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Neurologic System. Development of the Nervous System. Myelinization of the brain and nervous system is completed during the first year of life Brain growth continues until 12-15 years Motor maturation: cephalocaudal direction

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Development of the nervous system l.jpg
Development of the Nervous System

  • Myelinization of the brain and nervous system is completed during the first year of life

  • Brain growth continues until 12-15 years

  • Motor maturation: cephalocaudal direction

    • Control of the head and neck develops first, followed by trunk and extremities

  • Motor development is a succession of integrated milestones

    • Orderly sequence to development (though variation in timing exists)

    • Many milestones develop simultaneously

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  • Posture

    • “Flexed”

    • Hands held fisted (1st 3 months)

  • Observe for spontaneous activity

    • Symmetry and smoothness of motion

  • Coordinated sucking and swallowing (cerebellum)

    *Note any sustained asymmetric posturing and/or rhythmic twitching (facial, extremity, trunk musculature)

    • Paroxysmal episodes… associated with seizure activity

© 1998 Anrig & Plaugher. Used with permission.

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Infant Cranial Nerve Exam


  • Gazes intensely at a close object or face

  • Focuses on and tracks an object with both eyes

  • Optical blink reflex

    • Shine a light at the infant’s open eyes

    • Observe quick closure of the eyes and dorsal flexion of the infant’s head

      *No response: poor light perception

  • Doll’s eye maneuver (CN VIII)

© 1998 Anrig & Plaugher. Used with permission.

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© 1998 Anrig & Plaugher. Used with permission.


  • Rooting Reflex

    • Touch corner of the mouth

    • Infant should open its mouth and turn its head toward the stimulation

      *If recently fed, minimal response is expected

  • Sucking reflex

    • Place your finger in the infant’s mouth

    • Feel the sucking action

    • Tongue should push up against your finger with good strength

    • Note pressure, strength, and pattern

© 1998 Anrig & Plaugher. Used with permission.

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  • Observe the infant’s facial expression when crying

  • Note ability to wrinkle the forehead

  • Symmetry of the smile

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CN VIII (Acoustic)

  • Acoustic Blink Reflex

    • Clap your hands close to the infant’s head

    • Note the blink in response to sound

      • Infant will habituate to repeated testing

    • *No response after 2-3 days of age may indicate hearing problems

  • Moves eyes in direction of sound

  • Freezes position with high-pitched sound

© 1998 Anrig & Plaugher. Used with permission.

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CN VIII (Vestibular)

  • Doll’s Eye Maneuver

    • Hold the infant under the axilla in an upright position

      • Head held steady by parent, facing you

    • Rotate the infant, first in one direction and then the other

    • Infant’s eyes should turn in the direction of rotation

    • When movement stops, eyes should move in the opposite direction

    • *If not, suspect vestibular problem or eye muscle paralysis

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© 1998 Anrig & Plaugher. Used with permission.


  • Swallowing

  • Gag reflex

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  • Coordinated sucking and swallowing ability

  • Pinch infant’s nose

    • Mouth will open and tip of tongue will rise in a midline position

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Deep Tendon Reflexes

  • Use a finger to tap the tendon (VIDEO)

  • Interpret findings as for adults

    • Ankle clonus is common in infants

    • Patellar reflex present at birth

    • Achilles and brachioradialis appear around 6 months

© 1998 Anrig & Plaugher. Used with permission.

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Sensory function

  • Withdrawal of limbs to painful stimulus

  • May also use “Primitive Reflexes”…

    • Appear and disappear in a sequence corresponding with CNS development

    • Used to evaluate posture and movement of the developing infant

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As a general rule… birth to 6 months

Primitive Reflexes

  • Present in the newborn

    • Yawn

    • Sneeze

    • Hiccup

    • Blink at bright light and loud sound

    • Pupillary constriction with light

    • Withdrawal from painful stimuli

  • As the brain develops, some primitive reflexes are inhibited as more advanced cortical functions and voluntary control take over

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Plantar reflex

  • “Babinski sign” – fanning of toes and dorsiflexion of the great toe

  • Retained until

    16-24 months of age

© 1998 Anrig & Plaugher. Used with permission.

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Palmar Grasp

  • Infant’s head midline

  • Touch palm of the infant’s hand from the ulnar side

  • Note the strong grasp around your finger

  • Sucking facilitates the grasp

  • Strongest between 1-2 months

  • Disappears by 3 months

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Plantar Grasp

  • Touch the plantar surface of the infant’s feet at the base of the toes

  • Toes should curl downward

  • Strong up to 8 months

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Moro (VIDEO)

  • Infant supported in semi-sitting position

  • Allow the head and trunk to drop back to a 30 degree angle

  • Observe symmetric abduction and extension of the arms

    • Fingers fan out & thumb and index finger form a C

  • The arms then adduct in an embracing motion, followed by relaxed flexion

  • Legs follow a similar pattern

  • Diminishes in strength by 3-4 months

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  • Hold the infant upright

  • Touch the dorsum of the foot to the edge of a flat surface

  • Observe flexion of the hips and knees and lifting of the foot (as if stepping up)

  • Age of disappearance varies

© 1998 Anrig & Plaugher. Used with permission.

