Neurological assessment seminar

1. Case Scenario
A baby weighing 1800 grams was born by NVD. Mother
couldn’t mention LMP. Baby required bag mask
ventilation for about 3 minutes to establish respiration
and he developed convulsion at 3 hours of age. Besides
Vitals and general examination, which assessment
should get emphasis for this baby?
Neurological Assessment
- Neurological deficit
- Encephalopathy grading
- Determining gestational age

2. What we usually practice?
• Although in an ideal world, each neonate should have a
comprehensive neurological examination
• But, in practice, this is often difficult and, in hospitals
with a large number of deliveries and frequent staff
shortages, infants receive a general medical
examination which includes only a broad assessment
of tone, alertness and the Moro response.
• Abnormal ultrasound findings provide the key to the
follow-up clinic, not clinical findings.

3. Neurological Assessment of
Newborn: Current Practice
and Proposed
Dr Humayra Akter
Resident, year 5
Dr Faria Yasmin
Resident, year 1
Department of Neonatology

4. Outline of Presentation
• Introduction
• What we usually practice
• Delivery room quick assessment
• Gestational age by neurological assessment
• Examination of head
• State of alertness
• Motor Examination
• Neonatal reflexes
• Cranial nerves
• Neonatal neurology in Bangladesh
• Rapid Neurodevelopmental assessment

5. Introduction
• The neonatal neurological assessment is a useful tool
in identifying babies needing closer evaluation for
potential problems.
• The neurological exam can be a challenging part of a
newborn’s full evaluation
• A comprehensive neonatal neurological assessment
should include evaluation of neurological status (i.e.
primitive reflexes, muscle tone and movement
patterns) and behavioural responses (i.e. state,
orientation to stimuli)

6. Background
• In the 1950s and 1960s Dr Suzanne Saint- Anne-
Dargassies 1st described the neurological
evalution of newborn.
• Their work was expanded upon by Dr Claudine
Amiel-Tison, who provided great insights on the
neonatal neurological examination and described
the stages of development and maturation from
28 to 40 weeks’ gestation
• Amiel-Tison were among the first to describe
maturational patterns of tone and primitive
reflexes in preterm infants as they grew towards
term, leading to the ‘Amiel-Tison’ exam.
• Similarly, Prechtl and colleagues crafted a system
based on observation of generalised movements
and behaviours termed ‘Prechtl Method’.

7. Goals of Neurologic Assessment
Assessing current status:
• To recognize emergent and
treatable issues
• To assist in localization of the
disturbance
• To establish a diagnosis
Predicting future:
• To help predict the long-term
outcome

8. Delivery room assessment: First Impression
• Observation of:
- Alertness
- Activity, and
- Tone.
• Brief physical examination:
- Dysmorphic features
- Examination of the spine
- Obvious cutaneous finding

9. Neurological Assessment of
gestational age
• Dr Amiel-Tison first described the neurological
assessment for gestational age in 1968.
• Her work led to further refinement of this assessment to
include physical criteria in addition to neurological
assessment by Dr Lilly and Victor Dubowitz, and more
recently by Dr Jeanne Ballard and colleagues.
The most accurate gestational age dating by ultrasonography occurs at 7 to 10 weeks’
gestation and is usually accurate to within –3 days. Measurements at 10 to 14 weeks’
gestation are accurate within –5 days.

10. New Ballard
Scoring for
Gestational
Age

11. Skin
• As the neurological system is derived
from the ectoderm, the skin may provide
important clues to underlying
neurological processes.
• Examination of the spine and gluteal
folds is performed to detect spinal
dysraphism or neural tube defects.
• Sacral dimples or sinuses may indicate a
tethered cord or spina bifida occulta
• Characteristic cafe au lait spots may
appear at birth in neurofibromatosis
• A nevus flammeus, or port-wine stain,
may signify Sturge-Weber syndrome
when it is located over the forehead and
upper lip.

12. Examination of Head
• Measurement of the fronto-occipital
circumference
• Fontanelle size and tension
• Palpation of sutures
• Inspection for any swelling or
protuberances.
• Transillumination may be useful if
hydrocephalus or hydranencephaly
• Auscultation of the fontanels is
performed for bruits if an
arteriovenous malformation or for
vein of Galen malformation.

