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Moro reflex

The Moro reflex, also known as the startle reflex, is a primitive, involuntary motor response observed in newborn infants, triggered by stimuli such as a sudden drop in head position or a loud noise, which simulates the sensation of falling and prompts a protective extension and abduction of the arms, followed by adduction and flexion toward the body.^[1]^[2] This reflex serves as an innate survival mechanism, activating the vestibular system in the inner ear to detect changes in balance and signaling the brainstem to initiate the response, often accompanied by crying, fanning of the fingers, and slight extension of the neck and spine.^[1]^[2] First described in 1918 by Austrian pediatrician Ernst Moro, the reflex is a normal feature in full-term infants and emerges during the third trimester of gestation, around 28 to 30 weeks post-conceptional age, due to the maturation of neural pathways in the brainstem.^[1]^[2] It is typically elicited during clinical examinations by gently allowing an infant's head to drop a short distance (about 1 inch) while held supine, without lifting the head first, though it can also occur spontaneously in response to startling sounds or movements.^[1] The reflex peaks in intensity around 1 month of age and gradually integrates with voluntary motor control, fading by 3 to 4 months and fully disappearing by 6 months as higher brain centers develop, often transitioning into the more coordinated Strauss reflex.^[1]^[2] In preterm infants, the reflex may be weaker due to lower muscle tone but still indicates appropriate neurological maturation if present.^[1] Clinically, the Moro reflex is a key indicator of central nervous system integrity in newborns; its absence at birth may signal severe conditions such as birth asphyxia, intracranial hemorrhage, or spinal cord injury, while asymmetry could point to brachial plexus damage, clavicle fracture, or unilateral neurological deficits.^[1] Persistence beyond 6 months raises concerns for developmental disorders like cerebral palsy or hyperekplexia, a rare genetic condition causing exaggerated startle responses, necessitating further pediatric evaluation.^[1]^[2] As one of several primitive reflexes assessed in neonatal care, it underscores the rapid neurological evolution in early infancy and aids in early detection of potential health issues.^[1]

Introduction and Description

Definition and Characteristics

The Moro reflex is a primitive, involuntary motor response observed in human infants, first described by Austrian pediatrician Ernst Moro in 1918 as the "embracing reflex."^[1] It is triggered by sudden disruptions to balance or intense sensory stimuli, such as a perceived fall or loud noise, and serves as an early indicator of intact neurological function in newborns.^[3] The response is symmetric and involves the upper limbs primarily, with the arms abducting and extending outward in a characteristic "embrace" posture, fingers splaying open, accompanied by extension of the neck and often a cry or startled facial expression.^[4] The reflex unfolds in distinct phases, beginning with an initial extension phase where the arms fling outward and upward as if reaching to grasp or protect, while the head and trunk may briefly extend.^[1] This is followed by a return phase, in which the arms adduct across the chest in a hugging motion, with fingers potentially curling and the limbs flexing back toward the midline, completing the sequence in approximately 1-2 seconds in full-term newborns.^[3] Lower limb involvement can occur variably but is not a defining feature.^[4] Unlike the adult startle reflex, which is predominantly flexion-dominant and primarily auditory in origin—featuring rapid elbow flexion, hand clasping, and forward head movement—the Moro reflex emphasizes extension movements and arises mainly from vestibular (balance-related) inputs.^[5] Notably, the Moro response can be elicited even in anencephalic infants lacking cerebral hemispheres, underscoring its brainstem-mediated nature, whereas the adult startle pattern requires higher neural integration and persists lifelong.^[6] In typical development, the Moro reflex integrates and disappears between 3 and 6 months of age as voluntary motor control emerges.^[1]