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Stepping (VIDEO)

  • Hold the infant upright under the arms

  • Allow the soles of the feet to touch the surface of the table

  • Observe for alternate flexion and extension of the legs (walking)

  • Disappears before voluntary walking

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Galant (VIDEO)

  • Suspend the infant prone over your hand

  • Stroke paraspinally from the shoulders to the buttocks

  • Trunk should curve toward the side stroked

  • Repeat on the other side

© 1998 Anrig & Plaugher. Used with permission.

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  • Suspend the infant prone over your hand

  • Stroke over the spinous processes from sacrum to occiput

  • Infant extends head and brings knees to chest; urinates

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Asymmetric Tonic Neck (aka Fencer’s)

  • Infant supine, turn head to one side

  • Observe for ipsilateral extension & contralateral flexion of the arms and legs

  • Repeat, turning head to the other side

  • Peaks around 2-3 months

  • Disappears by 6 months

    • Must disappear before the infant can roll or bring its hands to its face

  • Concern if infant never exhibits the reflex or seems locked in the fencing position

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Neck Righting

  • Infant supine, turn head to the side

  • Observe the infant turn its whole body in the direction the head is turned

  • Appears around 3 months (after Asymmetric Tonic Neck disappears)

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Landau (VIDEO)

  • Suspend the infant prone over both hands

  • Observe the infant’s ability to lift its head and extend its spine on a horizontal plane

  • Diminishes by 18 months

  • Disappears by 3 years

© 1998 Anrig & Plaugher. Used with permission.

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Parachute (VIDEO)

  • Hold the infant suspended (prone)

  • Slowly lower it head first toward a surface

  • Observe the infant extend its arms and legs (protecting itself)

  • This reflex should not disappear

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Plantar reflex

(Babinski) (VIDEO)

Palmer / plantar grasp (VIDEO)

Moro (VIDEO)


Stepping (VIDEO)

Galant (VIDEO)


Asymmetric tonic neck (aka Fencer) (VIDEO)

Neck righting

Landau (VIDEO)

Parachute (VIDEO)

Doll’s eye (VIDEO)

Rooting Reflex (VIDEO)


Please demonstrate…

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  • Observe the child at play

    • Fine motor coordination

    • Observe skill in reaching for, grasping, and releasing toys


      *No tremors or constant overshooting

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“Games” you can use as tests…

  • Ask the child to pick up a penny up off the floor

    • Tests vision and balance

  • Stick a moistened coin to the child’s nose and ask the child to walk across the room

    • Observe gait and posturing

  • Have the child balance a penny on the nose and dorsum of each extended hand

    • Tests Romberg

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  • Gait

    • Beginning walker: wide-based gait VIDEO

    • Older child: feet closer together, better balance VIDEO

  • Coordination skills

    • Heel-to-toe walking, hopping, and jumping

    • Modify into a game

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Deep Tendon Reflexes


  • Use same technique and grading as adults

  • Responses should be the same

  • May use a finger instead of reflex hammer

    • less threatening

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Light Touch

  • Ask the child to close their eyes and point to where you touch

  • Discriminate between rough and soft


  • Tuning fork; “buzzing” sensation

    Superficial pain

  • Not routinely tested in kids

    • Fear of needles and sharp objects

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Cranial Nerve Examination


  • Snellen Eye Chart

  • Visual fields

    • child may need the head immobilized

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CN III, IV, and VI

  • Cardinal planes of gaze

    • Have child follow an object with eyes

    • Immobilize head if necessary


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  • Observe the child chewing; note bilateral jaw strength

  • Touch forehead and cheeks with cotton

    • watch the child bat it away

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  • Observe the child’s face when smiling, frowning, and crying

  • Ask child to show teeth

  • Demonstrate puffed cheeks and ask the child to imitate

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  • Observe the child turn to sounds

  • Whisper a commonly used word behind the child’s back and have him or her repeat the word

  • Refer for audiometric testing

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CN IX and X

  • Elicit gag reflex

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  • Instruct child to “stick out the tongue”

  • Instruct child to “shrug the shoulders”

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Neurological Soft Signs

  • Nonfocal, functional neurologic findings

  • Provide subtle cues to an underlying CNS deficit or a neurological maturation delay

  • Children with multiple soft signs are often found to have learning problems

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Walking, running gait

  • Soft Sign Finding:

    • Stiff-legged with a foot slapping quality, unusual posturing of the arms

  • Latest Expected Age of Disappearance:

    • 3 years

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  • Soft Sign Finding:

    • Difficulty maintaining stance (arms extended in front, feet together, and eyes closed), drifting of arms, mild writhing movements of hands or fingers

  • Latest Expected Age of Disappearance:

    • 3 years

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One-foot standing

  • Soft Sign Finding:

    • Unable to remain standing on one foot longer than 5-10 sec.

