Documentation of Normal Neonatal Reflexes
When the Moro, sucking, and rooting reflexes are normal in a newborn, document: "Primitive reflexes intact: Moro reflex present and symmetric, sucking reflex strong and coordinated, rooting reflex present bilaterally." 1
Essential Documentation Components
Specific Reflex Findings
- Moro reflex: Document as "present and symmetric" when the infant demonstrates bilateral arm abduction followed by adduction in response to head drop, with no asymmetry between sides 1, 2
- Sucking reflex: Record as "strong and coordinated" when the infant demonstrates vigorous, rhythmic sucking on a finger or nipple 2, 3
- Rooting reflex: Note as "present bilaterally" when the infant turns toward tactile stimulation of the perioral area on both sides 1, 3
Quality Descriptors to Include
- Symmetry: Always document whether reflexes are symmetric, as asymmetry indicates potential brachial plexus injury, hemiparesis, or CNS pathology 1
- Strength/intensity: Use descriptors like "strong," "vigorous," or "brisk" for normal responses, as weak responses suggest brainstem or neuromuscular dysfunction 1, 2
- Completeness: Note whether the reflex cycle is complete (e.g., full Moro response includes both abduction and adduction phases) 4, 3
Age-Appropriate Context
- For newborns and infants up to 3 months, these reflexes should be readily elicitable and robust 1, 4
- The Moro reflex may begin weakening after 3 months but should still be present; document if response is diminishing appropriately for age 1
- Rooting and sucking reflexes remain present at 3 months but should be assessed for quality and coordination 1
Common Documentation Pitfalls to Avoid
- Never document simply "reflexes normal" without specifying which reflexes were tested and their characteristics 2, 3
- Avoid vague terms like "adequate" or "okay"—use specific descriptors of strength, symmetry, and completeness 2, 5
- Do not omit laterality for reflexes that should be bilateral (rooting, Moro)—asymmetry is a critical red flag 1, 5
- Document the infant's behavioral state during examination, as reflexes may be difficult to elicit in certain states (deep sleep, crying) 2
Recommended Chart Format
A concise, complete documentation example: "Neurological examination: Primitive reflexes assessed. Moro reflex present bilaterally with symmetric abduction-adduction response. Sucking reflex strong and coordinated. Rooting reflex present bilaterally with appropriate head turning to stimulation." 1, 2, 3