Examination of CRANIAL NERVES AND MOTOR SYSTEM OF CHILDREN- FOR UG PAEDIATRICS

1. EXAMINATION OF CRANIAL NERVES
&
EXAMINATION OF MOTOR SYSTEM

2. There are twelve cranial nerves, which le
ave the brain and pass through foramina in
the skull.
All the nerves are distributed in the head an
d neck except the
tenth, which also supplies structures in t
he thorax and abdomen
THE CRANIAL NERVES
I. Olfactory II. Optic III. Oculomotor IV.
Trochlear V. Trigeminal VI. Abducent
VII Facial VIII Vestibulocochlear
IX Glossopharyngeal X Vagus
XI Accessory XII Hypoglossal

4. 1rst Nerve- Olfactory
nerve

5. -
use oil of cloves or peppermint/as
afoetida/coffee
-
test each nostril separately
In newborn, the history suggests
the newborn turn towards breast
of mother
By smell

6. 2ND Nerve OPTIC NERVE

7. In newborns, fixing at soft light(light
from window of a dark room).
Follow red wool ball. Pupillary reflex
present from 28 weeks onwards.
--
Visual acuity younger age : use torc
h or bright toy
picture book/wall pictures
> 6 yrs : Snellen chart or finge
r counting
---
Color vision : use 3 primary color
( red, green, blue) ‐ > 3
yrs

8. younger children by moving a light/toy
Menace reflex
We test the defensive eye blinking reaction
of the child by moving the examiner’s
fingers suddenly and threateningly towards
the patients eyes.
This is used in uncooperative patients
whose vision is suspect

10. 3,4 & 6

12. Nystagmus : horizontal/vertical
Squint ‐
paralytic ‐range of eye movements impaired
vision normal
‐ nonparalytic /concomitant –
range of eye movements normal and vision defective

18. In babies, eye movements- spontaneous and elicited by doll’s
eye manoeuvre; pick up the baby and gently rock backwards
and forwards and from side toside observing eye movements.
Tonic deviation to one side could mean seizure.

20. 5 NERVE TRIGEMINAL NERVE

23. Motor ‐ ask to clench the teeth
and palpate over the cheek and templ
e (masseters & temporalis )
‐ask to open the mouth wide‐ja
w deviates to the paralyzed side (
pterygoid)
Sensory ‐test sensations over for
ehead, cheeks and chin ( ophtha
lmic, maxillary and mandibular division
s)

25. 7TH NERVE FACIAL NERVE

26. Observe the child cry.
Trauma of forceps
delivery most common
cause of LMN facial
palsy in the newborn

28. Lower motor neuron lesion of 7th ne
rve results in complete lack of ip
silateral facial movements
‐
Upper motor neuron lesion –
only lower half of the face is affecte
d (upper part of the face has bilatera
l cortical innervation )
‐ Bell’s phenomenon in LMN lesion‐(
when the child attempts to shut the
eyes ,eyeball will roll upwards)
11

29. 8TH NERVE VESTIBULO COCHLEAR NERVE

30. In babies, behavioural
response to sound( startle,
blinking, change in heart
rate etc). Bilirubin
encephalopathy and
intrauterine infection
cause deafness.

35. 9th nerve glosso -pharyngeal nerve

37. In babies,position of uvula during
crying.choking during feeding
Nasal regurgitation of fluids and nasal twang of voice

39. Bulbar palsy LMN palsy of nerves originating from t
he bulb(medulla) –
no jaw jerk or gag reflex pooling of secretions
Pseudobulbar palsy
UMN palsy of nerves originating from the medulla
Jaw jerk and gag reflex exaggerated
Pyramidal signs present Tongue small and spastic
f

40. 11 th Nerve; Spinal accessory nerve

43. Trapezius muscle
‐ Tested by shoulder shruggi
ng against resistance ‐ Dr
ooping of shoulder on paralyze
d side and scapula drop
to lower level

45. 12 th nerve hypoglossal nerve

47. In babies, suck
and swallow
9,10,12
Ask the child to protrude the tongue‐ it deviat
es to the paralyzed side
‐Fasciculation of tongue in Wernig –
Hoffman disease
‐Atrophy of tongue on affected side in
LMN palsy ‐ In UMN palsy ,tongue is spastic
, thin and pointed