13. Measuring Occipito-Frontal
Circumference
• Measured by using a tape
encircling the head above
the brow and prominent
point of occiput.
• The normal term infant’s
head circumference is 35
cm±2 cm.
Rennie and Roberton’s Textbook of Neonatology, Fifth edition

14. Fontanelle size and Tension
• Normal size of
anterior fontanelle is
0.6- 3 cm.
• Bulging fontanelle
may be associated
with raised ICP,
meningitis or
hydrocephalus
Rennie and Roberton’s Textbook of Neonatology, Fifth edition

15. Sutures
• Wide separated
sutures in
Hydrocephalus
• Fused suture or
craniosynostosis in
Apert’s syndrome
Rennie and Roberton’s Textbook of Neonatology, Fifth edition

16. State of alertness: Sensitive Indicator of Neural
Integrity
• The mental status assessment evaluates higher
brain function, and particularly cortical function
• Behavioral states can be assessed on the basis of
four feature:
- Eyes opening
- Regular respiration
- Gross movement
- Vocalisation
Rennie and Roberton’s Textbook of Neonatology, Fifth edition

17. Factors that play a role in alertness
• Gestational age
• Maternal anesthesia or narcotic administration
• Maternal medications
• Placental insufficiency, and
• Neonatal illness

18. State 1 Deep or quite sleep Eyes closed with regular respiration
and no movement
State 2 Rapid eye
movement sleep
Eyes closed with irregular respiration
and no gross movement
State 3 Awake and drowsy Eyes open, no gross movement
State 4 Alert Eyes open, gross movement, no crying
State 5 Crying Eyes open or closed, crying
Prechtl Scale for State of
Alertness
Rennie and Roberton’s Textbook of Neonatology, Fifth edition

19. Abnormal Behavioural States
• Irritability (agitated and cries with minimal stimulation
and is unable to be soothed)
• Persitent, high pitched cry
• Inconsolable or uncuddly crying
• Not arousable (by persistent shaking, perioral
stimulation, shining a light or ringing a bell)
• Stuporous or comatose

20. Motor Examination: Tone and Posture
• Active flexor tone appears between 28 and
34 weeks and matures from the feet and legs
upwards.
• Predominant flexion posture of all limbs
should be present by term
• Normal term babies have sufficient power in
their neck muscle to lift their head slightly
which can be elicited by pull-to-sit
manoeuver.
• Normal term newborn is in a state of relative
hypertonicity, with brief reflexes tending to
clonus
• Jitteriness is common in first 2-3 days in term
babies and generally benign.
Rennie and Roberton’s Textbook of Neonatology, Fifth edition

21. Abnormal Tone and Posture

22. ➤These are primitive reflexes , are peculiar to
infants, and disappear with maturation of
nervous system.
➤A normally developing newborn should respond
to certain stimuli with these reflexes, which
eventually become inhibited during 3 to 12
months of postnatal life.
Neonatal Reflexes

23.  Begins at 28weeks of gestation
 Initiated by any sudden movementof
the neck
 Elicited by -- pulling the baby halfway
to sitting position from supine & suddenly
let the head fall back
 Consists of rapid abduction & extension of
arms with the opening of hands, tensing of
the back muscles, flexion of the legs and
within moments, the arms come
together again
Moro Reflex

24. Clinical significance
Its nature gives an indication of muscle tone
Failure of the arms to move freely or the hands toopen
fully indicates hypotonia.
Persistence beyond 6 months is always abnormal.
Moro reflex

27.  Begins at 26weeks ofgestation
 Light touch of the palm produces reflex
flexion of the fingers
 Disappears at 3-4months
 Replaced by voluntary grasp at4-5 months
Clinical Significance:
 May be asymmetrical in hemiplegia & in
cases of cerebral damage
 Persistence beyond 3-4 months indicate
spastic form of palsy
Palmar Grasp
Rennie and Roberton’s Textbook of Neonatology, Fifth edition

28.  Placing finger beneath the toes causes
curling of toes
 Present at 26weeks ofgestation
 Disappears at 9-12months
• Clinical significance:
 Integrates at the same time that
independent gait first becomes
possible.
Plantar Grasp
Rennie and Roberton’s Textbook of Neonatology, Fifth edition

