The document provides guidance on performing a neonatal neurological examination. It should be done on newborns that had antecedent conditions or physical signs during a normal exam. The exam is best done when the infant is in an optimal state, usually between feeds for preterm infants. The exam involves assessing alertness, cranial nerves, tone, reflexes, and primitive reflexes in a structured sequence. Normal responses and abnormalities are described for each component. The exam allows for evaluation of the infant's neurological integrity.

1. Neonatal Neurological
Examination
Dr Anu Thukral DM (Neonatology)
Asst Professor
AIIMS, New Delhi
dranuthukral@gmail.com

2. Learning objectives
• Which neonates mandate comprehensive
neurological evaluation?
• When should it be done?
• How should it be done?
– Neonatal neurological evaluation

3. Which Neonates?
• Newborn has had any antecedent condition
which mandates a thorough neurolgical
examination
• Newborn has a directive physical sign during
normal physical examination

4. When should it be done?
• The examination should ideally be done two
third way in-between feeds when the infant is
more likely to be in optimal state
• Preterm infants who are on continuous
feeding : any time.
• Serial examinations

5. How should be neurological
examination be done?
• Gestational age assessment
– Neurological evaluation change with maturation
– Certain disorders are characteristic of infants
preterm AGA infants /SGA infants
– Different disorders have different impact on the
central nervous system

6. Sequence of examination
• General examination
• Level of Alertness (Higher mental functions)
• Cranial Nerves
• Posture
• Tone assessment (Active and Passive)
• Reflexes (Superficial, Deep and Primitive)
• Head and Spine

7. • Most sensitive marker of the integrity of
central nervous system
– Time of last feed
– Recent painful experience (like venepuncture)
– Gestational age
– Environmental stimuli.
– How to elicit?
Persistent gentle shaking, perioral stimulation, mild
pinching, shining a light or ringing a bell.
Higher Mental Functions: (i)Alertness

8. Higher Mental Functions: Alertness
Preterm Neonate
• < 28 weeks: difficult to
identify period of
wakefulness
• > 28 wks: arousable after
stimulation
• > 32weeks stimulation not
required (clinical sleep wake
cycles)
Term neonate
• Vigorous crying
• Increased wakefulness

9. Levels of alertness (Volpe)
Level of
alertness Appearance Arousal
response
Motor response
Quantity Quality
Normal Awake Normal Normal High level
Stupor
Mild Sleepy Diminished
(slight)
Diminished
(slight) High level
Moderate Asleep Diminished
(moderate)
Diminished
(moderate) High level
Severe Asleep Absent Diminished
(severe) High level
Coma Asleep Absent Absent Low level

10. (ii) Behaviour
• The NBAS (27 behavioural responses and 20
reflex items); 20 minutes to administer
• Prechtl and Brazelton behavioural scale
State Eyes Respiration Gross body
movements
Vocalisation
/ cry
1 Closed Regular - -
2 Closed Irregular + -
3 Open Regular - -
4 Open Irregular + -
5 Open/
closed
Irregular + +

11. (iii)Habituation
• Soft light (at the frequency of approximately
1/ sec)
• Blinking response diminishes in intensity after
3-5 exposure
• Similar observation (startle or optical blink) is
noted with repetitive auditory stimuli e.g. bell
tinkle or hand clap.

12. (iv)Consolability
• The neonate may get consoled-
1.Spontaneously
2.Talking
3.Putting a hand on abdomen
4.By being picked up & held
5. May not get consoled.

13. (v)Cuddlability
• The infants response should be assessed when
the infant is held when alert.
• Normal response is that the infant cuddles
and clings to the examiner when alert.

14. Cranial nerve examination
Optic nerve
Response to light:
• 26 weeks- consistent blink response
• 32 weeks- persistent eye closure until light is removed
• 32 weeks – Onset of visual fixation. This matures over the next 4
weeks.
• 34 weeks – 90% of infants can track a fluffy ball
• 37 weeks- turning of the eyes to soft light.
• Term gestation- Visual fixation and following well developed.
Colour perception:
• Demonstrable at nearly 2 months, even newborns follow coloured
objects, preferably red.
Visual discrimination:
• From 35 weeks onwards, newborns are able to recognise patterns

15. Cranial nerves examination
Pupillary Reflex:
• Look for pupillary size & reaction. Size in preterm infants is
3-4 mm; it is slightly wider in full term infants.
• 29-32 weeks, pupil starts reacting to light.
Visual acuity:
• Visual acuity of newborn infants has been estimated to be
around 20/150.
Fundus examination:
• Normal optic disc appears pale grey-white with diminished
vascularity
• Retinal hge normal in 20-40%

16. 3rd, 4th, 5th Cranial Nerve
• Eye position, eye movement and movement
elicited by dolls eye maneuver.
• Eyes of a newborn are slightly disconjugate at rest
• Doll’s eye movement: 25 weeks.
• Spontaneous roving eye movements: 32 weeks
• Movements of full term infants are jerky and do
not become smooth till the third month of life.

