2. Outlines
ā¢ History
ā¢ Anthropometry/Development assessment
ā¢ Examining of head / Dysmorphic Child
ā¢ The neurological examination
ā¢ HMF
ā¢ Cranial Nerves
ā¢ Motor system
ā¢ Sensory system
ā¢ Reflexes
ā¢ Signs of meningeal irritation
ā¢ Cerebellar signs
ā¢ Pearls on examining infants and Older Child
3. Introduction
ā¢ The CNS in a children is a dynamic, developing and maturing system
ā¢ A daunting task to assessment of CNS
ā¢ Special tricks and adoption of āplay attitudeā is mandatory
ā¢ History is often imprecise as child cannot explain or express
4. Normal Neurologic Growth and Development
ā¢ What additional questions are important for a complete pediatric neurology
history?
ā Antenatal
ā Perinatal
ā Neonatal Complications
ā Neurodevelopment
ā Immunizations
ā Behaviour
ā Family History
ā Social History
5. Key points in History
ā¢ Presenting symptom
ā¢ Onset: Sudden/ Subacute/ Insidious
ā¢ Evolution: Improving/Slow Progression/Rapid progression
ā¢ Any symptom of raised ICP/Seizure/LOC
ā¢ Development before onset of symptom
ā¢ Mental status- Alert/ irritable/ lack of interest/ drowsy/ stuporous/ comatose
ā¢ Feeding History/Family history/ Consanguinity
ā¢ Etiological history- Perinatal events/trauma/drugs toxin/infections if any
6. Principles and art of Examination
ā¢ Pre-requisite/ Essential tools
ā¢ Setting- well lighted room, colourful comfortable, warm hands
ā¢ Position
ā¢ 0-3 months ā Examination table
ā¢ 3mont ā 1 yr - Mothers lap
ā¢ 1-3 yr -Standing / Mothers lap
ā¢ After 3 yr - Examination table
ā¢ Adolescent girl - Female attendants
18. Developmental screening
ā¢ Gross motor Development
ā¢ Fine motor/ Visual
ā¢ Social/ Adaptive and language Development
ā¢ Red Alerts
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23.
24. Red Alerts
ā¢ Lack of Social smile by 2 months
ā¢ Absence of stable head control by 4 months
ā¢ Inability to recognize the mother by 6 months
ā¢ Inability to sit when pulled to sit by 6 months / independent sitting by 8 months
ā¢ Lack of creeping by 9 months
ā¢ Inability to stands without support by 1yr
ā¢ Inability to walk without support by 18 months
ā¢ Lack of pincer grasp by 1 yr
ā¢ Absence of syllabic babbling by the age of 1 yr
ā¢ Failure to make meaningful sentences by 3 years
25. Anthropometry
ā¢ Weight
ā¢ Length/ Height
ā¢ Head circumference
ā¢ Assessment of - Mid arm circumference/ Subcutaneous fat/ Arm span/
Obesity
26. Head Circumference
ā¢ Brain growth takes place 70% during fetal life, 15% during infancy and
remaining 10% during pre-school years.
ā¢ Head circumference are routinely recorded until 5 years of age.
ā¢ If scalp edema or cranial moulding-
measurement of scalp edema may be inaccurate until fourth or fifth day
27. Expected head circumference in children
ā¢ Head Circumference Growth Velocity
ļTill 3 months 2 cm/month
ļ3 months ā 1 year 2cm/3 month
ļ1 ā 3 year 1cm/ 6 month
ļ3 ā 5 year 1cm/ year
ā¢ During first year there is 12 cm increase in head
circumference , while 1 ā 5 year age , only 6 cm gain
occur in head size.
Age Head circumference (cm)
At birth 33 ā 35
2 months 38
3 months 40
4 months 41
6 months 42 - 43
1 year 45 - 46
2 years 47 - 48
5 years 50 - 51
30. Head Examinations
ā¢ Size/ Shape/ Symmetry/Sutures
ā¢ Fontanels-Depressed/ Flat/ Buldged
ā¢ Six at birth
ā¢ Two large ant/post
ā¢ Anterior fontanel (2.5Ć2.5cm) closes by 12-18 mnths
ā¢ Posterior fontanel small at birth closes by 6 weeks
ā¢ Two Anterolateral/ two posterolateral
40. Higher Mental Function
ā¢ Emotional status- Assess behaviour/ perception and emotional
liability/ hyperactivity/ attention/ distractibility/ impulsiveness
ā¢ Memory and Orientation
ā¢ Immediate/Recent/ Remote(above 5yrs)
ā¢ Time / Place / Person
ā¢ Name of school/ teacher/ father/ friends
ā¢ Ability to obey simple commands
ā¢ Tell a brief story and repeat the same
ā¢ Repeat no forward/ Backward
6yr repeat forward five digits and backward three digits,
10 yr six digits forward and four digits backward
41. Speech
ā¢ Aphonia/Dysphonia- Volume or intensity of speech affected
ā¢ A child is asked to blow out a candle or count 1 -100
ā¢ Wernickeās aphasia/ Brocaās Aphasia/ Dyslexia(slowness in reading, mirror
image writing, reading from right to left)
ā¢ Disorders of Articulation- āPaā āTaā āKaā
ā¢ Stammering/ lalling or baby speech
ā¢ Scanning and Staccatto speech/Slurred
ā¢ Spastic / Slurring dysarthria
ā¢ Nasal Speech
ā¢ Autism Spectrum disorders
42. Signs of Meningeal irritations
ā¢ Absent-infants <3 months/ malnourished child/ seriously sick pt.
Early Sign Late Sign
45. Cranial nerve exam:
Olfaction CN(I)
ā¢ Olfactory sensation as transmitted by the olfactory nerve is not
functional in the newborn
ā¢ Present by 5 to 7 months of age.
