Pediatric Neurology examination explained in details with Developmental Milestones and Anthopometry

1. Neurological Assessment
of Child
Presenter :Dr Fakir Mohan Sahu
AIIMS BHUBANESWAR
Dept of Neurosurgery
23/03/2021

2. Outlines
• History
• Anthropometry/Development assessment
• Examining of head / Dysmorphic Child
• The neurological examination
• HMF
• Cranial Nerves
• Motor system
• Sensory system
• Reflexes
• Signs of meningeal irritation
• Cerebellar signs
• Pearls on examining infants and Older Child

3. Introduction
• The CNS in a children is a dynamic, developing and maturing system
• A daunting task to assessment of CNS
• Special tricks and adoption of “play attitude” is mandatory
• History is often imprecise as child cannot explain or express

4. Normal Neurologic Growth and Development
• What additional questions are important for a complete pediatric neurology
history?
– Antenatal
– Perinatal
– Neonatal Complications
– Neurodevelopment
– Immunizations
– Behaviour
– Family History
– Social History

5. Key points in History
• Presenting symptom
• Onset: Sudden/ Subacute/ Insidious
• Evolution: Improving/Slow Progression/Rapid progression
• Any symptom of raised ICP/Seizure/LOC
• Development before onset of symptom
• Mental status- Alert/ irritable/ lack of interest/ drowsy/ stuporous/ comatose
• Feeding History/Family history/ Consanguinity
• Etiological history- Perinatal events/trauma/drugs toxin/infections if any

6. Principles and art of Examination
• Pre-requisite/ Essential tools
• Setting- well lighted room, colourful comfortable, warm hands
• Position
• 0-3 months – Examination table
• 3mont – 1 yr - Mothers lap
• 1-3 yr -Standing / Mothers lap
• After 3 yr - Examination table
• Adolescent girl - Female attendants

7. General Physical Examinations
• General appearance/Posture/ nature of disability/ Build and Nutrition
• Handedness(established around 3 years of age)
• Anthropometry
• Skull and Spine- Size /shape /sutures/ fontanels/ spinal deformities
• Skin and Appendages –Neuroectodermal dysplasia: Adenoma sebaceum/café –au-lait/ shagreen
Patch/ Swelling
• Vitals Sign- Anaemia/Cyanosis/ Icterus/ Clubbing/ LN pathy/ Organomegaly

8. Neurocutaneous markers
1. Cafe au lait spots
2. Ash leaf patch
3. Litsch nodules
4. Axillary and inguinal freckling.
5. Facial angiofibromas .
6. Cutaneous neurofibromatosis.
7. Multiple unqualified fibromas .
8. Shagreen patch.
9. Adenoma sebacum.
10. Hypo / hyper pigmented Macules
11. hairy tuft at sacrum.
12. Facial angioma /Port wine stain

9. Neurofibromatosis

10. Tuberous Sclerosis

11. Sturge Weber Syndrome

12. PHACE Syndrome
• Female predominance
Consists of
• Posterior fossa malformation
• Haemangiomas ipsilateral to the aortic arch
• Arterial anomalies
• Coarctation of the aorta, apalsia or hypoplasia of carotid
arteries, aneurysmal carotid dilatation, aberrant left subclavian artery
• Eye abnormalities- glaucoma, cataracts, microphthalmia, optic nerve
hypoplasia.

13. Myelomeningocele
Dermoid cyst
Lipoma
Sacrococcygeal Teratoma
Hairy Nevus
Spinal dysraphism
Encephalocele

16. Moro’s Reflex
Grasp reflex Rooting reflex
Asymmetric tonic Neck reflex
Placing Reflex

17. Lindau reflex
Parachute reflex

18. Developmental screening
• Gross motor Development
• Fine motor/ Visual
• Social/ Adaptive and language Development
• Red Alerts

24. Red Alerts
• Lack of Social smile by 2 months
• Absence of stable head control by 4 months
• Inability to recognize the mother by 6 months
• Inability to sit when pulled to sit by 6 months / independent sitting by 8 months
• Lack of creeping by 9 months
• Inability to stands without support by 1yr
• Inability to walk without support by 18 months
• Lack of pincer grasp by 1 yr
• Absence of syllabic babbling by the age of 1 yr
• Failure to make meaningful sentences by 3 years

