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Newborns do a lot of strange movements and behaviors that quite often scare parents. What are normal newborn reflexes, and when should parents worry?

The first one most parents know and call the startle reflex. It's technically called the Moro reflex. Parents often tell me it's when their baby gets scared, but that's not really the reason. Babies don't get scared as newborns. It's due to their nervous system response to a sudden change in sensory stimulation.

And it's a good thing, actually. In fact, it's able to be seen on ultrasounds when a mom is only 16 weeks pregnant, and a baby's own cry can even stimulate it. It lasts until babies are about 2 to 3 months old.

So when should you worry? Well, if you had a difficult labor and there was concern that your baby might have had some oxygen deprivation, then an exaggerated Moro reflex could be concerned for something called hypoxic-ischemic encephalopathy. Basically, the brain is hurt by having the oxygen supply cut down.

Neurologists can help evaluate and treat this, and the good news is it's picked up really closely after birth. And if there's any concern, your baby will be in the intensive care unit really quickly for a full evaluation. If your baby is otherwise in the normal newborn nursery and goes home, there's a good chance this is not what your baby has.

Another normal reflex is the suck or rooting reflex. And that's just what it sounds like. It's basically what helps the baby learn to find a food source and eat. This reflex doesn't start until about 32 weeks of pregnancy, which is why preemies have such a hard time learning how to eat. This reflex is fully developed at about 36 weeks.

Now, when parents see this, they automatically think their baby is hungry and often that's true. It could be that it's just the reflex and they suck on their fingers and hands as a self-soothing behavior. I see a lot of parents trying to force their babies to eat and then the babies get over-full and throw up.

Then there's the tonic neck reflex. We call it the fencing reflex because they have one arm outstretched and one bent and they're about to say, "En garde!" Some parents worry that there is a problem because both arms aren't in the same position or both arms aren't being used the same way at the same time. But this is normal, and it can last until they're about 7 months old.

Finally, this isn't a reflex, but it's something parents ask me about all the time at the newborn checkups. It's called periodic breathing. Babies do this weird thing where they look like they're breathing really fast, then they can hold their breath for up to 10 seconds, and then they take a big breath in and then they're back to normal breathing. And it can happen when they're sleeping or when they're awake. And it usually lasts until they're about 6 months old.

Babies' lungs are still developing and their brains are still trying to figure out how to send messages to the lungs to remind them to breathe. Basically, they are still trying to figure out this whole breathing thing and breathing patterns. And it looks scary, but it's normal.

So when should you worry about your baby's breathing? If they're consistently breathing more than 60 times a minute, if they're having retractions where it looks like their stomach muscles are sucking in under their ribs, if they are making grunting noises with each breath, or if they hold their breath for more than 20 seconds and turn blue, those are not periodic breathing, and that needs to be evaluated right away to see if your newborn's oxygen is low. Depending on how severe the symptoms are, the best place for your newborn to be evaluated for breathing issues may be the emergency room.

One last thing. What about those eyes? Well, babies have very little control over their eye movements right away. That's why they always look at you cross-eyed. They're trying to figure out how to control their eye movements and learn to focus on things.

Also, it's not uncommon for a baby to roll their eyes when they're sleeping or when they're almost asleep, like when they're going to sleep or trying to wake up. But this should not be the norm. If they are not rolling their eyes but doing more of a rhythmic back and forth, something called nystagmus, that is absolutely not normal.

If your baby rolls their eyes often, that is not normal. If your baby's eyes roll and your little one also has stiffness in their arms or legs or has shaking that doesn't look like the startle reflex, that could be a seizure and that's an immediate trip to your local children's emergency room.

Many things can cause seizures in a new baby, including low blood sugar, low calcium levels, metabolic diseases, or brain abnormalities, in addition to epilepsy and high fevers. Your child will probably be admitted to the hospital and see a neurologist for tests to determine why they are having these weird movements and possible seizures.

So while a lot of these normal behaviors look concerning, they are often just part of your baby adjusting to being in the outside world. If your baby has any of the not-so-normal behaviors I talked about, please have them see their pediatrician right away or go to your closest pediatric emergency room.

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Interviewer: The Will Smith movie "Concussion" focuses on a condition called Chronic Traumatic Encephalopathy. Dr. Colby Hansen is from the University of Utah Orthopedic Center Concussion Clinic. Dr. Hansen, tell me about this condition.

