Incurvation of the trunk, with theconcavity on the stimulated side
4 months
side Extension of the extremities on thechin side and flexion of thoseon the occipital side
3 months
e with Reflex extension of both lowerextremities, with adduction andinternal rotation into talipesequinus
4 weeks
Extension of the other lower limbwith adduction and internalrotation into talipes equinus
6 weeks
their Tonic flexion of the toes at thefirst metacarpophalangeal joint
4 weeks
, withthe
Rapid reflex extension of thelower extremity in question
3 weeks
a Abduction followed by adductionand flexion of upper extremities
6 months
he solead of
Combined extensor response:simultaneous dorsiflexion of thegreat toe and fanning of theremaining toes
Presence alwaysabnormal
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3Zafeiriou: Primitive Reflexes and Postural Reactions
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tems or as part of a developmental scale or optimalitycore. For example, Haataja et al. [6] favor an optimalitycore, which focuses among others on vertical suspension,arachute reaction, arm protection, and lateral tilting,hereas Scherzer [21] finds clinically relevant—and uses
ystematically—neck righting, parachute or protective ex-ension, and the Landau reaction. In one of the few reviewrticles dealing with the neurologic examination of thenfant, Fenichel [44] utilizes the traction response, verticaluspension, and the Landau reaction.
arly Diagnosis of Cerebral Palsy
As stated earlier, the evaluation of posture, muscle tone,rimitive reflexes, and postural reactions is an integral partf the neurologic examination of the infant in the first yearf life. Posture or muscle tone disturbances during the first2 months of life in high-risk infants are not alwaysrognostic of the later diagnosis; some of these infants areormally developed, whereas others have various types oferebral palsy or developmental retardation without motoristurbance [47-49].
The same is true for motor milestones such as sitting,
able 3. Eliciting the postural reactions according to references32] and [60]*
Reaction Position Method
raction Supine Placing the examiner’s index fingerin the infant’s hand and pullingthe infant at a 45° angle with theexamination bed
orizontal suspension Prone Suspending the infant by placingthe hands around the infant’sthorax without providing supportfor the head or legs
ertical suspension Vertical Placing both hands in the axillae,without grasping the thorax andlifting the infant straight upfacing the examiner
ojta response Vertical Suspension from the vertical to thehorizontal position facing theexaminer by placing both handsaround the infant’s thorax
ollis horizontalsuspension
Prone Placing one hand around the upperarm and the other around theupper leg and suspending theinfant in the horizontal positionparallel to the examination bed
ollis verticalsuspension
Prone Placing one hand around the upperleg and suspending the infant inthe vertical position with headdirected downwards
eiper-Isbert verticalsuspension
Prone Placing the examiner’s handsaround each upper leg of theinfant and suspending the infantin the vertical position with headdirected downwards
For normal responses at each month of the first year of life one,refer accordingly to [32]. An example of normal and abnormalresponses at the age of 6 months is presented in Figure 1.
ulling to stand, and standing: as Blasco [26] states, they r
PEDIATRIC NEUROLOGY Vol. 31 No. 1
epresent the basis for formulating locomotor prognosis inndividual patients with cerebral palsy; however, they doot contribute to an early diagnosis (i.e., in the first 6onths of life). In such cases, examination of primitive
eflexes or postural reactions has been advocated to serves a screening test for postural abnormalities, especiallyegarding cerebral palsy.
Infants with cerebral palsy have been known to demon-trate persistence of primitive reflexes or a delay in theirisappearance [39]. Persistence of obligatory primitiveeflexes beyond 12 months of age is an indicator of a poorrognosis regarding ambulation [39,50]. This early workas led the Kennedy group to develop a “Primitive Reflexrofile” to be used as a clinical research diagnostic tool27]. Another step was to obtain normative data for ninerimitive reflexes in 381 normal infants by documentingrospectively their sequential changes during the first 2ears of life [51], as well as to describe the evolution of therimitive Reflex Profile for the preterm infant [25]. Thelinical experience with the Primitive Reflex Profile andts contribution to an earlier diagnosis (6 to 8 months ofife) were subsequently underlined by its developers, asell as other investigators [25,48]. This organized exam-
nation’s schema has led several investigators like Futagi30] and our group [31,33,34] to test and suggest separatend distinct patterns of the Primitive Reflex Profile,ndicative of cerebral palsy, as well as of developmentaletardation.