17. Cranial nerve examination
5th nerve
• To assess the motor
component assess the
rooting and sucking reflex
and assess muscle strength
by allowing biting on finger.
• To assess the sensory
component the facial
sensation can be tested by
response to pinprick.
7th nerve
• The width of the palpebral
fissure has to be noted.
• Presence of nasolabial fold
• Note the position of the
angle of mouth
• The sucking reflex has to be
assessed.

18. 8th nerve
• Neonate shows a startle
Test with a bell.
• From 28 weeks- startle or
blinks in response.
• With maturation – subtle
responses like cessation of
breathing / change in
RR/HR/ opening of eyes.
9th / 10th and 12th nerve
• Pooling of secretions; also
note the position of the soft
palate;
• Observe a feeding session and
assess the swallowing
• Gag reflex
• Active contraction of the soft
palate with upward movement
of uvula and posterior pharynx
must be observed.
• 12th nerve: size and symmetry
of tongue
movements/fasciculations
Cranial nerve examination

19. Motor system evaluation
• Quality, quantity and asymmetry
• Passive tone
• Active tone
• Reflexes
• Primitive reflexes

20. Motor system evaluation
Quantity, quality and symmetry of movements:
• Slow twisting movements at 28-32 weeks
• Alternating flexor movements by 36 weeks.
• At birth, “writhing” movements that change
to a “fidgety” pattern by six to nine weeks of
age which resolve by 20 weeks.
• Absence of fidgety movements at a time when
they should be present is predictive of
subsequent long-term neurologic sequelae.

21. Passive Tone
Rule of thumb
This is assessed by observing the posture at
rest and the resistance to movement.
Make sure the head and the trunk are in the
same axis.
The measurement of different limb-angles
diminishes as the muscle tone increases.

22. Passive tone assessment
• Posture
• Flappability
• Axial tone
Normally ventral incurvation is much easier
than dorsal incurvation, in central nervous
system pathology the dorsal incurvation is
increased much more than ventral
incurvation.
• Appendicular tone

23. Passive tone assessment

24. Active tone assessment
Righting reaction of lower extremities and trunk:
• With the baby in the standing position, assess the support
of body weight and the righting of the trunk..
Righting reaction of the head:
• Neck extensors-With the baby sitting and the head hanging
down on the chest, move the trunk slowly backward and
observe the reaction of the head; this allows the tone of
the extensor muscles on the back of the neck to be tested.
• Neck flexors- With the baby lying on the table, grasp the
hands (or the shoulders if a very small premature) and pull
him slowly to the sitting position, observing the position of
the head in relation to the trunk. This enables the tone of
the flexor muscles on the front of the neck to be checked.

26. Active tone assessment
• Stepping response can be obtained in infants born ≥32 weeks CA
• Vertical suspension measures the strength of the neonate's
shoulder girdle. The examiner holds the infant in an upright position
by placing the hands under the arms and around the chest with feet
unsupported
• Head control − By 40 weeks CA, the infant has sufficient neck and
truncal strength to maintain the head in line with the trunk for one
to two seconds while being pulled from the supine to sitting
position (figure 5).
• Ventral suspension measures the strength of the infant's trunk and
neck.
– The infant is held in a suspended prone position in the air by placing a
hand under the chest.
– A normal term infant will keep his/her head in the horizontal plane
momentarily with flexion of both the upper and lower extremities

27. Reflexes
An examiner's finger that is placed over the tendon to be tested
can be lightly struck with a percussion hammer to elicit the
reflex.
• Jaw
• Biceps
• Brachioradialis (supinator)
• Knee (patellar)

28. Superficial reflexes
• Abdominal reflexes
• Cremasteric reflex
• Anal wink reflex
• Corneal reflex
• Plantar reflex/ Babinski

29. Reflex How to elicit?
What is normal?
What is abnormal?
Palmar grasp
 Appears: 28 wk
 Fully developed: 32
wk
 Disappears: 2-3 m
Head in midline and arms semi flexed.
Without touching the dorsal surface of the
hand, place your index finger across the
palm and apply gentle pressure. Preferably,
both hands should be tested
simultaneously.*
Normal response
All fingers should flex around the
examiners finger with the strong grasp.
After obtaining the grasp the fingers are
drawn gently upwards. This elicits a
reinforcement of the grip with progressive
tensing of muscles from wrist to shoulder
until baby hangs from fingers momentarily.
Exceptionally strong and
persistent grasp may be seen
in spastic cerebral palsy or
kernicterus.
Asymmetry is noted in
hemiplegia.
Primitive reflexes

30. Rooting Reflex
 Appears: 32 wk
 Fully developed:
36 wk
 Disappears: 3-4 m
The newborn's cheek is lightly
stroked.
Normal response
Baby turns to find the expected
mother's nipple
Not turning to stimulus
Primitive reflexes