Elicitation Procedures

The Moro reflex is typically elicited in clinical settings using a standardized procedure that simulates a sudden loss of support to the infant's head, triggering the innate startle response. The infant is positioned supine on a soft, padded surface to ensure safety and comfort. The examiner gently supports the infant's head and upper body, lifting it slightly forward—just enough to shift some body weight—before abruptly releasing the head to allow a passive drop of approximately 2-3 cm backward, while immediately providing support to prevent any impact. This method does not require fully lifting the head off the surface or causing an actual fall, and it reliably produces the reflex in healthy newborns without risk of injury.^[7]^[8]^[1] An alternative standard approach involves grasping the infant's arms gently at the wrists while in the supine position and pulling them upward slightly in a symmetrical manner, followed by a sudden release to mimic a head drop sensation. This arm-release technique is particularly useful in neurological examinations as it avoids direct head manipulation and can be performed without elevating the infant's body. In both methods, the response consists of an initial phase of arm abduction and extension followed by adduction, observable within seconds.^[1]^[9] Variant elicitation methods are employed when the standard techniques yield inconsistent results or for specific observational purposes. The "baby drop" method positions the infant supine with the examiner's hands supporting the chest and head in midline; the entire body is then abruptly lowered 10-20 cm and halted suddenly, simulating a free-fall stimulus that activates the vestibular system. Another variant uses a subcutaneous painful stimulus applied to the epigastrium, which heightens sensitivity in cases where milder triggers are insufficient, though this is less common due to the discomfort it may cause. These variants maintain the same supine positioning but adjust the intensity of the stimulus for targeted assessment.^[9] Reliable elicitation requires the infant to be in a relaxed, awake state without distress, crying, or recent feeding, as agitation can suppress the reflex or lead to asymmetric responses. The procedure is most consistently observable in infants at a post-conceptional age of 30 weeks or greater, when muscle tone is sufficient; preterm infants below this threshold often exhibit weak or absent responses due to immaturity. Testing should be conducted symmetrically to evaluate bilateral integrity, and multiple trials may be needed if the initial response is subdued.^[1]^[9]^[8] Precautions are essential to prevent harm during elicitation, including the use of a firm yet padded surface, limiting any head or body drop to minimal distances (no more than 2-3 cm for head release or 20 cm for full-body lowering), and ensuring immediate support to avoid hyperextension or collision. The reflex should be brief and symmetric; prolonged or unilateral responses warrant further evaluation but do not alter the procedural approach. These methods are integral to newborn neurological screening, confirming typical primitive reflex integration.^[7]^[9]^[8]

Physiological and Functional Aspects

Neural Mechanisms

The Moro reflex is primarily mediated by brainstem structures, particularly the pontine reticular formation and vestibular nuclei, which serve as key integration centers for sensory inputs from the vestibular system, neck proprioceptors, and auditory pathways. These structures enable rapid processing of sudden stimuli, such as changes in head position or loud sounds, without requiring higher brain involvement in newborns.^[10] The sensory-motor pathway begins with afferent signals from vestibular stimulation via cranial nerve VIII, relaying to the vestibular nuclei in the medulla, or from auditory input through the cochlear division of cranial nerve VIII to the pontine reticular formation. Proprioceptive feedback from neck receptors, detecting head displacement, converges in these brainstem areas. This integrated input activates efferent pathways, including the vestibulospinal and reticulospinal tracts originating from the pontine reticular formation, which descend to excite bilateral motor neurons in the spinal cord at levels C5 to T1, resulting in coordinated upper limb extension and abduction.^[10] As neural development progresses, the Moro reflex becomes modulated by descending inhibition from higher cortical regions, reflecting the maturation of suprasegmental control over brainstem circuits; in early infancy, the absence of significant cortical participation underscores its primitive, reflexive nature. This brainstem-centric organization positions the Moro reflex within a hierarchy of primitive reflexes, where it operates at a supraspinal level distinct from purely spinal reflexes like the palmar grasp, yet shares reticular formation activation for overarching motor coordination.^[10]

Protective Function

The Moro reflex functions primarily as a protective response to sudden disruptions in balance or startling stimuli, such as a perceived fall, prompting the infant's arms to extend and then adduct in a motion resembling clinging to secure attachment to a caregiver. This involuntary action enhances immediate physical safety.^[1] The reflex further integrates with crying to reinforce its alerting role while supporting the foundational development of vestibular and motor systems essential for postural control and balance. Evidence from clinical studies indicates that the absence of a robust Moro reflex at birth correlates with motor developmental delays, particularly in very low birth weight infants, highlighting its contribution to early neurological integrity and adaptive motor readiness.^[11]^[12]

