Good afternoon

1. Introduction
The purpose of the pediatric neurologic examination is to identify neurologic problems, and
acute neurologic injuries.
 The child’s neurologic system may be adversely affected during the prenatal and postnatal
periods as a result of various insults, such as hypoxemia, ischemia, trauma, or infections (e.g.
Bacterial meningitis).
 Complaints of headaches, signs of increased intracranial pressure (ICP), developmental
delays, or any injury to the head or spine necessitate a thorough neurologic assessment
 It is important for the pediatric health care provider to be adept at this assessment to ensure early
diagnosis and treatment of neurologic disorders or developmental delays.
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2. ANATOMY AND PHYSIOLOGY OF THE
NEUROLOGIC SYSTEM
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3. 1. CENTRAL NERVOUS SYSTEM
A. brain
 The brain is divided into;
 cerebrum,
 cerebellum,
 and brainstem .
 The brain is housed by the skull, or cranium.
 The brain is covered by three protective layers of meninges:
the Dura mater,
arachnoid, and
pie mater.
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4. Cont’d
Cerebrum. The cerebrum is the largest part of the brain.
 Its outer surface or cerebral cortex is covered by a thin layer of unmyelinated neurons, called the
gray matter, and
 an inner core called the white matter,
 The cerebral cortex (gray matter) , control most of the brain’s high-level functions including
memory, behavior, and reasoning.
 The basal ganglia are located deep within the white matter;
 they affect motor function by regulating voluntary body movements, inhibiting excessive body
movement, controlling fi ne motor movements, and maintaining muscle tone.
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5. Cont’d
Have two hemispheres right and left
cerebral hemispheres divided into four lobes:
 frontal,
 temporal,
 parietal, and
 occipital and Each lobe has distinct functions:
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6. Cont’d
• Frontal Lobe, which controls voluntary musculoskeletal movement , high-level
functions such as
 personality,
 thought processes,
 intellectual functions,
 and the ability to concentrate;
• in the frontal lobe controls the ability to articulate speech.
Damage to this area causes expressive aphasia.
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7. Cont’d
• Parietal Lobe. The parietal lobe controls sensory function. such as sensation
of
 pressure,
 temperature,
 pain,
 vision,
 hearing,
 taste, and smell;
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8. Cont’d
• Occipital Lobe.
The occipital lobe is the visual sensory area of the brain.
 It interprets and integrates visual images, and it associates visual images with past
experiences.
• Temporal Lobe.
The temporal lobe perceives and interprets sounds.
It also integrates sound stimuli into pitch, quality, and loudness and plays a role in
controlling behavior and emotion. 10/9/2023
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9. Cont’d
• Embedded deep within the cerebrum is the diencephalon, which contains
the
thalamus
hypothalamus,
 and epithalamus .
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10. Cont’d
Cerebellum.
The next largest part of the brain,
the cerebellum, is located posterior and inferior to the cerebrum between the occipital
lobes and brainstem
also divided into two hemispheres, each of which is composed of gray and
white matter.
The cerebellum is; it coordinates voluntary movements, such as walking, balance,
coordination, and maintenance of muscle tone.
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11. Cont’d
Brain Stem.
The brainstem lies between the cerebral cortex and the spinal cord;
it is primarily composed of nerve fibers.
It contains three structures:
the midbrain,
pons,
and medulla oblongata
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12. Cont’d
B. Spinal Cord
• The spinal cord is a long, cylindrical structure that is an extension of the
medulla oblongata.
• The spinal cord is housed and protected by the vertebral column
• The spinal cord itself is composed of white and gray matter.
• The white matter contains thousands of myelinated nerve fi bers, which
form the ascending (sensory) and descending (motor) tracts.
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13. 2. PERIPHERAL NERVOUS SYSTEM
The PNS includes the
1 SNS,
2.ANS,
3 spinal nerves,
4. and the cranial nerves.
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14. Cont’d
1. Somatic Nervous System
• The SNS controls all voluntary muscle function in the body with the exception of
the reflex arc.
2.Autonomic Nervous System
• The ANS controls all unconscious, automatic body functions and is involved in
emotional responses to stress and situations requiring increased energy.