29.  By stimulating the dorsum of the
foot, usually by bringing it into
contact with the edge of the bed,
baby can be induced to step over the
edge.
 Present at birth, fades awayby 5
months
• Clinical significance
 Reflex is readily demonstrable inthe
newborn and persistent failure to elicit
it at this stage, is thought to indicate
neurological abnormality
Placing Reflex

30. Holding the infant upright under
his arms while supporting his
head, have his feet touch a flat
surface, the infant will appear to
take a step and walk.
Present at birth, disappearsat
approx 4 months
Walking/Stepping reflex

32.  Appears by 35 weeks
 With the baby supine, head is slowly turned to
one side, resulting in increased extensor tone in
the arms on that side and increased flexor tone in
the arms on the opposite side (fencing posture)
 Disappears by 7 months
• Clinical significance
 Persistence is the most frequently observed
abnormality of the infantile reflexes in infants
with neurological lesions
Asymmetric Tonic Neck Reflex
Neonatology, Tricia Lacy Gomella, 7th edition

33.  Deep pressure appliedsimultaneously to
the palms of both hands while the infant
is in supine position
 Stimulus is followed by flexion or forward
bowing of the head, opening of the
mouth and closing of the eyes
 Persistence beyond 12 weeks suggest spastic
–motor developmental disorder.
Babkin Reflex
Neonatology, Tricia Lacy Gomella, 7th edition

34. Galant Reflex
• Elicited by suspending the
infant in prone position,
back is stroked on a side in
cephaocaudal direction
• Response: moving the hips
towards the stimulated
side

35. Crossed Extensor Reflex
• One leg is held in extension
and the sole is rubbed
• Response: Other leg at first
flex and adduct and then
extend with fanning of the
toes
• Disappears by 8 months
Rennie and Roberton’s Textbook of Neonatology, Fifth edition

36.  Stroking the baby’s lip and corner of the
mouth will result in
- turning in that direction and
- opening of the mouth
 Appears after 28 weeks
 Well established by 32 weeks
 Disappears by 3-4 months
Clinical significance
 Absence of this is seen in neurologically
impaired infants.
Rooting reflex

37. Onset~ 28
weeks iu
Well-
establised~
32-34
weeks iu
Disappear~
around 12
months
Elicited by~
introducing
a finger into
the mouth
Sucking Reflex

38. Reflex Appears Well established Disappears
Sucking and
swallowing
32 weeks 34 weeks
Palmar grasp 28 weeks 32 weeks 3-4 months
Asymmetric tonic
neck reflex
35 weeks 44 weeks 2-3 months
Moro 28 weeks 37 weeks 3-4 months
Placing and stepping 35 weeks 37 weeks 6 weeks
Crossed extension 34 weeks 38 weeks 4-5 months
Timing of Appearance and disappearance of
reflexes

39. Deep Tendon Reflexes
• The tendon reflexes develop earlier in the legs than the
arms and responses are generally attainable by 33
weeks’ gestation
• Performance of the tendon reflexes in a newborn only
requires tapping of a couple fingers placed over the
tendon rather than using a tendon hammer.
• Eliciting tendon reflexes is of less value in neonatal
period
• Very brisk reflexes and clonus are not reliable indicator
of an upper motor neuron lesion until about 6 months
Rennie and Roberton’s Textbook of Neonatology, Fifth edition

40. BABINSKI Reflex
• Stroking of the planter
surface of the foot from the
heel to toe results in upward
movement of big toe and
other toe’s fan out.
• Babinski is always extensor
in babies
• Best to omit it as the stimulus
is painful

41. Cranial Nerve Examination
Cranial Nerve Examination
CN I : Olfactory Neonates > 32 weeks respond to familiar smell like mother’s milk
by arousal or sucking
CN II: Optic 28 weeks: blinks by light
32-34 weeks: visual fixation
37 weeks: turns toward soft light
Pupillary reflex: present after 32 weeks
CN III, IV, VI Pupillary reflex and size and asymmetry
CN V: Trigeminal Rooting reflex
CN VII: Facial Look for facial asymmetry, eye closure, nasolabial fold during
crying; also rooting and corneal reflex
CN VIII:
Vestibulocochlear
Ringing bell or clapping: Blinking, startle
CN IX, X and XII Sucking and swallowing reflex and gag reflex

