Pediatric and Infant Neurologic Examination by William Hills:
PMH: immunization status, accidents, chronic medical problems; Espec pertinent to szs—head trauma, febrile szs, status epilepticus, meningitis Medications (when discussing szs, include previous AEDs and response) Developmental milestones (may use the Denver II) Family history: epilepsy, neurocutaneous syndromes, migraines, neurodegenerative disorders, etc
General Physical :
field of vision, noting the location at which the child turns his or her head towards this second toy -The blink reflex appears at about 3 to 4 months. Present in about 50% at 5 months and 100% of children at 12 months.
CN III, IV, and VI (oculomotor, trochlear, abducens) (LR6SO4). -extraocular movements -pupillary size and reaction to light. Pupils may be large and not responsive to light in babies earlier than 30 weeks -The Doll’s eyes phenomenon can also be used to assess extraocular movements in a comatose patient with an intact brainstem. -In conscious patients, the cortical input “overrides” the Doll’s eyes phenomenon. -cold calorics. In order to do this test, 5 mL of ice water is squirted into the external ear canal in comatose patients or 0.5 mL in alert, awake patients, and the action of the eyes are noted. -There are three possible responses to this test. 1) comatose patient with an intact brainstem, the eyes move in the direction of the stimulus. 2) alert, awake patients, there is nystagmus with the quick component in the opposite direction of the stimulus. 3) without a functioning brainstem, there is no movement of the eyes when cold calorics are performed. ***One needs to remember that cold calorics test vestibular function (CN VIII). CN V (trigeminal) -sensation of the face. -temporalis and masseter muscles can test the motor roots of this cranial nerve. –corneal reflex also checks the ophthalmic branch of CN V.
CN VII (facial nerve) -facial asymmetry. -Taste in the anterior two-thirds of the tongue is innervated by the chorda tympani branch of VII, and can be checked by applying salt or sugar solutions by cotton-stick applicators.
CN VIII (auditory) cochlear and vestibular function can be tested by the child’s response to a bell or by recalling a whispered word or number. Noting the eye movements after turning the infant several times in a clockwise and counterclockwise direction can check vestibular function. CN IX, X (glossopharyngeal, vagus) -uvula and palate. -If there is a vagal nerve problem, the uvula will deviate toward the unaffected side, and the palate will move away from the affected side. -The gag reflex actually tests parts of IX and X –IX is the afferent sensory limb (sensory to the back of the pharynx) –X controls the muscles of the pharynx and elevation of the palate.
CN XI (spinal accessory) -turn his/her head against resistance, sternocleidomastoid muscle.
CN XII (hypoglossal) -tongue deviates toward the affected side.
3. Motor System
Observing the child’s posture and simple maneuvers such as retrieving a ball or running outside the examination room can check motor integrity. The following grading system can be used for assessing muscle strength: 0 – No muscle contraction 1 – Flicker or trace of contraction 2 – Active movement without gravity 3 – Active movement against gravity 4 – Active movement against gravity and resistance 5 – Normal strength (for age, keeping in mind that you as the examiner may be stronger) pronator sign – sensitive test to assess the strength for the upper Barré sign. having the child keep both knees at right angles while lying prone. Strength of the flexors of the knee
4. Cerebellar function how a child reaches for and manipulates toys can check for coordination. FFM, FTN, RAM, or rapid tapping of the foot can assess for dysdiadochokinesia
5. Sensory – -pinprick, light touch, position, and vibration sense -Object discrimination, which tests for higher cortical functions, can be done using coins, paper clips, or rubber bands.
6. Reflexes. Jaw jerk (CN V) biceps (C5-6) triceps (C6-8) brachioradialis (C5-6), patellar (L2-4) ankle (S1-2). Babinski’s sign – pyramidal tract dysfunction + Babinski’s sign = dorsiflexion of the great toe and fanning of the toes. Can be normal up to 1 year of age so symmetry is the important feature to look at below 1 year. May be seen after a seizure. Clonus – maintaining dorsiflexion of the foot. Sustained clonus is abnormal at all ages
Neurological examination of the infant. 1) Posture and muscle tone 2) Primitive reflexes 3) Age invariable items.
7. Posture and muscle tone. 1) resting posture -observing the infant undressed. The infant should have flexion of the elbows, hips, and knees (varying with age). Hypertonia in the extremities decreases after 3 months of age, with the upper extremities then the lower extremities. At the same time, tone in the trunk and neck increases. 2) passive tone – determining resistance of passive movements of the joints while the infant is awake and not crying. One can do this by flapping the hands and feet, and by other maneuvers. The scarf sign is where the arm is pulled across the chest and if the elbow passes the midline, then hypotonia is present. 3) active tone – traction response up to 3 months of age. The infant’s hands are held with the examiner’s thumbs in the infant’s palms, and the fingers around the wrists. The infant is slowly pulled to a sitting position. Normally the elbows flex and the neck raises the head. If hypotonia is present, then the head lags backward, then as the erect position is assumed, the head then drops forward. If hypertonia is present, the head is maintained backwards.
Primitive reflexes. -present from the time of birth -represents spinal reflexes until the infant becomes older and higher cortical functions suppress them.
Vertical suspension. The infant is suspended by holding the chest with both hands and lifting the patient in an upright position, with the legs dangling. Scissoring or hyperextension of the legs is seen= spasticity is present; consider cerebral palsy
Horizontal (ventral) suspension (Landau reflex) – Infant is held prone with the examiner’s hand under the trunk, is gently lifted upwards. Normally, the spine extends a little so that the eyes are looking just below the horizontal. If the body collapses into an upside down “U” shape, then hypotonia is present.
Segmental medullary reflexes. sucking reflex -afferent fibers of CN V and IX -efferent fibers of CN VII, IX, and XII.
Moro reflex. -head hyperextended, falling back about 3 centimeters in relation to the trunk. A normal response is seen when the infant opens his hands, extends and abducts the arms, and then brings them together, followed by a cry. It is present in all newborns and disappears before the age of 6 months.
Tonic neck response. (AKA fencer’s stance) -this reflex can be elicited when the head is turned to the side while the rest of the body lies flat on the table. A normal response is extension of the arm and leg on the side that the head is turned, and flexion of the arm and leg on the opposite side (similar to a fencing stance). Abnormal responses occur when this response is sustained or if it occurs differently when the head is turned to the right or left (i.e., the response is not the same when tested on both sides). It usually disappears about 6 to 7 months of age.
Palmar and plantar grasp reflexes. They are performed by applying gentle pressure to the palm or sole. An abnormal response occurs when this response is absent before 2 to 3 months of age or asymmetric. The palmar grasp reflex should disappear by 6 months; the plantar by 9 to 10 months.
Parachute response. The infant is suspended horizontally with the face down, and is brought quickly down toward the floor, making sure that the infant is firmly held. A normal response should be seen at 8 to 9 months and consists of arms extended and hands open. Reflex placing and stepping responses. Reflex placing is seen when the dorsum of the foot is placed against the edge of the examination table. Reflex stepping is seen when the sole of the foot is placed on the table, and the infant appears to be walking. This reflex disappears at about 4 to 5 months of age.