• The ANS is divided into the sympathetic and parasympathetic nervous
systems,
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15. cont’d
3. Spinal Nerves
There are 31 pairs of spinal nerves that originate in the spinal cord and exit
the vertebral column,
each having a motor and sensory root.
These spinal nerves are named according to their exit point on the spinal
cord .
4.Cranial Nerves
• There are 12 pairs of CNs that arise from the brainstem, innervating the
same side of the body from which they originate.
•
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16. Fig 1. The spinal cord and vertebral column.
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17. table. 1Summary of Cranial Nerve Function and Location
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18. Cont’d
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19. ASSESSMENT OF THE NEUROLOGIC SYSTEM
HISTORY
• Neurologic problems in children can be acute or chronic.
• For children who are examined for the first time, a complete past medical history,
surgical history, family history, and social history are obtained.
• These histories are updated as needed when the child presents for health
maintenance visits.
• A focused history is required when the child presents with a neurologic complaint
or developmental delay.
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20. Cont’d
Past Medical History
• Prenatal History. The prenatal history is essential when completing a
pediatric neurologic assessment; any prenatal insult (e.g., intrauterine hypoxia,
infection, toxic exposure) can cause long-term neurodevelopmental sequelae.
• Neonatal History. The provider must inquire about any conditions that
may have occurred during the neonatal period, such as severe respiratory
distress, extreme hypoxia, or extreme acidosis, which lead to permanent
neurologic complications.
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21. Cont’d
Review of Systems
 General: Alteration in growth patterns (i.e., height, length,
weight, body mass index, head circumference), history of high
fevers, changes in appetite or weight, and fatigue
 Skin: lesions (e.g., neurofibromatosis),hemangiomas, Weber
syndrome), or pigmentation changes
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22. Cont’d
• Head/Face/Neck: Microcephaly, macrocephaly, hydrocephaly,
headaches , craniosynostosis, wide sutures, bulging fontanelles,
altered head control, facial pain,,, migraines, or facial
dysmorphism (e.g., fetal alcohol syndrome)
• Eyes: Blurred vision, diplopia, nystagmus, strabismus, sunset eyes
(indicates increased ICP), pupillary changes, or photophobia
• Ears: Low-set ears (can indicate a syndromic feature), hearing
loss, vertigo, or tinnitus 10/9/2023
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23. Cont’d
• Cardiovascular system: Hypertension, widened pulse pressure, orthostatic
hypotension, bradycardia, vasovagal syncope, fainting spells, arrhythmia, stroke,
congenital heart disease, or rheumatic heart disease
• Respiratory system: Irregular respirations, conditions that cause hypoxia, or acid–
base imbalance
• Genitourinary system: Tanner staging or urinary tract disease
• Musculoskeletal system: Spasticity of extremities, difficulty with balance,
coordination, or muscle strength; cerebral palsy, paralysis, or muscular dystrophy
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24. Cont’d
• Neurologic: including
 Encephalocele, spina bifi da, meningocele, myelomeningocele,, aneurysm, seizures , status
epileptics, tremors, spasms, weakness, dizziness, bacterial meningitis, viral meningitis,
encephalitis, episodes of loss of consciousness, memory loss, changes in concentration,
CNS neoplasm, ataxia, aphasia, head trauma, irritability, lethargy, chronic fatigue, sleep
disorders,
• Metabolic disorders:
 Diabetes mellitus (hypoglycemia, hyperglycemia)
 thyroid disorders (hyperthyroidism ,hypothyroidism)
 hyper- or hypokalemia
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25. Cont’d
• Hematologic: Sickle cell disease (predisposes child to stroke), polycythemia, or
coagulopathies
• Immunity: Leukemia, lymphoma, history of radiation, or chemotherapy
• Psychosocial: Drug or alcohol addiction, stress, emotional lability, irritability, breath-
holding spells, behavioral disorders, eating disorders, anxiety, depression, history of
suicidal ideation, schizophrenia, hallucinations, bipolar disorder, or mood changes
• Developmental: Age of achievement of major developmental milestones, intelligence,
memory, ability to adapt to new environments or tasks, or speechand language disorders
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26. Cont’d
Surgical History
The provider must determine what surgeries the child has
undergone that are related to his or her neurologic
status or diagnoses.
