Pediatric Neurologic Examination

HISTORY
Document in chronological order the onset of symptoms Thorough description of frequency, duration and associated characteristics Comprehensive review of function of other organ systems Review of pregnancy, labor and delivery particularly if congenital anomaly is suspected

HISTORY
maternal illness cigarette/alcohol consumption drug use fetal activity birthweight, length, HC APGAR score neonatal course

HISTORY
Comprehensive understanding of developmental milestones is essential
Abnormal development from birth: intrauterine or perinatal cause Slowing of rate of acquisition of skills later: acquired abnormality Loss of skills over time (regression): degenerative disease

Screening Scheme for Developmental Delay: Upper Range

AGE (MO) 3 6 9 12

GROSS MOTOR Supports weight on forearms Sits momentarily Pulls to stand Walks with one hand held Walks upstairs with assistance Runs

FINE MOTOR Opens hands spontaneously Transfers objects Pincer grasp Releases an object on command

SOCIAL SKILLS Smiles appropriately Shows likes and dislikes Plays pat-a-cake, peek-a-boo Comes when called

LANGUAGE Coos, laughs Babbles Imitates sounds 1 2 meaningful words

18 24

Feeds from a spoon Mimics actions of At least 6 others words Builds a tower of 6 blocks Plays with others 2 3 word sentences

HISTORY
Family history History of neurologic disorder: epilepsy, developmental delay, heredo-familial illnesses History of unexplained deaths in the family Consanguineous marriage Patients school performance academic social

EXAMINATION
Observation = Key to examination facies, unusual posture, gait disturbance Catch-as-Catch-Can procedure Do not scare the child Examine the child in a playful manner to gain his cooperation Ball, small toys, bell, other objects that would attract the childs attention

Tools in Neurological Examination Ophthalmoscope Otoscope Neurologic Hammer Tongue Blade Bell Stethoscope Tape measure

Tools in Neurological Examination Brightly colored toys Bell/Rattle Cubes/ Pencils/crayons Pictographs Doll

THE HEAD
Document size and shape premature closure of sutures: craniosynostosis frontal bossing: hydrocephalus Head Circumference: record on every patient at every visit plot on head growth chart place tape over midforehead and extend to the most prominent portion of the occiput take HC of parents and siblings PT: 0.5 cm/ first 2 weeks, 0.75 cm/third week, 1cm/4th week and thereafter until 40th week FT: 34-35 cm at birth, 44cm by 6 mos, 47 cm by 1 yr

THE HEAD

Tools in Neurological Examination

HEAD CIRCUMFERENCE CHARTS

THE HEAD

NORMAL RATE OF HEAD GROWTH

ABNORMAL DECELERATION OF HEAD GROWTH

THE HEAD
Fontanels: normally slightly depressed and pulsatile best examined when baby is held upright and is asleep or feeding bulging = increased ICP, but may be normally protuberant in crying infant

THE HEAD
posterior fontanel: may be closed at birth or admits tip of finger usually closed and nonpalpable after 6-8 weeks persistence suggests hydrocephalus, hypothyroidism anterior fontanel: about 2 x 2 cm. average time of closure is 18 months, may close as early as 9-12 months

THE HEAD
Palpation: over-riding of sutures due to pressure during descent through the birth canal craniotabes: peculiar softening of the parietal bone producing a sensation similar to indenting a ping-pong ball; often associated with prematurity

THE HEAD
Auscultation: Cranial Bruits: AF, temporal region, orbits loud or localized bruit is usually significant and warrants further investigation

CRANIAL NERVES

CN I: Olfactory
Anosmia: most commonly found in association with URTI Basal skull and cribriform plate fracture, frontal lobe tumor Reflex reaction to inhalation of irritants is transmitted by CN V Use aromatic, nonirritating substance (coffee, peppermint) Test each nostril separately

CN II: Optic
Funduscopy Ask someone to show the child a toy behind your shoulder where he can fixate on ROR, AV ratio, disc margins, hemorrhages, exudates

CN II: Optic
Papilledema rarely occurs in infancy because sutures are capable of separating to accommodate the expanding brain Optic nerve becomes hyperemic Capillaries constrict, veins dilate

CN II: Optic
Vision Visual acuity in term infants approximate 20/150 and reaches adult level of 20/20 by 6 months old Older children: use standard eye charts, E chart

CN II: Optic
Dazzle reflex: involuntary avoidance response to a light shined into the eye may be present in normal 28-week-old premature infants by 32 weeks, maintains eye closure until light source is removed

CN II: Optic
Blink reflex: closure of the eyelids when an object is suddenly moved towards the eye (presence of functional vision) Absent in newborn appears by 3-4 months should be present in all infants by 1 year

