Neurologic Examination of the
Pediatric Patient
Introduction: The neurologic
examination of the infant/child is very
similar to that of the adult with one
very important exception. It is much
harder!! You have to rely on your powers
of observation as the child usually can
not tell you what the problem is.
Symmetry vs. asymmetry is very important
in the pediatric neurology examination.
Basic Components of the Pediatric
Neurological Examination
Chief complaint, history, mental status,
cranial nerves, motor, sensory,
coordination, gait
Chief complaint: What is the
patient’s or parent’s perception of the
problem that brought them in to see you
today. You may be surprised at the
answers you get if you remember to ask
this question at the beginning of your
encounter.
History: Make sure to include all
components of the history as described
below.
History of present illness. Describe
chronology in terms of “days prior to
this visit”. Descriptors such as “2
weeks ago” are unhelpful to others
reviewing your history at a later date.
How long have they had this problem? Is
it something they have noticed or was it
noticed/brought to their attention by
their doctor, school etc. Has it ever
happened before? What evaluations have
they already had for this problem. What
treatments have they tried (you know,
the “what makes it better, what makes it
worse”)
Birth History
1) Prenatal history: Duration of the
pregnancy, maternal infection, maternal
use of medications, drugs including
alcohol, tobacco, toxemia, vaginal
bleeding, maternal disease such as
diabetes, thyroid, myasthenia gravis,
maternal PKU, quality/quantity of fetal
movement during the pregnancy, product
of multiple gestation pregnancy
2) Birth: C-section? Why?, hx of fetal
distress, apgars, prolonged rupture of
membranes, maternal fever, duration of
labor, did the infant required
resusitation? Apgar scores? Growth
parameters at birth.
3) Perinatal/neonatal: Neonatal
jaundice, neonatal fever, cyanosis,
hypotonia, apnea, seizures, length of
hospital stay
Developmental history: Be sure to ask
the age at which skills are acquired.
Any loss of milestones, slowing of
development or regression. Review of all
developmental areas is critical: Motor
(gross and fine) Social, Language,
Cognitive. Early onset handedness: hand
preference develops at around 18months.
Children that are “right handed” since
birth may have a left hemiparesis!
“Potty training” is an important
milestone. Loss of bowel or bladder
control may signify seizures, spinal
cord disorders such as tethered cord
syndrome or mass.
Review of systems: It’s true what
they told you in medical school, this
really is important. It’s your chance to
find out what other symptoms they might
be having.
Go through the standard organ
systems. In addition, questions
important for neurologic history
include: Have their been frequent
hospitalizations for dehydration or
feeding intolerance. Lead exposure? Head
trauma?
Family History
-seizures
muscular dystrophy (age of presentation
of relatives, level of severity
-consanguinity
-frequent spontaneous abortions in
mother and first degree relatives (ask
sex of fetus)
-blood disorders
-abundant birth marks
Examination
OBSERVATION, GENERAL MEDICAL
EXAMINATION, MENTAL STATUS, CRANIAL
NERVES, MOTOR, REFLEXES, SENSORY,
CEREBELLAR, GAIT
OBSERVATION
Watch the child during your history.
Observe him during play/interactions
with family and surroundings. Look for
any hyperactivity, any asymmetry to
movements, excessive irritability,
lethargy
GENERAL EXAMINATION
You should do a complete general
examination of the child.
HEENT/HEART/LUNGS/ABDOMEN/GU/EXTREMITIES
HEAD
RECORD GROWTH
PARAMETERS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
YOU MUST MEASURE HEAD CIRCUMFERENCE ON
ALL YOUR PATIENTS!!!!!!!!!!!!!!!!!
Mean HC at birth is 35 cm. Compare
all growth parameters as microcephaly in
the context of a normal height and
weight is obviously more concerning.
Head grows 2 cm in the first month, 6 cm
by 4 months and 12 cm by the first year.
If you suspect microcephaly/macrocephaly
always measure the parents and siblings
head.
-Ascultation of the head may reveal
bruits.
Examination of the anterior
fontanelle is important.
-This is best done when infant is
upright.
- Pulsations are normal.
-a soft, full fontanelle is acceptable
when the baby is crying or lying down
Appearance
Dysmorphic Features
Birth marks
-hypopigmented macules: tuberous
sclerosis
consider woods light (ultraviolet light
examination of child and parents)
-hyperpigmented spots: neurofibromatosis
-linear nevi on scalp (may be associated
with seizures)
Examine midline of neck and back looking
for skin dimples
Check the palmar creases
Check ear position
Unusual body odors : may suggest
metabolic disorders
Cranial Nerves
This is a difficult exam in the
uncooperative child. Much of what you
learn is from close observation of the
child.