25. Anthropometry
• Weight
• Length/ Height
• Head circumference
• Assessment of - Mid arm circumference/ Subcutaneous fat/ Arm span/
Obesity

26. Head Circumference
• Brain growth takes place 70% during fetal life, 15% during infancy and
remaining 10% during pre-school years.
• Head circumference are routinely recorded until 5 years of age.
• If scalp edema or cranial moulding-
measurement of scalp edema may be inaccurate until fourth or fifth day

27. Expected head circumference in children
• Head Circumference Growth Velocity
Till 3 months 2 cm/month
3 months – 1 year 2cm/3 month
1 – 3 year 1cm/ 6 month
3 – 5 year 1cm/ year
• During first year there is 12 cm increase in head
circumference , while 1 – 5 year age , only 6 cm gain
occur in head size.
Age Head circumference (cm)
At birth 33 – 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

28. 10 cms /yr for boy

30. Head Examinations
• Size/ Shape/ Symmetry/Sutures
• Fontanels-Depressed/ Flat/ Buldged
• Six at birth
• Two large ant/post
• Anterior fontanel (2.5×2.5cm) closes by 12-18 mnths
• Posterior fontanel small at birth closes by 6 weeks
• Two Anterolateral/ two posterolateral

31. Abnormal head/ facies/ Dysmorphic child
• Hydrocephalus
• Microcephaly
• Dolichocephaly
• Brachycephaly
• Frontal bossing's
• Acrocephaly / Oxycephaly
• Trigonocephaly
• Plagiocephaly
• Caput quadratum/ hot cross burn appearance
• Flat Occiput/ Prominent occiput

32. Microcephaly
Macrocephaly with frontal bossing
Craniotabes
Proptosis NF Down syndromes

33. Hydrocephalus

35. SCAPHOCEPHALY
Trigonocephaly

36. PLAGIOCEPHALY
Turricephaly

38. Higher Mental Function
• Level of Consciousness
Alert
Response to Voice
Response to pain
Unresponsive to any stimulus
Coma Scale

39. Coma Scale

40. Higher Mental Function
• Emotional status- Assess behaviour/ perception and emotional
liability/ hyperactivity/ attention/ distractibility/ impulsiveness
• Memory and Orientation
• Immediate/Recent/ Remote(above 5yrs)
• Time / Place / Person
• Name of school/ teacher/ father/ friends
• Ability to obey simple commands
• Tell a brief story and repeat the same
• Repeat no forward/ Backward
6yr repeat forward five digits and backward three digits,
10 yr six digits forward and four digits backward

41. Speech
• Aphonia/Dysphonia- Volume or intensity of speech affected
• A child is asked to blow out a candle or count 1 -100
• Wernicke’s aphasia/ Broca’s Aphasia/ Dyslexia(slowness in reading, mirror
image writing, reading from right to left)
• Disorders of Articulation- “Pa” “Ta” “Ka”
• Stammering/ lalling or baby speech
• Scanning and Staccatto speech/Slurred
• Spastic / Slurring dysarthria
• Nasal Speech
• Autism Spectrum disorders

42. Signs of Meningeal irritations
• Absent-infants <3 months/ malnourished child/ seriously sick pt.
Early Sign Late Sign

43. Neck rigidity

44. Tripod Sign

45. Cranial nerve exam:
Olfaction CN(I)
• Olfactory sensation as transmitted by the olfactory nerve is not
functional in the newborn
• Present by 5 to 7 months of age.
• Anosmia/ Parosmia

46. Cranial Nerve-
• Optic nerve(II)
Visual Acuity-
Infants Blinking response/ Turning of head towards light
Above 3 yr – 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
“E” chart

47. III, IV, VI CN
• Movements are complete in all directions by
approximately 4 months of age,
• Acoustically elicited eye movements appear at 5
months of age .
• Ptosis/ Diplopia
• Head tilt
• Dolls eye movement Infant
• Depth perception using solely binocular cues
appears by 24 months of age
• Stable binocular alignment and optokinetic
nystagmus.