43. Sensory Examination
• The sensory examination can be challenging at this
age.
• When touched : - facial response or grimace
- be alerted, or
- demonstrate a change in behavior
• Painful stimuli: - crying and/or
- withdrawal of the extremity

44. Examination of Vision
• 26 weeks: blinks in response to light
• 32 weeks: Eye closure
• 34 weeks: Fix and track a bright object briefly
• 37 weeks: Turn to soft light and can track reliably

45. Auditory testing
• Babies from 28 weeks respond to sound by
- turning their heads
- arousing from sleep
- increasing body movement

47. Sarnat and Sarnat staging for
Encephalopathy

48. Investigation
• Cranial Ultrasound scanning is now standard in
neonatal units and widely used
• MRI
• EEG
• Auditory and visual evoked potential

49. Several validated method for
neurological assessment
• Dubowitz Neurological Assessment of the Preterm and
Full-term Infant
• The neurological assessment by Amiel-Tison
• The Assessment of Preterm Infants' Behaviour (APIB)
• Neonatal Intensive Care Unit Network Neurobehavioural
Scale (NNNS)
• Prechtl's Assessment of General Movements (GMs)

50. Neonatal Neurology in Bangladesh
• In BSMMU, neonates with neurological problems are
treated by department of Neonatology in
collaboration with department of neurology
• Also, in other hospital there is no ideal set-up for
neonatal neurology
• In Dhaka Shishu Hospital, all the high risk neonates
are assessed at discharge by Rapid
Neurodevelopmental Assessment (RNDA).
• But in BSMMU, all the high risk neonates are
discharged with the advice of neurodevelopmental
follow-up at 1 ½ months of age.

51. • RNDA canbecomeanintegral part of all neonatesbeing
dischargedfromhospitals
• It providesafunctional profileof the child to the parents
for goal-directed functional interventions
• It providesabasisfor appropriate and early referral
• Many‘outgrow’ their functional limitations towards an
optimum quality oflife
Rapid NeuroDevelopmental
Assessment (RNDA)

52. Domains Assessed by RNDA
• Primitive reflexes
• Gross motor
• Fine motor
• Vision
• Hearing
• Speech
• Cognition
• Behaviour
• Seizure

53. Quick Assessment

54. CONCLUSIONS: The RNDA can be used by professionals from a range of
backgrounds with high reliability and validity for determining functional
status of children who are younger than 2 years. The study findings have
important practical implications for early identification and intervention to
mitigate neurodevelopmental impairments in large populations that live in
developing countries where professional expertise is sparse. Pediatrics
2010;125:e755–e762

55. Results: Among the enrolled 103 preterm infants during RNDA at neonatal period,
abnormal domains found in primitive reflexes 41(39.7%), gross motor 42(40.7%), fine
motor 32(31%), vision 40(38.7%), hearing 32 (31%), speech 40(38.7%), cognition 3(2.8%),
behavior 3 (2.8%) and 3(2.8%) had seizure. Again in RNDA at 3 months of age, the no. of
preterm infants having abnormal developmental domains are: gross motor 49(47.5%),
fine motor 19(18.3), vision 9(8.6%), hearing 16(15.4%), speech 15 (14.5%), cognition
6(5.7%), behavior 11(10.6%) and 3 (2.9%) had seizure.
Conclusion: The identification of neurodevelopmental impairments in early months of
preterm infants should offer a valuable tool for identification of at risk infants for long
term sequalae (in neurodevelopmental impairment).

56. 22CHILDDEVELOPMENTCENTERS
http://www.hsmdghs-bd.org/ShishuBikashKendro_ChildDevelopmentCenter.htm
15 Public
Hospitals
6 Specialized
NonProfit
1 Privatefor
Profit

57. Proposed for improving
Neurodevelopmental Outcome
In BSMMU, Pediatric Neurology department is
planning for establishing RNDA for all high risk
newborns before discharge in collaboration with
dept. of Neonatology, which will definitely improve
the outcome of the babies being discharges after
prolonged and eventful neonatal period in NICU.

58. Way Forward
• Neonatology:
- Identify all high risk babies
- Timely referral to pediatric neurology
• Pediatric neurology:
- Starting RNDA by trained staff
- Neurodevelopmental follow-up
• Research activities