31. Moro reflex
 Appears: 28-32 wk
 Fully developed: 37
wk
 Disappears: 3-4 m
There are three ways:
1. Baby in supine, head midline . Pull
both arms to raise the shoulder slightly
off the table . Release the arm allow the
infant to fall on the table .
2. Suspend the baby with supporting the
trunk on one hand and head with the
other and lower rapidly both the hands
without flexing the head
3. Head bang which is done for ill, spinal
cord injury, ventilated incubator. With
the infant supine, slap sharply on the
mattress on either side of the infant.
Normal response
Symmetrical abduction of arms
Extension of forearm, followed by
adduction of arm and flexion of forearm
Hands open completely and the infant cries
or grimaces
Infant habituates after 3 attempts in term
and 10 attempts in preterms
Failure to extinguish or non
habituate
Persistence beyond 4
months of age indicates poor
cerebral function above the
brain stem or absence of
cortical inhibition.
Asymmetric Moro reflex is
seen in unequal muscle tone
or weakness due to injury of
humerus or clavicle.

32. Placing
 Fully developed:
birth
 Disappears: 10-12 m
Hold the infant with both hands under
the arms and around the chest. Support
the head with thumbs and jaw with index
finger. Lightly touch the dorsum of
infant feet to the sides of the table and
lift him to draw the foot against the
edge.
Normal response
Infant should flex the lower extremity
enough to bring his foot up and place it
on the surface.
 Asymmetrical, absent
or weak response with
poor movement of
lower extremity.
 Marked extension after
initial stimulus.
Walking/ stepping
 Fully developed:
birth
 Disappears: 10-12 m
Hold the infant in the same position as
described above; then hold him upright
over a table with the sole of the foot
presses against the table.
Normal Response
Reciprocal flexion and extension of legs
-

33. Asymmetrical TNR
 Appears: 35 wk
 Fully developed: 1 m
 Disappears: 2-3 m
Baby: lying supine, head in mid line, shoulder
horizontal
Head turned till jaw over either shoulder and
held for 15 sec and released.
Normal response:
Mental extension, occipital flexion; arm and
leg on the mental side extend and arm and leg
on the occipital side flexes.
If it occurs spontaneously, it is an active
reflex.
 Sustained/exaggerated
response i.e. failure to
move out of position while
head is held for 15 sec or
after release
 Consistent failure to move
an extremity
 Persistence of reflex
beyond 6 months.
 Obligatory ATNR – infant
cannot break the response
while the head is rotated.
Symmetrical TNR
 Fully developed: 4-6 m
 Disappears: Before
crawling
Support the child prone on your thighs while
you sit on chair, passively flex the neck and
observe the response and then extend the
neck. Now observe the response again
What is normal response?
When the neck is flexed the arms flexes and
the legs extends
When the neck is extended the arm extends
and legs flexes
 Persistence beyond 6
months is abnormal,
 In cerebral palsy, this reflex
is overactive. If the head is
lowered the arm flexes, leg
extends and the infant falls
on his face, hence is unable
to crawl.

34. Parachute reflex
 Fully developed: 9 m
 Disappears: Throughout life
Plantar grasp
 Appears: Birth
 Disappears: 9-10 m
Landau Reflex
 Appears: 3 m
 Fully developed: 6-10 m
 Disappears: 9-10 m
Truncal incurvation
 Appears: Birth
 Disappears: 1-2 m
Primitive reflexes.......

35. Head and spine
• Size
• Shape
• Sutures
• Fontanelle
• Spine
• Transillumination

36. Neurological exam in sick neonate
• Level of Alertness
• Habituation
• Pupils, Dolls eye movement
• Posture
• AF
• Tone (Popliteal angle, fisting)
• Reflexes
• Head and spine

37. Preterm corrected Term
• When examined at term, preterm infants tend to
have less flexor tone
• Head control in the sitting posture shows less
extensor tone in the neck compared to full-term
infants

38. Abnormalities of tone
• Increased Extensor tone in babies:
HIE, Bilirubin encephalopathy, IVH, Meningitis,
Raised ICP

39. Predictive ability of CNS evaluation for CP
• Tone abnormality of
trunk, UL, LL
• Diminished cry for 1 day
• Weak/absent suck
• Diminished activity for
more than 1 day
• 12-15 fold
• 21 fold rise
• 14 fold
• 19 fold
Nelson K B. Collaborative Perinatal Project of NIH. Pediatrics 1979

40. Points to remember!!
• Standard format
• Ten minute examination
• Serial exam and not one would help
• Prognosis (Discharge Neuro exam)
• Early Intervention
• Normal from Abnormal

41. Remember!
• Persistent neurologic dysfunction is associated
with an increased risk of permanent disability.
• The risk of cerebral palsy increases in infants
with persistent hypotonia, weak cry, poor
sucking, and decreased level of activity.
• Persistent asymmetric findings often are
associated with an underlying abnormality
• Composites of neurologic findings are better
predictors of outcome.

42. Thank you