ā¢ Anosmia/ Parosmia
46. Cranial Nerve-
ā¢ Optic nerve(II)
Visual Acuity-
Infants Blinking response/ Turning of head towards light
Above 3 yr ā E Chart
Field of vision
tested after 3yrs(confrontation)
Perimetry feasible after 8-9 yrs
Colour vision
above 3 yr
Fundus exam
Optic disc infant- pale
Papilledema/Papillitis- elevated disc,
blurred edges, obliteration of physiological cuff
āEā chart
47. III, IV, VI CN
ā¢ Movements are complete in all directions by
approximately 4 months of age,
ā¢ Acoustically elicited eye movements appear at 5
months of age .
ā¢ Ptosis/ Diplopia
ā¢ Head tilt
ā¢ Dolls eye movement Infant
ā¢ Depth perception using solely binocular cues
appears by 24 months of age
ā¢ Stable binocular alignment and optokinetic
nystagmus.
49. Facial (VII) CN
ā¢ Impaired motor function is indicated by facial asymmetry.
ā¢ The McCarthy reflex, ipsilateral blinking produced by tapping the supraorbital
region, is diminished or absent in lower motor neuron facial weakness.
ā¢ Palpebral reflex, bilateral blinking induced by tapping the root of the nose, it
can be exaggerated by upper motor neuron lesions.
ā¢ In hemiparesis or peripheral facial nerve weakness, the contraction of the
platysma muscle is less vigorous on the affected side, This sign also carries
Babinski's name.
ā¢ Failure to pull the affected side of the mouth backward and downward when
crying.
ā¢ Sensory-----Ant.2/3 of tongue.
50. Vestibulocochlear(VIII)
Cochlear part(hearing)
ā¢ At birth ---Moro reflex.
ā¢ Younger deviate to sound.
ā¢ Later Rinne s test+ Weber test.
Vestibular part(Vertigo+ Nystagmus)
ā¢ Can be assessed easily in infants or small children by holding the youngster
vertically so he or she is facing the examiner, then turning the child several
times in a full circle.
ā¢ Clockwise and counterclockwise rotations are performed. The direction and
amplitude of the quick and slow movements of the eye are noted.
52. IX, X, XI CN
ā¢ Sensory ā¦ā¦loss of post 2/3 of tongue.
ā¢ Motorā¦ā¦pharyngeal O/Eā¦.
ā¢ 1-gag reflexā¦absent in bulber palsy UMNL
exaggarated in pseudo bulber palsy LMNL.
ā¢ 2-Uvula ā¦.normally central & mobile.
ā¢ In unilateral lesionā¦.uvula deviate to healthy side.
ā¢ In bilateral lesionā¦uvula is central but immobile.
Spinal accessory N.
ā¢ Sternomastoid-ability to rotate head to healthy side.
ā¢ Trapezius-dropping of shoulder in affected side
55. Muscle tone
ā¢ Hypotonia is characterized by decreased resistance to passive
movement and hyperextension at the joints.
ā¢ Hypertonia can be either spastic in nature or characterized by muscle
rigidity.
ā¢ UMNL =Pyramidal lesionā¦.. spasticity(clasp knife) resistance on the start of movement.
ā¢ Extrapyramidal lesionā¦.. rigidity(resistance is all over movement (cog-weal or lead)
56. Muscle power
ā¢ 1-Young childā¦ā¦.painful stimulation on the opposite side of the
tested muscle.
ā¢ 2-Older childā¦.ask to move against resistance.
ā¢ 3-Test every joint for its muscle group.
ā¢ 4-Grading of muscle power
58. Involuntary movements
Usually with extrapyramidal lesion.
ā¢ Choreaā¦.sudden irregular purposeless
dancing movement affect big proximal joint.
ā¢ Athetosisā¦slow twisting movement affect
distal joint.
ā¢ Dystoniaā¦.slow twisting movement in trunk.
ā¢ Tremorsā¦.rapid alternating movement
around small joint.
59. Incoordination
ā¢ 1st year ā¦ā¦grasp reflex & object transfer.
ā¢ -2nd yearā¦ā¦button & unbutton.
ā¢ ->3yearsā¦ā¦U.L.
ā¢ 1- Finger to nose test
ā¢ 2-Finger to finger test
ā¢ 3-Dysdiadochokinesisā¦inability to perform rapidly
alternating movement
ā¢ 4-Rebound test L.L.
Heal to shin test
Toe finger test
Foot Tapping test
Inco-ordination = ataxia.
60. Sensory system
ā¢ Sensory examination in young children is often imprecise, and only
gross deficits can be detected.
ā¢ In children > 5 -6 years sensory function is evaluated in the same
manner as in an adult
ā¢ Touch
ā¢ Pain & Temperature
ā¢ JPS
61. Pearls on examining infants and Older Child
ā¢ Accuracy depends upon the observational ability and intelligence
ā¢ Concerns of Parents/ Attendants
ā¢ Dietary/ Immunization/ Perinatal/ Developmental history
ā¢ Approach of examination Unstructured
(unpleasant examination postponed to the end)
ā¢ Signs of meningeal irritation may be minimal or absent during first year
of life (especially first 3 months) and in malnourished children
62. Pearls on examining infants and Older Child
ā¢ Primitive reflexes are present in birth disappear by 4-5 months
ā¢ Developmental screening is a must/ early markers of Cerebral palsy
ā¢ Deep tendons reflexes are normally brisk during infancy
ā¢ KJļ crossed adductor response/ Cremasteric reflex
ā¢ Plantar normally extensors up to 2yrs
ā¢ Fundus normally pale in infants/ Papilledema appears after 3 yrs