Developmental Timeline

Onset in Gestation

The Moro reflex emerges during the third trimester of fetal development, with initial components becoming detectable prenatally. Observable elements, such as arm extension in response to stimuli, can be identified as early as 25 weeks post-conceptional age through ultrasound imaging, reflecting the onset of primitive neural pathways in viable fetuses.^[1] This early detectability aligns with observations in extremely premature infants born at similar gestational ages, where the extension phase of the reflex is present in some cases, indicating intrauterine maturation of motor responses.^[13] Full maturation of the reflex, marked by a complete and symmetric response involving bilateral arm abduction, extension, and subsequent adduction, typically occurs by 28 to 32 weeks of gestation. This timeline corresponds closely with the developmental milestones of the brainstem and vestibular system, which provide the foundational neural substrate for integrating sensory inputs like sudden head movement or displacement with coordinated motor output.^[1] Prenatal factors significantly influence the reflex's onset and expression. Prematurity often delays the full elicitation of the response, as seen in infants born before 32 weeks, who may exhibit incomplete or asymmetric patterns due to underdeveloped neuromuscular coordination. Similarly, very low birth weight infants, particularly those under 1,500 grams, demonstrate weaker reflex intensity at birth, attributable to immature central nervous system maturation and reduced muscle tone.^[13]^[1] In utero assessment of the Moro reflex holds diagnostic value in fetal neurology, aiding evaluations of neuromuscular integrity and central nervous system function. Ultrasound-guided observation of startle-like responses to vibroacoustic or positional stimuli serves as a non-invasive marker for fetal well-being, correlating with reassuring biophysical profiles and helping identify potential neurological risks when absent or atypical.^[14]^[15]

Integration and Disappearance

In full-term infants, the Moro reflex exhibits its strongest response during the early postnatal phase, particularly in the first 1-2 months of life, when it serves as a prominent protective mechanism against sudden disruptions in balance.^[1] This period coincides with the reflex's full elicitation at birth, following its prenatal onset, and it begins to integrate into more voluntary motor patterns around 8-12 weeks as the infant's nervous system matures.^[16] During this integration, the reflex's intensity gradually decreases, allowing for the emergence of controlled movements that replace involuntary responses. The fading process of the Moro reflex occurs through a gradual diminution driven by descending cortical inhibition from the maturing pyramidal tracts, which suppress brainstem-mediated primitive reactions in favor of higher-level motor control.^[3] In full-term infants, this results in the reflex typically becoming absent by 4-6 months of age, marking a key aspect of neurological maturation.^[1] For preterm infants, the timeline is evaluated using corrected gestational age, with integration generally aligning to the same 4-6 month window; however, weaker initial responses due to lower muscle tone may extend observed persistence slightly, though retention beyond 6 months corrected age often signals delayed myelination or other maturational delays.^[16] This resolution of the Moro reflex aligns closely with major developmental milestones, such as the achievement of head control around 2-3 months and supported sitting by 6 months, signifying the transition from reflexive to voluntary movements that enhance postural stability and exploration.^[2] The coincidence underscores the reflex's role in early balance protection, which diminishes as cortical pathways strengthen to support intentional actions.^[11]

Clinical Evaluation

Assessment in Newborns

The assessment of the Moro reflex is a standard component of the newborn neurological examination, typically conducted within the first 24 hours after birth to evaluate overall neurodevelopmental integrity.^[11] This reflex is elicited bilaterally by placing the infant in a supine position, supporting the head and neck, gently lifting the head slightly, and then allowing it to drop back approximately 2 cm while maintaining support, prompting observation of the characteristic phases: initial abduction and extension of the arms followed by adduction and flexion toward the midline.^[1]^[7] Clinicians assess for symmetry between sides and amplitude of the response.^[17] The examination is performed in a quiet, dimly lit environment to minimize external stimuli that could confound the response.^[18] Scoring criteria for the Moro reflex emphasize its completeness and quality rather than numerical quantification in routine screening. A full, complete response—encompassing both extension and return phases with symmetric arm movement—is scored as positive and normal.^[1] An incomplete response, limited to extension without adduction, or an absent response may indicate variations in tone or maturity, while asymmetry suggests potential focal issues.^[19] These observations contribute to a qualitative evaluation within the broader primitive reflex profile, without a standardized numerical scale in typical newborn checks.^[17] Age-specific norms guide interpretation, with a robust, symmetric Moro reflex expected in all healthy term newborns (gestational age ≥37 weeks) from birth onward, reflecting mature brainstem function.^[1] In preterm infants born before 30 weeks gestation, the reflex is typically weaker or incomplete due to hypotonia and immature neural connectivity, though it strengthens with postmenstrual age progression toward term equivalence.^[1] The reflex normally integrates and diminishes between 3 and 6 months postnatal age in full-term infants.^[1] The Brazelton Neonatal Behavioral Assessment Scale (NBAS) incorporates detailed evaluation of the Moro reflex as part of its motor maturity and reflex cluster, scoring it on a 4-point scale for quality and integrating it with behavioral observations like habituation to provide a holistic neurobehavioral profile. In clinical practice, the reflex is routinely reassessed during well-child visits at 2, 4, and 6 months to monitor its expected integration, ensuring timely detection of persistent primitive responses.^[17]