49. EXAMINATION OF
MOTOR SYSTEM
• Bulk of muscles ‐
• Tone of muscles •
• Muscle Power
• Co‐ordination
• Involuntary movements if any

50. BULK OF MUSCLES
• Measure the size of the muscles

51. Tone is the resistance offered by the muscles to passive stretching
• Hypotonia – LMN lesions, spinal shock of UMN lesions , some cerebellar lesions
• Hypertonia ‐ spasticity or rigidity
Spasticity –
pyramidal tract involvement unequal involvement of gravity and
antigravity muscles
Rigidity ‐ extrapyramidal involvement uniformly increased in both agonist and
muscle groups
Muscle tone examined by
Inspection‐
Palpation
Passive movements Shake test
Small infants by different angles –
adductor , popliteal , dorsiflexion an
gles etc

53. In small infants, tone can be assessed by different angles.Angles are not assessed beyond 12 months
of age.The head must be kept in the midline as turning to oneside changes the tone. These include
Scarf sign
In the supine infant, the upper limb is pulled across the chest holding the flexed elbow.Elbow does
not cross the midline in infants less than 3 months of age where in hypotonic infants, it crosses the
midline.

54. Heel to ear manoeuvre
Lift both the legs of the supine infant without lifting the pelvis from table and try
to bring it to the ear.

55. Adductor angle; In the supine infant , the hips are abducted by holding onto the
extended knee. The adductor angle between the thighs. It is less than 75 degree
below three months of age.
Ankle dorsiflexion: It is the angle between the dorsum of the foot and the
anterior aspect of leg when the foot is dorsiflexed on to the anterior aspect of
the leg

57. MUSCLE POWER ‐ GRADING
0 – no movements
1 – flickering/feeble movements
2‐ with gravity eliminated
3 – against gravity
4 ‐ against partial resistance
5 ‐ full strength
Tested for groups of muscles moving various joints
‐ neck, shoulder, elbow , wrist, intercostals, diaphr
agm, abdomen, hip, knee, ankle

59. Neck : Extend and flex the neck against resistance offered at occiput and chin respectively
Movements at shoulder: abduct and elevate the arm beyond 90 degree resistance offered at mid arm.
Flex (bring towards the chest) and extend the arm
Movements at elbow: Flex and extend the fore arm against resistance. Test supination and pronation against
resistance.
Movements at wrist: Let the child make fist with hand: now the child is requested to flex and extend at wrist joint
against resistance.
Grip: Ask the child to grasp examiner’s finger with the examiner trying it to pull it off.When done simultaneously
on both sides, the power can be compared in unilateral weakness.
Upper abdomen: Ask the child to raise the head and chest in supine position without arm support.
Lower abdomen: Ask the patient to raise his extended legs without arm support.
Movements at hip: ask the supine child to raise the extended leg off the couch against resistance offered at thigh.
Movements at knee; test knee flexion and extension. Gravity eliminated movement is tested in side position.
Movements at ankle: Test dorsiflexion, plantar flexion, inversion and eversion against resistance.

60. COORDINATION MOVEMENTS
‐ Finger‐nose test and heel‐knee test in older
children
-
For smaller children closing a pen with cap or o
pening chocolate wrapper etc
- Tested only if power is > grade 3

61. INVOLUNTARY MOVEMENTS
• Tremor Rhythic involuntary oscillatory movements. Tested by asking the child to keep
the hand outstretched with the fingers apart.
Fine – hyperthyroidism, anxiety
Coarse ‐ intention tremor
• Fasciculation ‐ muscle bundle Fibrillation ‐ single muscle fibre
• Chorea ‐ semi purposive ,sudden jerky movements
Milk maid sign: Ask the child to grasp the examiners fingers, Alternate squeezing and
relaxing of the child’s fingers will be felt by the examiners fingers
Pronator sign: Ask the child to hold the extended upper limbs above the head with palms
facing eachother. The hands tend to pronate.
Jack in box sign;Ask the child to protrude the tongue and keep it outside.The tongue goes
on moving in and out of mouth
• Athetosis ‐ slow writhing movements of extremities seen in extrapyramidal type of
cerebral palsy
• Dystonia – sustained muscle contraction in abnormal postures also seen in
extrapyramidal type cranial palsy