CN 1: Not always tested. May not be
functional until 5-7 months. Babies who
grimace after given a noxious stimulus
probably had their trigeminal nerve
stimulated
CN 2: Funduscopic exam in children is
similar to playing a Nintendo game.
Discs are normally pale in the infant
and appear like optic atrophy in the
adult. Retinal hemorrhages are seen in
1/3 vaginally delivered infants. Note
whether infant can track objects. At 8
wks the infant should be able to fixate
and follow. Look for optokinetic
nystagmus as a way to check for
fixation. To check visual fields in a
child, show them a toy in their central
vision and slowly bring in another toy
from the periphery. Check the red reflex
on #10 black of the ophthalmoscope.
CN 3,4,6: Note position of the eyes at
rest. Loke for “setting sun sign” as a
sign of increased intracranial pressure.
Check eye movements in all four
quadrants-try to get child to follow
brightly colored toy. Upgaze is limited
for the first six months of life
LR6 (SO4) 3 Lateral rectus is cranial
nerve 6, superior oblique is cranial
nerve 4, all the rest of the Extraocular
muscles are cranial nerve 3
CN 5: Sucking- tests masseter
strength.
Corneal reflex: sensory 5, motor 7
Jaw jerk- if hyperactive suggests upper
motor neuron lesion
CN 7: Look for symmetry upon smiling
and crying. Rooting reflex
UMN: only lower face
LMN: upper and lower face
CN 8: Ability to turn eyes to the
direction of a sound (7-8 weeks)
Turning of eyes and head to sound (3-4
months)
CN 9: Asymmetry of palate, uvula.
Palate sensation and gag
CN 10, 11: Excessive drooling, hoarse
cry
CN 12: Note how strong the suck is.
Observe for tongue fasiculations. The
tongue deviates toward the paralyzed
side. ( The normal function of the
genioglossus is to push the tongue to
the opposite side)
Motor System
Think BATS
BULK, ABNORMAL MOVEMENTS, TONE, STRENGTH
BULK
Look for any asymmetry in muscle bulk
(hemiparesis, lower motor neuron palsy)
vs a generalized decrease
( muscular dystrophy/anterior horn cell
disease, nutritional)
Abnormal movements
Tremor, fasiculations, myoclonus
Tone
The normal resting tone of the full
term infant is predominantly flexor.
They rest with their arms and legs
semi-flexed.
-premature infants are hypotonic in
comparison
*look for extended legs at rest, history
of “great head control” at birth as
clues to hyPERtonicity
*look for frog-leg position of lower
extremities, exaggerated “scarf sign” as
clues to hyPOtonicity.
( In the scarf sign the baby’s arm is
drawn medially across the chest noting
the position of the elbow. If the elbow
crosses the midline in the full term
infant this is a sign of decreased
tone.)
Hypotonic infant: think sepsis,
drugs, hypoglycemia, chromosomal,
cretinism, anterior horn cell disease,
myopathy.
Strength
Grading of muscle strength
0: No muscle contraction
1: A “flicker” of muscle contraction
2: Active movement of a joint with
gravity eliminated
3: Active movement of a joint against
gravity
4: Active movement against gravity and
against resistance
(weak of varying degree (4+/5, 4/5,
4-/5)
5: Normal
Hand preference develops at 18-24
months. Early hand preference suggests
hemiparesis. Compare thumb size of two
hands. An old hemiparesis usually has a
smaller thumb on that side.
Test a child’s distal strength by
offering a toy and noting the resistance
to your pull. Test a child’s proximal
muscle strength by asking them to stand
up from a supine position with arms
folded across their chest. If they use
their hands to “walk up themselves”,
this is an indication of proximal
weakness (Gower’s sign)
Reflexes
Deep tendon reflexes are normally brisk
in children even into adolescence.
Looking for symmetry is the key.
Triceps reflex is usually not developed
in the infant
4-6 beats of ankle clonus is acceptable
up to two months of age
Crossed adductor reflex can be present
up to one year
Extensor plantar reflexes (babinski
sign) are acceptable up to the time the
child learns to walk
Grading of reflexes
0: no response
1+ decreased response
2+ normal
3+ hyper
4+ hyper + clonus
Sensory exam
Difficult and unreliable in the infant
Primary sensory modalities are touch,
pain, temp, vibration (with a 128 hz
tuning fork)
Cortical (integrated sensory modalities)
are stereognosis, graphesthesia, 2 point
discrimination
Cerebellar
Finger to nose: show child a light and
ask him to touch the light
Rapidly alternating movement-synkinesis
(mirror movements of opposite hand)
common up to preschool age
Gait
Look for hemiparetic gait, circumduction
of the foot, clumsiness, wide-based
nature to gait.
Ask child to walk on heels, toes and
tandem walk (difficult for children
before school age)
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