The dates and any complications of all surgeries should be
included.
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27. Cont’d
Family History
• The provider must obtain a family medical history to assess the prevalence
of neurologic conditions or genetic disorders, such as Tay-Sachs disease,
congenital hypothyroidism.
• The provider also determines if there is a family history of seizures,
migraines, learning disorders.
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28. cont’d
Social History
• The social history focuses on aspects of the family’s living conditions, lifestyle, and any risk
factors that could predispose the child to neurologic infections, injuries.
Medications
The provider should inquire about any medications the child is taking on a regular or as
needed basis, including OTC medications and complementary or alternative treatments.
• Some medications have neurologic, vestibulotoxic, or sedating side effects that must be
noted.
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29. Cont’d
Allergies
• Assessment of allergies, including the type of reaction, should be included as
part of a pediatric neurologic assessment.
• For example, chronic environmental allergies may cause nasal congestion,
affecting smell; anaphylaxis can result in loss of consciousness if not
treated promptly.
• A history of severe allergies or anaphylaxis should be considered when
an atopic child presents for care and has an altered level of consciousness.
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30. Cont’d
History of Present Illness
• When a child presents with a neurologic complaint
(e.g., head or spinal injuries, recurrent headaches, persistent fever,
developmental delays, identified neurologic disorder),
• the provider must obtain a focused history
• (i.e., history of the present illness [HPI]), including information about onset
(sudden or gradual), duration, and progression.
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31. Cont’d
• For infants and young children, the parent provides the information.
• Older children may have difficulty with memory or speech after a head
injury, and the parent may need to provide the historical information.
• With adolescents, the history may need to be obtained with the parent out
of the room to glean the most accurate information, especially concerning
drug and alcohol use or a possible pregnancy, which can be associated with
fainting.
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32. Common Pediatric Neurologic Problems
• Ataxia
• Cerebral palsy
• Developmental delay
• Headaches
• Head injuries
• Lead poisoning
• Meningitis
• Myelomeningocele
• Seizures
• Spinal cord injuries
• Status epilepticus
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33. NEUROLOGIC EXAMINATION
The pediatric neurologic examination is conducted in the following sequence,
beginning at the highest level of neurologic functioning and concluding with the
lowest:
1. Mental status exam
2. Cranial nerves assessment
3. Motor system assessment
4. Sensory system assessment
5. Reflex testing
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34. The necessary equipment includes the following:
• Penlight
• Ophthalmoscope
• Tongue blades
• Reflex hammer
• Tuning fork
• Familiar small objects (e.g., coins, paperclips,
pencil) Cotton-tipped applicators
• Snellen chart
• Tape measure f
• Aromatic substances familiar to children
(e.g., bubble gum, mint, chocolate, soap,
isopropyl alcohol)
• Sweet and sour items for tasting (glucose,
salt, lemon juice)
• Two small tubes: one containing hot water
and the other containing cold water
• Safety pin
• Cotton balls
• Small ball
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35. 1. Mental Status Evaluation
Mental status assessment include assessment of ;
A.appearance,
B.behavior,
C.cognition
D.and thought process
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36. Cont’d
A. Appearance.
The provider assesses the child’s overall appearance,
 including whether the child appears to be the stated age, is clean and well
groomed, and is dressed appropriately for age and weather.
In adolescents, lack of grooming or cleanliness may indicate depression;
 In young children, it often indicates neglect. Thus, an assessment of the family’s
socioeconomic status is important, as poverty and homelessness can have a major
impact on the child’s dress and hygiene.
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37. Cont’d
B. Behavior
Level of consciousness: look, is the child awake, alert and aware of stimuli
from the environment and responds appropriately?
The LOC, which is assessed according to age and can be quantified by the
pediatric Glasgow Coma Scale (GCS) score
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38. Score is obtained by determining the score for each of the three criteria (eye-opening, best motor
response, best verbal response) and
adding them. 13–15 mild head injury; 9–12 moderate head injury; and 8 severe head injury.