Abnormal Presentations and Implications

The absence of the Moro reflex in newborns is a significant indicator of severe neurological compromise, often resulting from perinatal insults such as birth asphyxia, intracranial hemorrhage, or extreme prematurity.^[1]^[20]^[21] In cases of bilateral absence, this finding particularly suggests central brain damage, as it reflects a generalized disturbance of the central nervous system rather than localized peripheral issues.^[22] The reflex may be notably weak or diminished in very low birth weight infants, who often exhibit associated motor delays due to immature neuromuscular development.^[1]^[23] An asymmetric Moro reflex, where the response is diminished or absent on one side, typically points to peripheral injuries sustained during delivery, including brachial plexus palsy, clavicle fracture, or cervical spine trauma.^[1]^[3] This unilateral weakness is more pronounced on the affected side and arises from mechanical stretching or compression of nerves or structures during birth.^[24] Persistence or hyperactivity of the Moro reflex beyond the typical integration period of around 6 months is associated with underlying neurodevelopmental disorders, such as spastic cerebral palsy, where primitive reflexes fail to inhibit appropriately.^[1]^[25] Similarly, exaggerated or hyperactive responses can occur in hyperekplexia, a genetic startle disorder characterized by excessive muscle tone and startle reactions, or in severe congenital anomalies like hydranencephaly.^[1]^[3] In neonatal opioid withdrawal syndrome, a hyperactive Moro reflex is a common central nervous system sign, reflecting irritability and heightened excitability from in utero exposure.^[26] Retention of the reflex past 6 months generally signals broader developmental delays and warrants monitoring for conditions impacting neurological maturation.^[23] These abnormal presentations carry important diagnostic implications, prompting immediate further evaluation to identify and address underlying pathology. An absent or persistent reflex often leads to neuroimaging studies, such as MRI or CT scans, to assess for central nervous system damage like hemorrhage or hypoxic-ischemic encephalopathy.^[1] Asymmetry, in contrast, necessitates orthopedic or neurological referral to evaluate for fractures, nerve injuries, or spinal trauma, potentially involving physical examination and imaging of the affected limb or neck.^[27] Early identification through these variants facilitates timely intervention, improving outcomes in affected infants.^[11]

Historical Background

Discovery by Ernst Moro

The Moro reflex was first observed and described by Ernst Moro, an Austrian pediatrician, in 1918 during routine examinations of newborns.^[1] While placing an infant supine on an examining table, Moro noted that tapping the pillow on either side of the infant's head elicited a characteristic response: the infant's arms would suddenly abduct and extend outward, often accompanied by a cry, before adducting and flexing in an embracing motion.^[28]^[29] This observation highlighted a distinct primitive reflex in healthy term infants, distinguishable from other startle-like behaviors.^[28] Moro detailed this finding in his 1918 publication titled "Das erste Trimenon," presented as a lecture on May 7, 1918, to the Society of Natural History and published in the Münchener Medizinische Wochenschrift (volume 65, pages 1147–1150).^[28] In the paper, he named the reflex the Umklammerungsreflex, or embracing reflex, interpreting the arm movement as an instinctive clasping action reminiscent of an infant seeking maternal protection. The term 'Moro reflex' was later adopted in English and international literature to honor its discoverer, while retaining the original German designation in some contexts.^[30] Moro emphasized its potential protective function, suggesting it served as an adaptive response to perceived threats in the newborn's environment.^[31] This discovery occurred amid the early 20th-century surge in pediatric research, as neonatology emerged as a specialized field focused on newborn physiology and reflexes, driven by advances in understanding infant development and survival.^[32] Initially, Moro and contemporaries viewed the reflex primarily as a generalized startle response to sudden stimuli, though subsequent refinements identified its primary vestibular basis through head position changes.^[1]