CN II: Optic
Visual Fields Check quadrants of each eye separately In younger children: present the object from behind, outside the childs field of vision

CN II-III: Optic-Occulomotor
Pupillary light reflex Pupil size, anisocoria: will give you clue as to the level of involvement Direct and consensual light reflex

CN III-IV-VI: Occulomotor-TrochlearAbducens Extraocular movements Visual tracking: complete in all directions by about 4 months of age Acoustically elicited eye movements appear at 5 months old Test in H-pattern Test each eye separately and together Dolls eye maneuver in comatose patients

CN III-IV-VI: Optic-Occulomotor-Abducens Sunset sign: Persistent downward gaze

CN V: Trigeminal
Motor: masseters and temporalis Check the bite Check for atrophy Sensory: V1, 2, 3 Ophthalmic Maxillary Mandibular Corneal Reflex: V-VII: touching the cornea with wick of cotton and observe for eye closure response

CN VII: Facial
Motor: Facial asymmetry Upper motor versus Lower motor neuron

CN VII: Facial
Sensory: Taste Anterior 2/3 of the tongue: chorda tympani Apply sugar or salt solutions to previously dried and protruded tongue

CN VIII: Vestibulo-Cochlear
Younger children: Present auditory stimulus from outside range of vision Turn eyes to sound by 7-8 weeks Turns head to sound by 3-4 months

CN VIII: Vestibulo-Cochlear
Cochlear Hearing Weber testing Conductive hearing loss defective ear Sensori-neural hl better ear Rinne testing air >bone conduction Conductive hl bone> air conduction Normal or sensorineural HL air > bone Vestibular Balance and orientation Oculo-vestibular respone

CN IX-X: Glossopharyngeal-Vagus Phonation and articulation Palatal elevation Swallowing/Gag reflex Taste: Posterior 2/3 of the tongue extremely difficult and not worth the effort

CN XI: Spinal-Accessory
Strength of trapezius and SCMs Turn neck against resistance Elevate shoulders against resistance

CN XII: Hypoglossal
Tongue deviation on protrusion Motility, size, shape, atrophy, fasciculations: ripple or twitch Fibrillations: random, spontaneous contraction of an individual denervated muscle fiber (seen on EMG)

MOTOR EXAMINATION

MOTOR EXAMINATION
Strength Bulk Tone Posture Locomotion and motility Deep tendon reflexes Presence of primitive reflexes

MOTOR EXAMINATION
Muscle strength: Test each muscle group 0- no contraction 1- flicker, trace 2- without gravity 3- against gravity 4- against gravity with some resistance 5- normal power against resistance

 Gowers sign: proximal muscle weakness in which the child climbs up the legs to assume an upright position; Duchenne muscular dstrophy

Gower Sign

MOTOR EXAMINATION
Muscle bulk: atrophy, pseudohypertrophy Muscle tone: muscle resistance the examiner feels when manipulating a joint Hypotonia: abnormally diminished tone Floppy infant: difficulty in maintaining head support or a straight back while sitting

Frog-leg position in supine position

MOTOR EXAMINATION
Hypertonia: Spasticity- initial catch or resistance followed by a yielding of the muscles (clasp knife spasticity) Rigidity: increased resistance felt throughout entire range of motion (lead pipe rigidity)

Scissoring

MOTOR EXAMINATION
Posture: Decorticate: flexion of upper extremities Decerebrate: marked extension of extremities Opisthotonus: Over-contraction of extensor muscles

MOTOR EXAMINATION
Locomotion and Motility: Ataxia: incoordination of movement or disturbance of balance Truncal: cerebellar vermis Peripheral: cerebelar hemispheres Dysmetria: errors in maintaining distances Rebound: inability to inhibit a muscular action Dysdiadochokinesia: diminished performance of rapid alternating movements Romberg sign: unsteady when eyes are closed

MOTOR EXAMINATION
Gait: Lordotic, waddling gait: muscular dystrophies with proximal weakness Toe-drop or foot-drop gait Bilateral foot-drop or steppage gait Hemiplegic gait Ataxic gait

MOTOR EXAMINATION
Abnormal movements Chorea: incessant, random, moderately quick movements Athetosis: slow, writhing movements of fingers and extremities Dystonia: prolonged contraction and relaxation of agonists and antagonists Hemiballismus: violent flinging movements of half of body Tics: quick, lightning-fast stereotyped movements of face, tongue or extremities

MOTOR EXAMINATION
Free-walking, toe and heel walking, tandem walking, deep knee bend, hop on each foot, run Pronator sign: Hand pronates to palm outward as the arms are raised over the head Barre sign: Ask the child to maintain legs in flexion at right angles at the knee