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39. Level of consciousness
Normal/alert/awake-aware: spontaneous eye opening and
responding to command
Drowsy/lethargy: awake in response to stimuli (loud noise or
deep pain stimuli), answering to simple questions, falling asleep if
not stimulated
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40. Cont’d
Stupors: eye opening in response to deep pain, answering simple
questions with yes or no.
The patient becomes unconscious spontaneously and is very hard
to awaken.
Comatose: no eye-opening in response to pain. The patient is
completely unresponsive
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41. Cont’d
C. Cognitive functions
assess the following:
Time: by asking day of week, date or year
Place: ask present location or name of city
Person: ask own name, age, or name of well-known person.
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42. Cont’d
D. Thought Processes.
evaluation of thought organization and appropriateness of responses is an
important assessment, keeping in mind the child’s age and developmental level.
assessed in toddlers by asking the child to point to pictures or body parts;
preschoolers can be asked to identify colors.
In children older than 4 to 5, the provider can ask the child questions about his or
her life, family, friends, and pets, and then judge the appropriateness of the answers.
Abnormal thought processes occur with mental retardation, schizophrenia, and
depression.
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43. 2. cranial nerves
1. Cranial nerve I – olfactory nerve
• Rarely tested in neonates and infants.
• When tested place a strong smelling under the nose.
• Congenital anosmia in neonates and infants may indicate Kallman’s syndrome which
runs in families.
• Neonate or infant startles, grimaces, sniffs or cries in response to strong odor.
• Child can identify familiar smell.
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44. Cont’d
2. Cranial nerve II – optic nerve
• In infants vision is tested by checking blinking response to bright light or turning head towards diffuse
light or following red moving ball or a ring 60 to 90 degrees.
• Visual acuity in 3 years and above is examined using Snelles picture chart or E chart.
• Visual acuity in term new born is 6/45, 6/18 at one year, 6/6 at 6 to 7 years.
• Confrontation test in older child and moving of toy or light in younger children is used to test visual
field.
• Color vision- testing 3 primary colors red, green and blue for younger children and test more colors for
older children.
• Test pupil size, shape and reflexes.
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45. Cont’d
3. Cranial nerve III, IV, and VI ( Oculomotor, Trochlear, and abducens nerve)
• Infant Shine a penlight at the eyes and move it side to side.
• Focuses on and tracks the light to each side.
• Assess doll eye movement (gently rotate the infant’s head side to side; eyes should move in
opposite direction of rotation).
• Child Move an object through the six cardinal points of gaze, tracks object through all fields
of gaze and test doll eye movement.
• In all ages Inspect eyelids for drooping, inspect pupillary response to light.
• Eyelids do not droop and pupils are equal size and briskly respond to light.
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46. Cont’d
4. Cranial nerve V- Trigeminal nerve
Infant
 Stimulate the rooting and sucking reflex.
 Turns head toward stimulation at side of mouth and sucking has good strength and
pattern.
Child
 Observe the child chewing a cracker.
 Touch forehead and cheeks with cotton ball when eyes are closed.
 Bilateral jaw strength is good..
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47. Cont’d
5. Cranial nerve VII ,facial nerve
Motor
 Note mobility and facial symmetry as the person smile, frown, close eyes tightly, lift
eyebrows, show teeth and puff cheeks.
 Press the puffed cheeks and air should escape equally from both sides.
 Infants - Observe the child cries or smiles, the ability to suck and swallow is assessed..
Sensory
 Not routine
 Applying a small amount of Suger, Salt or limon juice solution and asking the to identify
the taste.
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48. Cont’d
6.Cranial nerve VIII- Vestibulocochlear Nerve
 Function- sound perception and maintenance of body balance ;(Voice test, Weber and Rinne’s test.)
Infant
 Produce a loud sound near the head.
 Blinks in response to sound, moves head toward sound or freezes position.
Child
 Use a noisemaker near each ear or whisper words to be repeated.
 Turns head toward sound and repeats words correctly.
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49. Cont’d
7. Cranial nerves IX and X (Glossopharyngeal and Vagus nerves)
Motor
 Depress the tongue with a tongue blade, and not pharyngeal movement as the person
says. “Ahhh”
 Uvula and soft palate rises in midline
 Infants are evaluated for pitch, strength, stridor or hoarseness.
 In all ages of pediatrics elicit gag reflex to observe the stimulation.
 In infants observe swallowing during feeding and good swallowing pattern.
 Abnormal- uvula deviates to side.
 In Cranial Nerve X paralysis, the soft palate fails to rise and the uvula deviates to the
opposite side.
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50. Cont’d
8. Cranial nerve XI – spinal accessory nerve
 Not tested for infants.
 Examine the sternocleidomastoid and trapezius muscles for equal size and strength
 by asking the child to rotate the head forcibly against resistance applied to the side
of chin and shrug the shoulders against resistance.
 Should feel equally strong.
 Abnormality: Atrophy, muscle weakness or paralysis
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51. Cont’d
9. Cranial nerve XII – hypoglossal nerve
 Infant - Observe feeding, and the coordination of sucking and swallowing.
 Ask the child to stick out his or her tongue and move it from side to side.
 Listen to child speak and notes articulations, tongue strength is assessed by asking the child to
press the tongue against a tongue blade.
 Note midline positions as the child protrudes the tongue.
 Atrophy of tongue on affected side in lower motor neuron syndrome.
 In upper motor neuron palsy, tongue is spastic, thin and pointed.
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52. 3. Motor System Examination
In this part cerebellar function is assessed.
• Normal cerebellar function is determined by assessment of balance and coordination.
• A child must be developmentally able to cooperate with these assessments; typically, children
preschool ages and older are able to do so, depending on the assessment.
• When making these assessments, the examiner notes symmetry and smoothness of
movements.
• Impairment in the ability to perform these tests (e.g., nystagmus, ataxia, weakness, or
inability to complete the test) indicates a cerebellar dysfunction.
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53. Cont’d
Cerebellar function can be assessed by evaluation of
• gait
• The Romberg test
• hopping in place
• heel-to-toe walking (tandem walking),
• heel-to-shin test,
• and the finger-to-nose test.
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54. Cont’d
Gait and Balance.
• The child’s gait can be assessed by observing as the child walks across the room,
turns, and walks back.
• the child’s gait should be smooth and symmetrical wit an easy alternate arm swing.
• The toddler normally has a wide-based gait as a result of physiologic lordosis;
• a wide-based gait is abnormal beyond toddler age.
• It is normal for preschool-aged children to be knock-kneed when ambulating.
• Some abnormalities in gait include cerebellar ataxia, scissors gait, and toe-walking.
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55. Cont’d
Romberg Test.
• This test assesses proprioception and is primarily performed in children who are preschool
aged and older;
• young children may not be able to cooperate fully.
• To conduct this test, the child stands upright with the feet together, eyes closed, and
arms at his or her sides while the provider observes the child’s balance for several
seconds.
• Only mild swaying should occur.
• If the child leans to one side or loses his or her balance, this indicates a problem
with proprioception.
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56. Cont’d
Hopping in Place
By age 4, the child should be able to hop in place.
The examiner asks the child to stand straight, bend one knee, and then hop
in place, first on one leg and then on the other.
The child with intact cerebellar function should be able to maintain balance
on one leg.
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57. Cont’d
Heel-to-toe Walking (Tandem Walking)
The child is asked to walk heel-to-toe in a straight line; children are typically
able to do this by age 6.
If a child has a hemispheric lesion, walking in this manner decreases support
for the upper body; some side-to-side swaying is normal.
Ataxia, lack of coordinated movement, or impaired judgment of
distance indicates cerebellar dysfunction.
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58. Fig 2.Assessment of heel-to toe walking
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59. Cont’d
Rapid Alternating Movements
(for Children 8–9 Years or Older).
To assess rapid alternating movements, the examiner instructs the child to place his
or her hands face down on the thighs and then rapidly turn his or her hands over
with palms up, then lift them off the thighs in quick alternating movements.
The child is then asked to repeat the process as rapidly as possible for 10 seconds;
movements should be quick and rhythmic.
Inability to perform rapid alternating movements is likely a result of cerebellar
tumor.
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60. Fig 3. Rapid Alternating Movements
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61. Cont’d
Finger-to-Nose Test
 (for Children 8–9 Years or Older).
 This examination tests fi ne motor movements in the child.