Combining the results of these studies with the pioneerork of Vojta [32], it emerges that early diagnostic clues
oncerning whether a high-risk infant will become normalt the age of 2 years are as follows: the presence of theuprapubic extensor reflex, the crossed extensor reflex, theossolimo reflex, and the heel reflex after 3 months; aositive Galant and asymmetric tonic neck reflex after 5onths; a positive palmar grasp reflex after 7 months; andnegative plantar grasp reflex after 3 months [30]. In a
ignificant number of patients with spastic cerebral palsy,he Moro reflex cannot be elicited in the first months ofife, appears subsequently in the fifth or even the seventhonth, and is retained until the age of 11 months,
upporting the hypothesis that the Moro reflex is blockedy certain inhibitory mechanisms at the first 3 to 5 monthsn children with spastic cerebral palsy and then starts beinglicited, either because of central nervous system matura-ion or because of a physical therapy effect [34].
Last, but not least, in the chaos of reflexology, theresence of a combined extensor plantar response orabinski response (i.e., dorsiflexion of the great toe with
anning of the remaining toes) was found to be a reliablerognostic clinical tool, which contributed to an earlieriagnosis of spastic cerebral palsy, already from the firstonth of life [33]. On the basis of these primitive reflexes,
eurologically abnormal children could be diagnoseduch earlier (at the first 3 months of life). Moreover,
elay in the disappearance of the asymmetric tonic neck
eflex, Moro, plantar grasp, and Galant reflexes is more
FsLL
igure 1. Upper half: Eliciting the seven postural reactions—normal response at the age of 6 months. From left up to right down corner: verticaluspension, horizontal suspension, Vojta response, traction response, Collis horizontal reaction, Collis vertical reaction, and Peiper-Isbert reaction.ower half, left up to down: Abnormal Vojta response, horizontal suspension, and vertical suspension in suspected spastic cerebral palsy (age 6 months).ower half, right up to down: The same postural reactions in fixed cerebral palsy (age 15 months). (From reference [60] with permission)
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onspicuous among athetoid than spastic infants30,31,34,52-54], whereas the presence of a Babinskiesponse, as well as a Rossolimo, a crossed extensor, auprapubic extensor, and a heel reflex is indicative ofpastic cerebral palsy [30,31,34]. In fact, the combinedxamination of the reflexes mentioned earlier can clearlyistinguish between spastic and athetoid cerebral palsy;owever, the diagnosis of ataxic cerebral palsy, develop-ental retardation, or mixed cerebral palsy forms cannot
e made on this basis alone.In a considerable number of patients with spastic
erebral palsy, some of the above tested reflexes such ashe Moro, the Galant, and the asymmetric tonic neck reflexould not be elicited in the first months of life, appearedubsequently in the second half of the first year of life, andere retained until the end of the first year, supporting theypothesis that these primitive reflexes are blocked byertain inhibitory mechanisms at the first months of life inhildren with spastic cerebral palsy and then start beinglicited, either because of central nervous system matura-ion or because of a physical therapy effect [31,34]. Theirreservation in spastic cerebral palsy seems to be relatedo pyramidal tract involvement. However, the fact thathese reflexes persist throughout the first year in almost allatients with athetoid cerebral palsy suggests that path-ays other than pyramidal (likely related to basal ganglia
ircuits) are also involved in their retention in theseatients.The diagnostic relevance of the various postural reac-
ions is variably recognized with limited data available.leck underlines the predictive value of failure to developostural reactions such as the parachute reaction andquilibrium in standing [55]. Scherzer finds clinicallyelevant—and uses systematically—neck righting, para-hute or protective extension, and the Landau reaction21]. As a rule of thumb, Molnar [56] stated that normalisappearance of primitive reflexes and delayed disappear-nce of postural reactions are more characteristic ofental retardation. Mandich et al. [29] demonstrated a
tatistically significant relationship between tonic labyrin-hine reflex in supine position at hospital discharge (37eeks corrected age) and appearance of pull to sit and
olling at 8 months, between asymmetric tonic neck reflext hospital discharge and rolling prone to supine and viceersa at 8 months, as well as between parachute reaction atmonths and sitting without support at 12 months. In the
ame context, onset of independent walking occurredpproximately 4 months after the appearance of parachuteeaction in a prospective study of 190 normal infants [57].
Earlier studies, which have used the seven posturaleactions according to Vojta, have concentrated on therognostic reliability of postural reactions, especially re-arding the classification of central coordination distur-ance (i.e., a tentative diagnosis of postural abnormalities)n relation to the extent of abnormalities of posturaleactions [32,58,59]. According to this classification, a
ery light central coordination disturbance was diagnosed LPEDIATRIC NEUROLOGY Vol. 31 No. 1
n infants with 1-3 abnormal postural reactions, a lightentral coordination disturbance in infants with 4-5 abnor-al postural reactions, a moderate central coordination
isturbance in infants with 6-7 abnormal postural reac-ions, and a severe central coordination disturbance innfants with 7 abnormal postural reactions and an abnor-al muscle tone. Infants with a moderate or severe central
oordination disturbance were, as expected, more prone toevelop cerebral palsy (for an example see Fig 1); theriginal results of Vojta were subsequently confirmed byhese study groups.
