This document discusses the neurological assessment of a newborn baby. It begins by outlining the current practice of neurological examinations in hospitals, noting that full examinations are often not possible due to large patient volumes and staffing shortages. The document then provides details on various components of a comprehensive neurological assessment, including gestational age assessment, examination of the head and fontanelles, assessment of tone, posture and reflexes, and cranial nerve evaluation. It discusses the typical timing of appearance and disappearance of various reflexes. The document concludes by discussing the use of rapid neurodevelopmental assessments at discharge to screen for developmental issues.
IT IS UPLOADED TO HELP NURSING AND PARAMEDICS EDUCATOR TO TEACH THEIR STUDENTS REGARDING NEW BORN CARE. IT ALSO HELPS TO CREATE AWARENESS AMONG GENERAL PUBLIC ABOUT THE NEW BORN CARE.
Normal newborn care, by Dr Amal Khalil, Dean of Nursing college, Port said University, Port said. Presented in the NICU nursing workshop, organized by Nursing syndicate in Suez canal & Sinai in cooperation with Port said university college of nursing & Port said neonatology society, December,2014 Port said
IT IS UPLOADED TO HELP NURSING AND PARAMEDICS EDUCATOR TO TEACH THEIR STUDENTS REGARDING NEW BORN CARE. IT ALSO HELPS TO CREATE AWARENESS AMONG GENERAL PUBLIC ABOUT THE NEW BORN CARE.
Normal newborn care, by Dr Amal Khalil, Dean of Nursing college, Port said University, Port said. Presented in the NICU nursing workshop, organized by Nursing syndicate in Suez canal & Sinai in cooperation with Port said university college of nursing & Port said neonatology society, December,2014 Port said
Health Assessment of the Newborn
The newborn requires thorough skilled observation to ensure a satisfactory adjustment to extra uterine life.
Health assessment of newborn after delivery can be divided into:
1. Initial Assessment
2. Transitional Assessment
3. Assessment of gestational age
4. Behavioural asessment
5. Systemic physical examination
Initial Assessment:
Initial assessment is done by using the APGAR scoring system.
APGAR score: It is method use to assess the newborn’s immediate adjustment to extra uterine life.
• The score based on five signs
1. Appearance (colour)
2. Pulse (Heart rate)
3. Grimace (Reflex irritability )
4. Activity (Muscle tone)
5. Respiratory rate
• Each item is given a score 0, 1, or 2
• 0-3 severe distress
• 4-6 moderate difficulty
• 7-10 no difficulty adjusting to life
• Evaluations of all five categories are made on 1-5 min after birth.
APGAR score:
Sign 0 1 2
Appearance (colour) Blue or pale Body pink, Extrimities Blue Completely Pink
Pulse (Heart rate) Absent Slow (<100 /> 100/m
Grimace (Reflex irritability ) No response Grimace Cough Or Sneeze
Activity(Muscle tone Limp Some flexion Active movement
Respiratory rate Absent Slow, Irregular Good, Crying
Other initial assessment are-
• Stabilization
• Measuring weight.
Transitional Assessment during the period of reactivity
First period of reactivity (6- 8 hours after birth):
During the first 30 minutes the newborn is very alert, cries vigorously, may suck a first greedily, and appears very interested in the environment. Physiologically the respiratory rate can be as high as 80 breaths/ min, crackles may be heard, heart rate may reach 180 beats/min, bowel sound are active, mucus secretions are increased and temperature may decrease slightly.
Second period of reactivity:
Began when the newborn awake from the deep sleep, it lasts about 2-5 hours. The newborn is alert and responsive, heart and respiratory rate are increased, gastric and respiratory secretions are increased, and passage of meconium commonly occurs.
Following this stage is a period of stabilization of physiologic systems & vacillating patern of sleep & activity.
Topic 03: Health Assessment of the Newborn
The newborn requires thorough skilled observation to ensure a satisfactory adjustment to extra uterine life.
Health assessment of newborn after delivery can be divided into:
1. Initial Assessment
2. Transitional Assessment
3. Assessment of gestational age
4. Behavioural asessment
5. Systemic physical examination
Initial Assessment:
Initial assessment is done by using the APGAR scoring system.
APGAR score: It is method use to assess the newborn’s immediate adjustment to extra uterine life.
• The score based on five signs
1. Appearance (colour)
2. Pulse (Heart rate)
3. Grimace (Reflex irritability )
4. Activity (Muscle tone)
5. Respiratory rate
• Each item is given a score 0, 1, or 2
• 0-3 severe distress
• 4-6 moderate difficulty
• 7-10 no difficulty adjusting to life
• Evaluations of all five categories are made on 1-5 min after birth.
APGAR score:
Sign 0 1 2
Appearance (colour) Blue or pale Body pink, Extrimities Blue Completely Pink
Pulse (Heart rate) Absent Slow (<100 /> 100/m
Grimace (Reflex irritability ) No response Grimace Cough Or Sneeze
Activity(Muscle tone Limp Some flexion Active movement
Respiratory rate Absent Slow, Irregular Good, Crying
Other initial assessment are-
• Stabilization
• Measuring weight.
Transitional Assessment during the period of reactivity
First period of reactivity (6- 8 hours after birth):
During the first 30 minutes the newborn is very alert, cries vigorously, may suck a first greedily, and appears very interested in the environment. Physiologically the respiratory rate can be as high as 80 breaths/ min, crackles may be heard, heart rate may reach 180 beats/min, bowel sound are active, mucus secretions are increased and temperature may decrease slightly.
Second period of reactivity:
Began when the newborn awake from the deep sleep, it lasts about 2-5 hours. The newborn is alert and responsive, heart and respiratory rate are increased, gastric and respiratory secretions are increased, and passage of meconium commonly occurs.
Following this stage is a period of stabilization of physiologic systems & vacillating patern of sleep & activity.
Gestational Age Assessment
An accurate assessment of age is important for 2 reasons
• Age and growth patterns appropriate to that age aid in identifying neonatal risks
• Help in developing management plans
Gestational age can measure by weight for gestational age chart.
Gestational Age Number of weeks that have elapsed since the first day of the last menstrual period to the time of birth. This is usually retrieved from mother’s Antenatal History.
Gestational Age:
• SGA- small for gestational age-weight below 10th percentile •
• AGA-weight between 10 and 90th percentiles
• LGA-weight above 90th percentile
Behavioural Assessment
While babies may not speak their first word for a year, they are born
Fourth stage of labor: The hour or two after delivery when the tone of the uterus is reestablished as the uterus contracts again, expelling any remaining contents. These contractions are hastened by breastfeeding, which stimulates production of the hormone oxytocin.
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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.
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
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
25.
26.
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
31.
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
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
42.
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
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
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).
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
Editor's Notes
and is a reflection of the underlying intracranial volume
Normal muscle offers a resistance to stretch which is felt by the examiner as tone.
This progression correlates with increasing myelination of the subcortical motor pathways originating in the brainstem.
Hypotonia can be present with encephalopathy, arterial or venous ischemic injuries, hemorrhage, sepsis, metabolic disturbances, or congenital malformations
Hypertonia represents more chronic injury to the corticospinal tracts and therefore, tends to present later
Newborn have visual acuity of 20/600, 30 times lower than adult