 It involves having the child close his or her eyes and hold the arms out in front of the body.
 The examiner asks the child to touch the tip of his or her nose with the right index finger,
then the left index finger, repeating this process several times, with gradually increasing
speed.
Movements should be smooth and accurate
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62. fig 4.Finger-to-Nose Test
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63. Cont’d
Heel-to-Shin Test
 (for Children 8–9 Years or Older).
 This test assesses coordination of the lower extremities.
 The provider asks the supine child to place the right heel on the left shin, just below the knee, and then
slide the heel down the shin to the top of the foot.
 This maneuver should be repeated as quickly as possible and then repeated with the opposite foot. The
child should be able to perform this maneuver without difficulty.
 If not provider should suspect an alteration in motor strength, proprioception, or a cerebellar lesion.
 An asymmetric finding suggests an ipisilateral cerebellar lesion.
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64. Fig 5.Heel-to-Shin Test
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65. 4.Sensory Examination
• The sensory examination evaluates the child’s ability to perceive and discriminate
sensation.
• This includes assessment of light touch, deep pressure, pain, proprioception,
temperature, and vibration.
• Evaluating response to a painful stimulus can determine sensory function in the
neonate.
• This examination is limited in infants and young children because of their inability to
cooperate; most children over age 3 can cooperate.
• The sensory examination includes the following assessments.
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66. Cont’d
Light Touch.
• The examiner lightly touches the child’s skin in various areas with a stretched
cotton ball.
• The child should be able to identify the area of the body that is being
touched.
The provider asks the child to describe any difference in sensation in
different areas tested.
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67. Cont’d
Proprioceptive Sensation.
The examiner assesses motion and position sense of the limbs by
grasping the child’s toe and moving it up and down and then
asking the child what direction the toe is being moved and what
position it is in; this process is repeated on the other foot.
The child should correctly identify the direction of movements.
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68. Cont’d
Pain.
 Using the sharp and dull ends of a reflex hammer, the examiner checks for
mild pain sensation by
• asking the child to identify sharp or dull sensations verbally
The child should be able to differentiate between sharp and dull sensations.
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69. Cont’d
Temperature.
• Assessment of the child’s ability to identify hot and cold temperature is only
done when the child’s perception of pain is abnormal.
• When tested, the examiner uses two tubes, one filled with hot water and the
other with cold water, and then touches the skin in different areas, asking the
child if the sensation felt is hot or cold.
The child should be able to distinguish between hot and cold temperatures
over various areas of the skin.
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70. Cont’d
Stereognosis.
• The ability to recognize objects by touch is tested by placing a familiar object
in the child’s hand, such as a coin, paperclip, or pencil, and asking the child to
name the object; this is repeated in the opposite hand.
• Impaired stereognosis in children can be caused by cerebral palsy
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71. Cont’d
Two-point Discrimination.
 This tests spatial discrimination by asking the child to discriminate touch. At
different spots on the skin, first with two points in proximity and then with
one point, the examiner asks the child to identify if one or two pinpricks
were felt.
The child should be able to correctly identify the points touched.
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72. Cont’d
Vibration.
Vibration perception is assessed by using a low-pitched tuning fork placed on a
bony prominence(e.g., on the wrists, elbows, medial malleoli, patella).
The examiner strikes the tuning fork and then holds the base of the tuning fork on
the bony prominence.
The child is asked to state when the vibration stops; this is then repeated on the
opposite side of the body for comparison.
The child should correctly identify the sensation.
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73. 5. Reflex Testing
Reflex testing is a particularly useful portion of the neurologic examination
Because the results are quantified, reflex testing provides concrete, objective
data about the level of functioning of the nervous system.
• Reflex testing is especially useful with children because it requires minimal
cooperation.
• Both deep tendon and superficial reflexes are assessed, with attention paid to
symmetry and strength of reflexes tested.
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74. Cont’d
Deep Tendon Reflexes. Deep tendon reflexes (DTRs), are elicited by tapping a tendon briskly with a
reflex hammer, which causes the tendon to suddenly stretch and contract.
 These reflexes are assessed to evaluate the function of the refl ex arcs and the spinal cord segments.