  • Latest Expected Age of Disappearance:

    • 5 years

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Visual tracking

  • Soft Sign Finding:

    • Difficulty following object with eyes when keeping the head still; nystagmus

  • Latest Expected Age of Disappearance:

    • 5 years

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  • Soft Sign Finding:

    • Unable to identify common objects placed in own hand

  • Latest Expected Age of Disappearance:

    • 5 years

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Right-left discrimination

  • Soft Sign Finding:

    • Unable to identify right and left sides of own body

  • Latest Expected Age of Disappearance:

    • 5 years

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Hopping in place

  • Soft Sign Finding:

    • Unable to hop rhythmically on each foot

  • Latest Expected Age of Disappearance:

    • 6 years

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Two-point discrimination

  • Soft Sign Finding:

    • Difficulty in localizing and discriminating when touched in one or two places

  • Latest Expected Age of Disappearance:

    • 6 years

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Heel walking

  • Soft Sign Finding:

    • Difficulty remaining on heels for a distance of 10 ft

  • Latest Expected Age of Disappearance:

    • 7 years

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Tip-toe walking

  • Soft Sign Finding:

    • Difficulty remaining on toes for a distance of 10 ft

  • Latest Expected Age of Disappearance:

    • 7 years

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Tandem gait

  • Soft Sign Finding:

    • Difficulty walking heel-to-toe, unusual posturing of arms

  • Latest Expected Age of Disappearance:

    • 7 years

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Finger-nose test

  • Soft Sign Finding:

    • Unable to alternately touch examiner’s finger and own nose consecutively

  • Latest Expected Age of Disappearance:

    • 7 years

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  • Soft Sign Finding:

    • Unable to identify geometric shapes you draw in child’s open hand

  • Latest Expected Age of Disappearance:

    • 8 years

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Rapid thumb-to-finger

  • Soft Sign Finding:

    • Rapid touching thumb to fingers in sequence is uncoordinated; unable to suppress mirror movements in contralateral hand

  • Latest Expected Age of Disappearance:

    • 8 years

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Rapid alternating movements of hands

  • Soft Sign Finding:

    • Irregular speed and rhythm with pronation and supination of hands patting the knees

  • Latest Expected Age of Disappearance:

    • 10 years

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  • Inflammatory process in the meninges

    • Bacterial / viral


    • Fever

    • Chills

    • Nuchal rigidity

    • Headache

    • Seizure

    • Vomiting

    • Altered level of consciousness

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S/S of Meningitis in the Young Infant:

  • Very irritable and inconsolable

  • Fever

  • Diarrhea

  • Poor appetite

  • Toxic appearance

    *Note: infants do not demonstrate nuchal rigidity until 6-9 months of age

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  • Inflammation of the brain and spinal cord (also involves meninges)

    Onset is often a mild, febrile viral illness and a quiescent stage often precedes the disturbance in CNS function

    • Headache

    • Drowsiness

    • Confusion, progressing to stupor and coma

    • Motor function may also be impaired

      • Severe paralysis

      • Ataxia

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Space-Occupying Lesions / Intracranial Tumors

  • Abnormal growth of neural or nonneural tissue within the cranium

    • Primary or metastatic cancer

      Peak age of incidence:

    • 3-12 years

    • 50-70 years

      *Threaten function by compression or destruction of tissue

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Early Signs & symptoms:

  • Headache

  • Vomiting

  • Change in cognition

  • Motor dysfunction

  • Seizures

  • Personality changes

    *Vary by location of the tumor

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Cerebral Palsy

  • Nonprogressive neuromuscular disorders

    • Abnormal muscle tone

    • Coordination

  • Caused by insult to the cerebellum, basal ganglia, or motor cortex

  • Disability depends on the extent of damage

    • Some can expect near normal levels of functioning

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Signs include:

  • Delayed gross motor development

  • Altered muscle tone

  • Abnormal posture

  • Abnormal motor performance

  • Abnormal reflexes

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Rett syndrome

  • Progressive encephalopathy

    • Unknown cause

    • Affects girls between 6-18 months of age

      *Develops after normal neurologic and mental development …

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Signs & symptoms:

  • Loss of voluntary hand movement

  • Loss of previously acquired hand skills

  • Hand wringing movements

  • Gradual development of ataxia & rigidity of the legs

  • Growth retardation

  • Seizures

  • Loss of facial expression

  • