This document outlines an approach to examining a floppy infant. It involves: 1) Introducing oneself and observing the infant and parents for at least 30 seconds 2) Examining the infant's posture, movements, facial features, head size, and areas affected 3) Touching the infant and examining their head, eyes, hearing, chest, abdomen, genitals, and limbs 4) Performing maneuvers like pulling the infant to sit and tests like primitive reflexes Hypotonia can be due to central nervous system disorders above the level of the anterior horn cell ("floppy strong") or lower motor neuron disorders below that level which cause weakness ("floppy weak")

1. APPROACH TO FLOPPY
INFANT
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2. 1. Introduce self
and Proper
exposure
Look at parents’ faces
(myotonic dystrophy,
myasthenia gravis)
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3. 2. General
observation at least
for 30 seconds
a)Dysmorphic features
(e.g. Down, Prader–Willi
syndrome , MPS, lipidoses)
b)Head size
•Microcephaly (e.g. CP)
•Macrocephaly (e.g. associated
myelomeningocele, congenital
toxoplasmosis)
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4. c)Facial features
•‘Ex-premmie’ appearance (prematurity per se, CP)
•Alert (e.g. SMA)
•Expressionless (e.g. some congenital myopathies, Myotonic
dystrophy, Myasthenia gravis)
•Ptosis (as above)
•Ophthalmoplegia (as above)
•Nasogastric tube (e.g. hypotonic CP, some congenital myopathies,
MD, MG)
•Oxygen catheter (e.g. hypotonic CP, SMA, some congenital
myopathies, MD, MG)
•‘Fish’ (triangular) mouth (e.g. congenital myopathies or MD)
•Tongue fasciculation (SMA)

5. d)Posture
•‘Frog-leg’ lower limb posture (e.g. especially SMA,
congenital myopathies)
•Fisted hands (CP)
•Arthrogryposis (e.g. congenital muscular dystrophy,
MD)
e)Main areas affected
•Face (congenital myopathies, MD or MG)
•Lower limb (myelomeningocele)
•Proximal limb (e.g. SMA)
•Distal limb (congenital MD)

6. f)Normal movement (e.g. connective tissue disorders)
g)Fasciculations (e.g. SMA)
h)Previous intervention
•Tracheostomy/scar (e.g. infant botulism)
•Gastrostomy/scar (e.g. hypotonic CP, congenital MD)
i)Respiratory difficulties
j)Upper airway noises (e.g. CP)
•Tachypnoea (e.g. aspiration with SMA, CP, congenital MD,
Pompe)
•Paradoxical breathing , bell-shaped chest, splayed lower
ribs (e.g. SMA)

7. 3.NOW TOUCH THE CHILD

8. Head
•Inspect
•Palpate
•Auscultate
•Transilluminate
Eyes
Full examination for evidence of intrauterine infection, CP,
retinopathy of prematurity
Hearing
Test with bell and rattle for deafness from kernicterus,
intrauterine infection, CP

9. 4. Chest
Examine praecordium for cardiac enlargement and
dysfunction due to glycogenoses types 2 or 3, or for
congenital heart disease due to congenital rubella
CP
5. Abdomen
Examine for hepatosplenomegaly due to
intrauterine infection MPS (central), glycogen and
lipid storage myopathies (peripheral) Genitalia
(hypoplastic in PWS)

10. 6. Limbs
a)Inspection
•Decreased muscle bulk (e.g. SMA, undernutrition)
•Fasciculation (e.g. SMA)
•Muscle biopsy site
b)Palpate
•Confirm hypotonia
•Contractures (causes of arthrogryposis)
•Joint hypermobility (connective tissue disorders)

11. c)Power
•Weak (e.g. SMA, congenital MD, muscular dystrophy
or myopathies)
•Normal (e.g hypotonic CP, other central causes,
connective tissue disorders)
d)Reflexes
•Absent (e.g. SMA)
•Decreased (e.g. neuropathies or, later, myopathies)
•Normal (e.g. connective tissue disorders)
•Increased (CP)

12. 7. Manoeuvres: the 180° examination
a)Observe infant in supine position To describe: posture,
movement
b)Pull to sit To detect: degree of head control/lag
c)Sitting To describe:
•Degree of head control
•Degree of trunk control
•Ability to sit unsupported
d)Attempted weight bearing To detect:
•Lower limb hypotonia/weakness
•Lower limb scissoring (CP)
•‘ Advanced’ weight bearing (CP)

13. e)Ventral suspension To describe
•Posture of head, trunk and limbs (degree of
hypotonia; infants with CP may have extensor
posture)
f)Place infant prone and observe To describe
•Degree of head control
•Ability to lift head/trunk

14. 8. Primitive reflexes Test for:
•Suck
•Grasp
•Stepping
•Placing
•ATNR
•Moro reflex
Cover the patient and say thankyou

15. Hypotonia can be due to central or peripheral
nervous system disorders.

16. Central disorders include pathology at the levels of
the cerebral cortex, cerebellum or brainstem, all of
these being above the level of the anterior horn cell;
therefore, these are termed ‘upper motor neurone’
(UMN) disorders. Children affected by these may be
hypotonic but they are not weak, hence the
colloquial term ‘floppy strong’ applies to them; an
older term is ‘non-paralytic hypotonia’.

17. Disorders from the anterior horn cell to the muscle
cell are termed ‘lower motor neurone’ (LMN)
disorders. Children affected by these disorders are
weaker than typical children and the term ‘floppy
weak’ applies; an older term is ‘paralytic hypotonia’.
The causes of being ‘floppy weak’ can be divided
into pathologies at the anterior horn cell, motor
nerve, neuromuscular junction (NMJ) and muscle.

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