REFLEXES

MUSCLE STRETCH REFLEX

Jaw jerk: CN V Biceps: C5-6 Triceps: C6-8 Brachioradialis: C5-6 Patellar: L2-4 Ankle: S1-2 Strike a crisp blow with a swing of the hammer Jendrassik maneuver: ask the patient to contract a muscle you are not testing

MUSCLE STRETCH REFLEX Biceps ( C 5 - 6)

BICEPS C

MUSCLE STRETCH REFLEX Brachioradialis ( C 5 - 6 )

MUSCLE STRETCH REFLEX Triceps (C 6-8)

MUSCLE STRETCH REFLEX Knee (L2 4)

MUSCLE STRETCH REFLEX Ankle (S1-2)

SUPERFICIAL REFLEXES
Umbilical Migration test (Beevors Sign): stroke quadrants of abdomen towards umbilicus, umbilicus will migrate towards origin of stimulus Cremasteric reflex: L1-L2: Stroke inner thigh towards testicle, ipsilateral testicle will migrate upwards Anal pucker (S4-S5): Pricking the skin around the anus will cause quick, twitchlike constriction of the sphincter

SUPERFICIAL REFLEXES
Extensor toe sign: disturbed pyramidal tract function Normally seen in majority of 1-year-old children up to 2 years old Dorsiflexion of big toe with fanning of other toes Babinski: Chaddock: lateral side of foot Schaeffer: squeeze hard on achilles Oppenheim: squeeze calf muscles Bing: multiple light pinpricks on dorsolateral surface of foot

REFLEXES
Clonus: regular repetitive movement of a joint by a sudden stretching of the muscle Seen in some healthy neonates and tense older children a sustained clonus is abnormal at any age and suggests a lesion of the pyramidal tract

PRIMITIVE REFLEXES
appear and disappear in sequence during specific periods of development gradually suppressed as the higher cortical centers become functional their absence or persistence beyond a given time frame signifies CNS dysfunction

ROOTING REFLEX
Appears at 32 wks AOG less prominent at 1 month elicited by stroking the cheek infant will turn toward the side that was stroked and begin to make sucking motions with his mouth

MORO REFLEX
emerges at 28-32 weeks AOG inhibited between 5-6 months of life elicited by a sudden dropping of the head in relation to the trunk

MORO REFLEX
infant responds by abduction and extension of arms, hands open p abduction and flexion, closed fists

PALMAR GRASP REFLEX

appears at 28 wks AOG inhibited by 2-3 months place your finger into the palm of the baby's hand p thumb will come over and lock your finger, then the baby's other fingers will lock in the thumb and your finger very tightly

PLANTAR GRASP REFLEX

emerges at 11 wks AOG suppressed between 7-9 months place your finger or a stimulus into the metatarsal arch of the foot p ball of the foot drops and the heel comes in and the baby actually locks your finger, grasping it with the feet

TONIC NECK REFLEX

emerges at 35 weeks AOG inhibited between 6-7 months of life elicited when the head of a relaxed child, lying on his back, is rotated to the side

TONIC NECK REFLEX

arm toward which the infant is facing extends straight away from the body with the hand partially open, while the arm on the side away from the face is flexed and the fist is clenched tightly resembles the stance of a fencer

PARACHUTE REFLEX
Appears between 4-9 months elicited by holding the child upright then rotating the body quickly face forward (as if falling) The arms are reflexively extended as if to break a fall even though this reflex appears long before walking

Timing of selected Primitive Reflexes

Reflex Palmar Grasp Rooting Moro Tonic Neck Parachute Onset 28 wks 32 wks 28-32 wks 35 wks 7-8 mos Fully Developed 32 wks 36 wks 37 wks 1 mo 10-11 mos Duration 2-3 mos Less prominent after 1 mo 5-6 mos 6-7 mos Remains throughout life

SENSORY EXAMINATION
Pain and temperature: Use broken tongue depressor, sight of needles might scare the child Posterior columns: Vibration Position
Level of involvement C2: back of head C4: shoulders C6: thumbs T4: nipple line T10: umbilicus L1: inguinal area L5: big toe S1: small toe S2 posterior thigh

MENINGEAL SIGNS
Nuchal rigidity Kernigs Brudzinski

MENINGEAL SIGNS
Nuchal rigidity: Resistance to flexion but not extension Kernigs: bent-knee and straight-knee legraising test Brudzinski: adduction and flexion of the legs as you attempt to flex the neck

EXAMINATION OF INFANTS
Evaluation of Posture and Tone Resting Posture Passive Tone Active Tone Evaluation of Primitive Reflexes Examination of Age-Invariable Items

RESTING POSTURE
Inspect the undressed infant as the infant lies undisturbed

RESTING POSTURE
First few months: normal hypertonia of flexors of elbows, hips and knees