62. Superficial reflexes ‐ Corneal/conjunctival reflex‐ V /VII nerves ‐
Abdominal reflex ‐ T6 to T12 stroke abdominal wall from lateral to medial side
elicits contraction of the anterior abdominal wall muscles lost in cortical lesions
‐
Cremastric reflex ‐ stroke the medial thigh – L1,L2, elevation of ipsilateral testis ‐
Anal reflex‐ S3, S4 ‐stroke the perianal region puckering of anal surface ‐
Plantar reflex ‐ L5,S1‐ stroke the lateral aspect of sole normal response is plantar
flexion of big toe with fanning of other toes ; dorsiflexion of big toe sugges
ts an upper motor lesion (Babinski sign)
REFLEXES

63. GRADING OF DEEP TENDON REFLEXES
0 – absent
1 – sluggish , present only with reinforcement (+)
2‐ readily elicited, like normal ankle jerk (++)
3‐ brisk , like a normal knee jerk (+++)
4‐ clonus (++++)

64. Deep Tendon Reflex
Biceps jerk –
C5,C6‐ with he child’s arm semi flexed at the elbow ,resting on the examin
er’s arm, strike over examiner’s thumb placed over the biceps tendon

65. Supinator jerk –
C5,C6 Arm in same position as for Biceps jerk, strike on the styloid process of radius wit
h a hammer
supination of forearm
Triceps jerk –
C6, C7 Elbow flexed to 90 degree with wrist placed across the patient’s chest.
Strike the triceps tendon above the olecranon. Extension of elbow

66. JAW JERK (Trigeminal roots)
Place the examiner’s index finger on the patient’s lower jaw (with mouth slightly
open) and strike - closure of the mouth ‐
exaggerated reflex indicates a lesion above the pons and in quadriplegic cerebral
palsy.

67. KNEE JERK –
L2, L3, L4 1) Patient supine , flex the knee at 120‐ 150 degree which rests
on the examiner’s left palm ; tap on the patellar tendon 2) patient sitting u
p legs dangling freely --extension of knee

68. ANKLE JERK –
S1,S2 Keep the lower limb everted on the bed with slight extensi
on at knee. With the left hand of the examiner placed under the s
ole ,dorsiflex the foot to 90 degree so as to stretch the tendo Achi
lles and strike on the tendon - contraction of calf muscles and
plantar flexion

69. Repetitive rhythmic contractions of a muscle evoked by a stretch stimulus
Ankle clonus
–
flex the patient’s knees lightly and support the popliteal fossa with left hand. S
uddenly dorsiflex the fore foot with the right hand from the plantar aspect and
continue to apply pressure – sustained clonic contractions occur in calf muscles
Patellar clonus ‐ push the patella towards the foot –
series of contractions of quadriceps occur

70. PRIMITIVE REFLEXES
Assessment of primitive reflexes –
this needs to be performed in young children and children with developmental delay. These are normally
present in NB and disappear by 3 months to 1 year of life
Moro, rooting , sucking , grasp reflex etc
Moro reflex; sudden extension of head in relation to the trunk response- Opening of hands by 28 weeks
Extension and abduction of upper extremities by 32 weeks , anterior flexion and adduction 37 weeks
Audible cry
Disappears by 3-4 months, indicator of infants level of alertness. Depressed or absent moro –generalised
depression of the CNS.Bilateral exaggerated reflex seen in kernicterus
Sucking and rooting reflexes;present at birth if baby is 34 weeks or mature and persist upto 4 months when
awake & upTO 6 months when asleep. Rooting is elicited by touching the corner of mouth with finger and
baby turn toward it to latch on to it
Palmar grasp elicited by stroking the ulnar aspect of palm.
At 37 weeks palmar grasp strong to allow lifting up of infant from bed.Appears by 28 weeks and disappears
byb2-3 months Marked retention of this reflex beyond 6 months athetoid cranial palsy