Remember that the persistence of primitive reflexes is a sign that there is damage to the central nervoussystem (CNS), specifically, a lack of high-level control necessitating a workup for cerebral palsy (CP)
Remember that the persistence of primitive reflexes is a sign that there is damage to the central nervoussystem (CNS), specifically, a lack of high-level control necessitating a workup for cerebral palsy (CP): Excerpt from Avoiding Common Pediatric Errors
Author: Yolanda Lewis-Ragland, MD
What to Do - Interpret the Data
The CNS is the control center for thinking, learning, and moving that develops in a highly organized and regulated sequence from conception. Movement patterns define this sequence at each developmental stage. These patterns are called primitive reflexes, which are important for survival. As the
infant matures, the frontal lobes are responsible for suppressing primitive
reflexes, but these may reappear during adulthood under certain conditions
including dementia, traumatic lesions, and stroke. In infants who fail to suppress the primitive reflexes, CP must be entertained and currently, atypical
primitive reflexes are also being investigated as potential early warning signs
of Autism spectrum disorders.
Primitive Reflexes are Characterized by:
• Automatic, stereotyped movements, directed by the brainstem
• Executed without involvement of higher levels of the brain (the cortex)
• Short-lived and replaced by more sophisticated structures (postural
reflexes) controlled by the cortex once their function is no longer
needed
• Retained if they do not fulfill their function or injury/insult occurs
• Considered aberrant and evidence of CNS immaturity if present beyond
their usual time
What is Cerebral Palsy?
CP is a static encephalopathy caused by an insult to the brain during the
prenatal, perinatal, or postnatal period. CP can lead to global dysfunction
but always includes motor problems. CP is traditionally classified on the
basis of the type of motor disorder. The revised classification now in use
defines three main categories of motor disorders: (a) spastic (70%–80%), (b)
dyskinetic (10%–15%), and (c) ataxic (<5%).
Spastic cases are further classified by involvement of the extremities. In
quadriplegia (10%–15%), all four extremities are affected equally, and the
trunk is involved. In diplegia (30%–40%), the lower extremities are affected
more than the upper extremities. In hemiplegia (20%–30%), involvement is
observed on one side of the body, including an arm and a leg. In monoplegia
(rare), involvement is noted in one limb, either an arm or a leg; other causes
should be ruled out.
Clinical Presentations of Cerebral Palsy
• Abnormal muscle tone is the most frequently observed symptom. The
abnormalitiesmay range from hypo-to hypertonic depending on themuscular resistance to passive movements.
• A definite hand preference before age 1 year is common (especially in
patients with hemiplegia).
• An asymmetric crawl or failure to crawl
• Growth delay
• Joint contractures secondary to spastic muscles
• Persistent primitive reflexes: Examples such as Moro reflex, asymmetric
tonic neck, symmetric tonic neck, palmar grasp, tonic labyrinthine, foot
placement, are noted. A Moro reflex and a tonic labyrinthine should extinguish by the time the infant is aged 4 to 6 months; palmar grasp, by 5 to 6 months; asymmetric and symmetric tonic neck, by 6 to 7 months; and
foot placement, before 12 months.
Table 1.1 Diagnostic Studies for Cerebral Palsy
Laboratory Studies
• Thyroid studies
• Lactate level
• Pyruvate level
• Organic and amino acids
• Chromosomes
• Cerebrospinal protein: Levels may assist in determining asphyxia in the neonatal
period. Protein levels can be elevated along with an elevated lactate to pyruvate ratio.
Imaging Studies
• CT provides diagnostic information for congenital malformations,
intracranial hemorrhage, and periventricular leukomalacia.
• MRI is most useful after 2 to 3 weeks of life. MRI is the best study for assessing
white matter disease in an older child.
• Evoked potentials are used to evaluate the anatomic pathways of the auditory and
visual systems.
CT, computed tomography; MRI, magnetic resonance imaging.
The Diagnostic Workup for Cerebral Palsy
The diagnostic workup for CP included both laboratory and diagnostic radiologic studies, which are enumerated in Table 1.1. Neuroimaging studies
can help to evaluate structural brain damage and to determine those at risk
for CP. Data to support a definitive diagnosis of CP are lacking.
Suggested Readings
Cerebral Palsy Source. www.cerebralpalsysource.com. Accessed December 17, 2007.
National Institute of Neurological Disorders and Stroke. Cerebral palsy: Hope through research:
Available at: www.ninds.nih.gov/disorders/cerebral palsy/detail cerebral palsy.htm. Accessed December 17, 2007.
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Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
More About Cerebral Palsy
More Medical Textbooks Online about Cerebral Palsy
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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