RESTING POSTURE
3rd month: hypertonia decreases markedly; tone in neck and trunk increases 8th-12th month: further decrease in flexor tone with increase in extensor tone

By 3 months, baby starts to uncurl

PASSIVE TONE
Determines resistance to passive movement of various joints Infant should be awake and not crying Keep head straight, limb tone is affected by tonic neck reflex Passive flapping of hands and feet

PASSIVE TONE
SCARF SIGN: take infants hand and pull the arm across the chest towards the opposite shoulder if elbow passes midline p HYPOTONIA

PASSIVE TONE
FALL-AWAY RESPONSE: suspend the child by the feet, upside down, release each lower extremity in turn note rapidity in which the lower extremity drops NORMAL: stays up momentarily, then drops HYPO: drops immediately HYPER: released LE stays up

ACTIVE TONE
TRACTION RESPONSE: obtained by slowly pulling the baby by the hands to achieve a sitting position healthy infant < 3 months: elbows flex and a backward pull is felt by the examiner, flexor neck muscles are stimulated and head is maintained briefly in the axis of the trunk

ACTIVE TONE
TRACTION RESPONSE: HYPOTONIC: shows head lag, no arm pull is felt by the examiner, the arms remain extended as the body is pulled up, and the legs remain in contact with the bed

VERTICAL SUSPENSION
elicited by holding the child with both hands under the axillae NORMAL: good shoulder and head support and flexion at the hips, knees, and ankles

VERTICAL SUSPENSION
HYPOTONIA: poor shoulder support, the head drops, and the lower extremities remain extended and limp

VERTICAL SUSPENSION
HYPERTONIA: marked suspension or scissoring is an indication of spasticity

REFLEX PLACING AND STEPPING

Appears at 37 weeks disappears by 4-5 months PLACING: elicited by stimulating the dorsum of the foot against the edge of the examining table

REFLEX PLACING AND STEPPING

STEPPING: walking movements like those of an adult

LANDAU REFLEX
The Landau reaction is elicited by placing the child in a horizontal, prone suspension The child will extend his neck, head, and arms, Lower extremities are flexed. Appears by 9-10 months old

LANDAU REFLEX
With hypotonia, infants body tends to collapse in an inverted U-shape

RIGHTING REFLEX
Appears 4-8 mos. With the infant in supine position, the examiner turns the head to one side the healthy infant rotates the shoulder in the same direction, followed by the trunk and finally the pelvis abnormal: infant can be turned over like a log with shoulder, trunk and pelvis rotating simultaneously

RIGHTING REFLEX
Appears 4-8 mos. With the infant in supine position, the examiner turns the head to one side the healthy infant rotates the shoulder in the same direction, followed by the trunk and finally the pelvis abnormal: infant can be turned over like a log with shoulder, trunk and pelvis rotating simultaneously

AGE-INVARIABLE TESTS
Other tests similar to those performed in older children and adults DTRs: limited value except when asymmetric triceps and brachiordadialis: difficult to elicit during period of neonatal flexion hypertonia

AGE-INVARIABLE TESTS
CROSSED-ADDUCTOR REFLEX: Patellar reflex is accompanied by adduction of the opposite thigh disappears by 9-12 months of age

PERCENTAGE OF HEALTHY BABIES SHOWING VARIOUS INFANTILE REFLEXES WITH INCREASING AGE
SIGNS THAT DISAPPEAR WITH AGE
AGE IN MONTHS MORO TONIC NECK CROSSED ADDUCTION

SIGNS THAT APPEAR WITH AGE

LANDAU PARACHUTE NECKRIGHTING

1 2 3 4 5 6 7 8 9 10 11 12

93 89 70 59 22 0 0 0 0 0 0 0

67 90 50 34 31 11 0 0 0 0 0 0

? ? 41 41 41 21 12 15 6 3 3 2

0 0 0 0 29 42 42 44 97 100 100 100

0 0 0 0 0 3 29 40 76 79 90 100

13 23 25 26 38 40 43 54 67 100 100 100

REFLEX ROOTING PALMAR PLANTAR MORO TONIC NECK PLACING/STEPPING LANDAU

AGE APPEARS 32 WKS AOG 28 WKS AOG 11 WKS AOG 28-32 WKS AOG 35 WKS AOG 37 WKS AOG 9-10 MONTHS

AGE DISAPPEARS 1 MONTHS 2-3 MONTHS 7-9 MONTHS 5-6 MONTHS 6-7 MONTHS 4-5 MONTHS Covered up by voluntary action Covered up by voluntary action Covered up by voluntary action

PARACHUTE

4-9 MONTHS

RIGHTING

4-8 MONTHS

There is nothing right in my left brain, There is nothing left in my right brain