48. Trigeminal(Vth) CN
• 1-Sensory :ophthalmic-maxillary-mandibular.
• 2-Motor:masseter - temporalis –pterigoid.
• 3-Reflexes:corneal reflex-jaw reflex

49. Facial (VII) CN
• Impaired motor function is indicated by facial asymmetry.
• The McCarthy reflex, ipsilateral blinking produced by tapping the supraorbital
region, is diminished or absent in lower motor neuron facial weakness.
• Palpebral reflex, bilateral blinking induced by tapping the root of the nose, it
can be exaggerated by upper motor neuron lesions.
• 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.
• Failure to pull the affected side of the mouth backward and downward when
crying.
• Sensory-----Ant.2/3 of tongue.

50. Vestibulocochlear(VIII)
Cochlear part(hearing)
• At birth ---Moro reflex.
• Younger deviate to sound.
• Later Rinne s test+ Weber test.
Vestibular part(Vertigo+ Nystagmus)
• 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.
• Clockwise and counterclockwise rotations are performed. The direction and
amplitude of the quick and slow movements of the eye are noted.

51. Hearing development
BERA

52. IX, X, XI CN
• Sensory ……loss of post 2/3 of tongue.
• Motor……pharyngeal O/E….
• 1-gag reflex…absent in bulber palsy UMNL
exaggarated in pseudo bulber palsy LMNL.
• 2-Uvula ….normally central & mobile.
• In unilateral lesion….uvula deviate to healthy side.
• In bilateral lesion…uvula is central but immobile.
Spinal accessory N.
• Sternomastoid-ability to rotate head to healthy side.
• Trapezius-dropping of shoulder in affected side

53. Hypoglossal(XII)
• Hypoglossal N. …..
Deviation of the tongue to the affected side on protrusion.

54. Motor system
• Bulk
• Tone
• Power
• Deep/ Superficial reflexes

55. Muscle tone
• Hypotonia is characterized by decreased resistance to passive
movement and hyperextension at the joints.
• Hypertonia can be either spastic in nature or characterized by muscle
rigidity.
• UMNL =Pyramidal lesion….. spasticity(clasp knife) resistance on the start of movement.
• Extrapyramidal lesion….. rigidity(resistance is all over movement (cog-weal or lead)

56. Muscle power
• 1-Young child…….painful stimulation on the opposite side of the
tested muscle.
• 2-Older child….ask to move against resistance.
• 3-Test every joint for its muscle group.
• 4-Grading of muscle power

57. Scarf sign Heel Ear
Dorsiflexion toe

58. Involuntary movements
Usually with extrapyramidal lesion.
• Chorea….sudden irregular purposeless
dancing movement affect big proximal joint.
• Athetosis…slow twisting movement affect
distal joint.
• Dystonia….slow twisting movement in trunk.
• Tremors….rapid alternating movement
around small joint.

59. Incoordination
• 1st year ……grasp reflex & object transfer.
• -2nd year……button & unbutton.
• ->3years……U.L.
• 1- Finger to nose test
• 2-Finger to finger test
• 3-Dysdiadochokinesis…inability to perform rapidly
alternating movement
• 4-Rebound test L.L.
Heal to shin test
Toe finger test
Foot Tapping test
Inco-ordination = ataxia.

60. Sensory system
• Sensory examination in young children is often imprecise, and only
gross deficits can be detected.
• In children > 5 -6 years sensory function is evaluated in the same
manner as in an adult
• Touch
• Pain & Temperature
• JPS

61. Pearls on examining infants and Older Child
• Accuracy depends upon the observational ability and intelligence
• Concerns of Parents/ Attendants
• Dietary/ Immunization/ Perinatal/ Developmental history
• Approach of examination Unstructured
(unpleasant examination postponed to the end)
• 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
• Primitive reflexes are present in birth disappear by 4-5 months
• Developmental screening is a must/ early markers of Cerebral palsy
• Deep tendons reflexes are normally brisk during infancy
• KJ crossed adductor response/ Cremasteric reflex
• Plantar normally extensors up to 2yrs
• Fundus normally pale in infants/ Papilledema appears after 3 yrs

63. Thank You