Dr. Hansen: Well, I think in general there's still so much for us as a scientific community and as a medical community to understand about this entity that is highlighted in the movie, chronic traumatic encephalopathy. I mean, it seems pretty clear that trauma is a common denominator, but we don't know to what degree genetics may play into this, to what degree other types of issues may play into it, either mental health disorders or whatnot. We don't know at what amount of exposure to trauma people are put at risk. Just frankly, there's a lot to tease out before we start being over-reactionary and pulling the plug on sports and things of that nature.

Interviewer: The condition that they're talking about in the movie, what exactly is that?

Dr. Hansen: Chronic traumatic encephalopathy is really a diagnosis that can only be made postmortem or after death by autopsy. What some of these researchers are seeing are abnormal collections of clumps of protein called tau that has also been linked to other degenerative diseases like Alzheimer's dementia. They've seen these under the microscope of some of these former athletes, and there's really no denying that they've seen this. So now they're in a phase of trying to characterize are there maybe certain areas of the brain where you get this kind of collection more than others, to what degree does this correlate with known behaviors or symptoms that the patient was experiencing while they were alive, and then ultimately trying to make the link back to the sport or the activity that they were engaged in. People would generally feel or believe that not every football player who progressed through to the NFL has this disorder, so who does and who doesn't and what are the differentiating factors between who does and who doesn't.

Interviewer: Do people that don't play football develop this disease?

Dr. Hansen: At least in terms of the case series, the group at Boston led by Dr. Ann McKee, who's a neuro pathologist there, has studied the most brains and they are not exclusively football players. This disorder was originally described many, many years ago, many decades ago, in boxers, and was termed Dementia Pugilistica which literally means "boxer's dementia." We would assume that the common denominator is trauma, but we don't know much beyond that. How much trauma, at what age the trauma occurred, there's even a lot of debate now not in just concussions, but just the repeated impacts that don't necessarily produce a clear, observable concussion.

At the end of the day there is so much for us to learn, to understand, about not only the impacts of a single concussion and how is the best way to manage it, how is the best way to assess it, but of course the long-term ramifications of concussions and repeated concussions in the health of our athletes and anybody who's active.

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Interviewer: Are concussions more serious than people think? We'll find out next on The Scope.

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Interviewer: Dr. Greg Hawryluk is a neurosurgeon at University of Utah Healthcare. It seems like there's a lot in the news and in popular culture about concussions nowadays, and we're starting to learn that maybe they're a little bit more serious than we first thought. It feels as though at one point, if you got a concussions somebody would go, "How many fingers am I holding up?" If you passed the test, great. You're okay. But it's a little bit more serious than that, we're starting to learn.

Dr. Hawryluk: That's exactly the case. First off, what I can tell you is that it's probably an epidemic. There's probably way more concussion out there than we've ever really known. We're only now starting to see a lot of people coming to doctors with their concussion.

Interviewer: So how serious is a concussion in terms of the damage caused to the brain?

Dr. Hawryluk: The problem there is that we really don't know. We don't think that a concussion implies a structural injury to the brain. We still think that it's probably sort of a chemical imbalance. But there's no question that we do think it puts you at risk for ongoing damage to the brain, perhaps over the rest of your life. We are seeing something we call chronic traumatic encephalopathy, changes consistent with Alzheimer's disease in the brain. It really is suggesting that athletes need to be a lot more careful in terms of avoiding concussions and having them treated by a doctor, than has been the case in the past.

Interviewer: So a concussion is when your brain actually hits your skull. Right? So it's not a physical bruise in terms of like what a muscle is. But it causes a chemical imbalance. Explain that.

Dr. Hawryluk: Yeah. There's a few misconceptions about concussion. So one is that you don't actually have to hit your head to have a concussion, and you don't have to lose consciousness. Really, all that has to happen is your brain sloshes around inside your skull. The hallmark is that there's at least a temporary change in brain function. But in fact, we don't see bruising of the brain. We think that probably it's a chemical imbalance that leads to the brain dysfunction. If it gets to the point where there's actually bleeding in or around the brain that is an even more serious condition.

Interviewer: What does that chemical imbalance look like? What's going on there?