In a study from our institution [60], the profiles ofostural reactions during the first year of life were ana-yzed prospectively in high-risk infants referred for neu-odevelopmental examination (being exclusively neonatalntensive care units survivors). All examined high-risknfants carried a higher risk for neurodevelopmental ab-ormalities compared with previous studies. Taking intoccount that all infants with 5 or more abnormal posturaleactions developed either cerebral palsy or developmentaletardation, we suggested that all infants with 5 or morebnormal postural reactions should be considered being atisk for either cerebral palsy or developmental retardation.owever, it should be the specific combination of postural
eaction abnormalities which eventually can predict moreccurately the type of neurologic impairment.
rimitive Reflexes in Adults
In adults, the clinical implication of a positive primitiveeflex is a controversial issue. Its presence is believed toignify frontal lobe damage or upper motor neuron dis-ase. It is generally considered as a marker of corticalisinhibition. The elicitation of these reflexes has beenncorporated in the neurologic examination of patientsith dementia or human immunodeficiency virus–infectedatients [61,62]; they have been also reported as useful inhe clinical assessment and diagnosis of various neuro-ogic disorders such as Alzheimer’s disease, schizophre-ia, multiple sclerosis, Parkinson’s disease, frontal lobeesions, and hydrocephalus [63-66].
ssessment of General Movements
A new approach to neurologic assessment, based onbservation of the spontaneous motility of fetuses, pretermnd term infants, has been recently proposed by Prechtl etl. [14,15,67]. The central idea of this approach is that thebservation of general movements, which are gross move-ents involving the entire body, is more reliable than the
ssessment of the incidence of specific isolated move-ents and can predict outcome in infants at risk. Although
his method is quick and easy to perform, it requiresraining of the examiner to make an interpretation; more-ver, standardized video equipment is required, somethinghat makes its use uneasy in nonhospital environments.
ast but not least, the “state” of the infant, an important
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arameter for Prechtl from the beginning of his research inhe 1960s, is crucial for the interpretation of the results;gain, time constraints make it difficult for both examinersnd parents to wait 1 or 2 hours to reach the desirable statef alertness.Earlier studies have reported that the quality of generalovements has good predictive value [15,67,68], contrary
o that of earlier instruments available to date. Most ofhese studies examined mature infants at birth who wereither term or �30 weeks gestation and included high-risknfants. Moreover, previous studies, which used repeatedeneral movements assessment weekly until 6 months ofge, suggested that the quality and presence of abnormalidgety movements, usually observed by 2 to 4 months ofge, are the most useful indicators of neurodevelopmentalutcome [15,67,69]. Therefore it would not be practicalor the daily clinical practice to perform weekly assess-ents over several months to identify the infants at risk for
eurodevelopmental disability. In a recent study of Maast al. [70], scoring general movement quality at termhronological age did not add to the power of the Prechtlest [8] to predict the neurologic and developmentalutcomes at 2 years chronological age. Nevertheless,ssessment of the general movements seems to be aromising diagnostic tool for the motor assessment of thenfant-at-risk.
onclusions
Although there are a considerable number of instru-ents dealing with the early diagnosis of motor abnormal-
ties, the combined examination of primitive reflexes andostural reactions still has a place in the neurologicxamination of the neonate or infant. It is quick and easyo perform, both in nonhospital environments and under-eveloped countries, where time and specific recourses areimited, as well as in developed countries, since manyevelopmental disorders such as cerebral palsy appear inonrisk groups whereas others are not detected by meta-olic screening programs. The combined examinationhould be considered by the child neurologist as a simpleut predictive screening test for the early identification ofnfants at risk for either cerebral palsy or developmentaletardation. In conjunction with the motor developmentalilestones, the classic neurologic examination, neurode-
elopmental evolution over time, and other subjective orbjective clinical evidence supporting neurologic dysfunc-ion (i.e., poor feeding and communication, disorder ofuscle tone and posture, motor stereotypies, failure of the
ead to grow at the appropriate rate for age, and evaluationith standard developmental screening tests such as theenver Developmental Scale [9]), the combined examina-
ion of primitive reflexes and postural reactions constitutessolid basis for the evaluation of neonatal and infantile
otor disorders [26,71].eferences
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