 When assessing DTRs, they should be tested bilaterally, and the response is graded as follows:
 0 Absent
 1= Hypoactive
 2= Normal
 3=Hyperactive without clonus
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75. Cont’d
• Hyperactivity of DTRs indicates upper motor neuron lesions, hypocalcemia,
or hyperthyroidism.
The following DTRs are assessed as part of the pediatric neurologic
examination.
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76. Cont’d
• Biceps Reflex (C5–C6).
• The examiner flexes the child’s arm at the elbow with the palm slightly lower
than the elbow.
• The examiner then places his or her thumb on the child’s biceps tendon in
the antecubital space, then strikes the thumb with the reflex hammer.
The normal response is a slight flexion of the arm at the elbow and a
contraction of the biceps
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77. Biceps Reflex (C5–C6).
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78. Cont’d
• Triceps Reflex (C7–C8). This reflex appears at approximately 6 months.
With the child’s arm flexed at the elbow (see procedure for biceps reflex),
• the examiner strikes the child’s triceps tendon slightly proximal to the
olecranon between the epicondyles.
A normal response is triceps contraction and elbow extension
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79. Triceps Reflex (C7–C8)
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80. Cont’d
• Patellar Reflex (L2–C4). This reflex is present at birth. For older children, the
examiner asks the child to sit on the examination table, knees bent, and legs
hanging freely.
• The examiner then strikes the child’s distal patellar tendon with the reflex
hammer.
The knee should extend, and the quadriceps muscle should contract
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81. Patellar Reflex (L2–C4).
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82. Cont’d
• Tendon Reflex (S1–C2)
• The child is asked to dorsiflex his or her foot slighty at the ankle then strikes
the Achilles tendon.
• Plantar flexion is the normal response.
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83. Tendon Reflex (S1–C2)
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84. Cont’d
• Plantar Reflex (L4–L5, S1–S2). This is tested by stroking the lateral aspect of the
sole of each foot with the end of the reflex hammer. The examiner observes for
flexion of the toes, which is normal (Fig. 22-11).An abnormal finding is extension
of the big toe and fanning of the other toes (Babinski sign)
• . For children who are not yet walking, a positive Babinski sign is normal for the age
group, because of the immaturity of the nervous system.
• If the child has a positive test, it may indicate lesions of the pyramidal tract or
motor nerves.
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85. Plantar Reflex (L4–L5, S1–S2).
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86. Cont’d
 Abdominal Reflex (T8, T9, and T10 Innervation in Upper Quadrants; T10,
T11, and T12 Innervation in Lower Quadrants)
 With the handle of the reflex hammer, gently stroke the abdomen toward the
umbilicus.
 The abdominal muscles should contract and the umbilicus should move toward
the stimulus in all four quadrants.
 Anal Wink Reflex (L4–S1)
 Tested by stimulating the perianal area with a cotton tip applicator.
 A normal response is quick contraction of the anal sphincter.
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87. Signs of meningeal irritation
• Neck stiffness
• Brudzinzki neck sign- flexing the patient’s neck causes the flexion of the
child’s hips and knee.
• Kerning’s sign- Flexing the patient’s hip 90 degree then extending the child’s
knee cause pain
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88. Reference
• Jarvis, C. (2008). Physical examination & health assessment (5thed.). St. Louis, MO:
Saunders Elsevier.
• Borgialli DA, Mahajan P, Hoyle JD, Powell EC, Nadel FM, Tunik MG, Foerster A,
Dong L, Miskin M, Dayan PS, Holmes JF, Kuppermann N (August 2016).
"Performance of the Pediatric Glasgow Coma Scale Score in the Evaluation of
Children With Blunt Head Trauma".
• learn.pediatrics.ubc.ca/body-systems/nervous-syste/the-pediatric-neurological-
history/
• Chiocca, E. M. (2011). Advanced pediatric assessment. Baltimore, MD: Lippincott
Williams & Wilkins
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89. ACKNOWLEDGEMENTS
• I would like to give my special thanks and appreciation to
our instructor Dr. Grum (PhD, Associate Professor) for
her excellent teaching skill & guidance in this course and
for providing me the opportunity to work on and learn
about focused assessment of the central nervous system.
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