Subsequent Research and Understanding

In the decades following Ernst Moro's 1918 description, researchers expanded the understanding of the Moro reflex by integrating it into standardized batteries of primitive reflexes for neonatal neurological assessment. During the 1920s to 1940s, early systematic evaluations, such as those in developmental schedules by Arnold Gesell, incorporated the Moro reflex alongside other primitive responses to gauge infant motor and sensory maturity, laying the groundwork for its use in detecting early neurological deviations. By the mid-20th century, Heinz F.R. Prechtl's foundational work in the 1950s and 1960s further refined these assessments, emphasizing the Moro reflex's role in evaluating brainstem function and overall neurodevelopmental integrity through observable response patterns.^[29] Mid-century investigations in the 1950s and 1960s clarified key distinctions between the Moro reflex and the adult-like auditory startle response, highlighting their differing neural pathways and elicitation mechanisms. Studies using animal models demonstrated that the Moro involves vestibular and proprioceptive inputs leading to bilateral arm extension and abduction, unlike the more rapid, flexor-dominant startle triggered primarily by auditory stimuli.^[29] Observations in anencephalic infants, who lack higher cortical structures but retain brainstem nuclei, confirmed the Moro's origins in the lower pons and medulla oblongata, as the reflex remained elicitable despite forebrain absence.^[29] These findings, reviewed in later syntheses, underscored the Moro's primitive, brainstem-mediated nature, distinct from the habituating startle pattern that persists into adulthood.^[29] Advancements in fetal ultrasonography from the 1980s through the 2000s enabled precise observation of the Moro reflex's prenatal emergence, confirming its onset around 25 weeks post-conceptional age in most cases, with full expression by 30 weeks. Pioneering ultrasound studies by Prechtl and colleagues in the 1980s visualized fetal startle-like responses to sudden movements, correlating them with maturing vestibular systems and providing empirical evidence for the reflex's gestational timeline previously inferred from postnatal exams. These non-invasive techniques, refined in the 1990s and 2000s, revealed variations in reflex amplitude tied to fetal maturity, enhancing prognostic tools for neurodevelopmental outcomes.^[29] In the 2010s, research linked the Moro reflex to evolutionary adaptations, interpreting its arm-abduction phase as a vestigial clinging behavior inherited from primate ancestors, where it facilitated infant attachment to caregivers during sudden displacements. Comparative studies of primate infants showed analogous responses strengthening grip on fur, suggesting the human Moro as a ritualized remnant promoting survival through parental proximity.^[33] Concurrently, genetic investigations tied exaggerated Moro persistence to hyperekplexia, a heritable disorder involving mutations in glycine receptor genes (e.g., GLRA1), disrupting inhibitory neurotransmission and amplifying startle responses; updates through 2025 highlight targeted therapies like clonazepam for symptom management.^[1]^[34] Recent studies have addressed gaps in understanding preterm variations and the reflex's communicative dimensions, moving beyond its classification as a mere protective arc. In preterm infants born before 34 weeks, the Moro often manifests as weaker or asymmetric, persisting longer post-term equivalent age due to delayed myelination, necessitating adjusted clinical benchmarks for accurate assessment.^[29]^[1] Furthermore, analyses portray the Moro as a ritualized nonverbal signal, integrating cry, gaze, and limb gestures to elicit caregiver response, with phylogenetic roots in mammalian separation-distress systems that foster bonding and reduce isolation risks.^[35]

References

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Stage 3 (severe): stupor, flaccidity, seizures, small pupils that react poorly to light, decreased stretch reflexes, hypothermia, and absent Moro reflex.
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Signs of NOWS . Central nervous system irritability. High-pitched, continuous crying. Decreased sleep. Tremors. Increased muscle tone. Hyperactive Moro reflex.
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