Dr. Hawryluk: It's something we really don't understand. It's something that's hard to study. What's really funny to me as both a neurosurgeon and as a scientist is that we haven't made more progress in this field. We can put people on the moon, but we really don't understand what's going on. In some senses, we're sort of at square one with concussion. The important thing is that we're recognizing the significance of it. But there's an awful lot more work to do to figure out what's going on and how to best treat these.

Interviewer: If I understand correctly, a single incident can be bad, can cause symptoms and damage. But it's the multiple incidents without recovery time that you're really worried about.

Dr. Hawryluk: Well, that's absolutely true. We're concerned about both cases. One concussion is certainly a concern and has to be appropriately treated. These days, we certainly advise that every concussion should be seen by a doctor. But our level of concern as physicians goes up quite a bit when we start to see multiple concussions. The worst case scenario that we worry about as doctors is basically a repeat head injury before the first concussion is fully resolved.
The reason that that's so important is because we actually see people die from that. There's something called "second impact syndrome." So if a player, for instance, goes back to playing football before their first concussion is resolved, some of those patients have died. We know that there's a tremendous amount of brain swelling that can occur in that instance, and that's one of the biggest things that we're trying to avoid and get word out to both players and coaches. That once you've had a concussion, you need to sit out and be seen by a doctor.

Interviewer: Outside of football is that the case, say for example, I was skiing and took a hard hit and got a concussion. Could the same thing happen if I got a second concussion as a football player?

Dr. Hawryluk: That's absolutely the case. One of the challenges with concussion is that a lot more things can cause concussion than I think a lot of people realize. Football is one that we would all think of. But I always tell people, I remember a time when I was younger and when I was on a roller-coaster, and I'm pretty sure I had a concussion on that roller-coaster. So, really anytime that you're jarring your head around that's a big issue.

Interviewer: If I get that one-time concussion, whether I'm playing a sport or in an accident, or something like that, should I be super-concerned above and beyond seeing a doctor?

Dr. Hawryluk: Well, the biggest thing is to see a doctor. The biggest change of concussion management over the last 10 years has been the idea of rest and graduated return to normal activities. We do think that we've learned that that leads to the best recovery from a concussion. After any sort of a concussion, the minimum amount of time it takes to fully get back to what you were doing before in terms of activities is about a week.
Some recommendations say that in children it should probably take twice that long to get back to normal activities. So, that needs to be medically supervised. There's usually six steps that we talk about as people go back to their normal activities. The good news with concussion is that the vast majority of people have a resolution of their symptoms and ultimately do quite well. There are, however, a minority of patients, maybe 20% that even six weeks out from a concussion are still having trouble, something we call "post-concussion syndrome." But the good news is that fortunately that's a minority of people.

Interviewer: Are there long-term repercussions to concussions then?

Dr. Hawryluk: Well, there certainly can be. So we think that at some level there is a brain injury, and we certainly worry about the accumulative effects. We are starting to learn, again with these professional athletes that perhaps these seemingly minor blows to the head when they're accumulative can lead to depression and behavior change. In fact, we think that maybe even some suicides have been linked to this.

Interviewer: Which comes back to that chemical imbalance [inaudible 00:06:16].

Dr. Hawryluk: That's exactly right.

Interviewer: That makes total sense.

Dr. Hawryluk: Yep.

Interviewer: What's the future hold? What do you think we're going to find in the next 5, 10 years? You said it's in its infancy. Where are things going?

Dr. Hawryluk: Yeah. It's a time where the concussion field is advancing in a lot of different directions. We're learning more and more about the basic science of the condition. We're learning more about how to treat these patients and how to manage them in terms of their sporting activities.
One of the things that is something I think an awful lot about is people that are participating in contact sports. I'm hearing a lot of parents these days with reservations about having their children play hockey or football. I think to a certain extent that's reasonable. But if I look back on my own life, the lessons that I learned playing sports with other kids is so important for socialization and it's important to be active and to be healthy.
So I just have a bit of concern that the way this conversation seems to be going is should kids be participating in some of these sports? What I always counsel my patients and their families is that I really think participation in sports have so many benefits that I hate to see kids pulled out. I think really what's important is encouraging safe play. The reality is that most concussions we think are probably preventable. Teaching players to treat each other with respect, to obey various rules for safety, I think those are the key. Again, I just worry about kids not participating because of some of these fears.

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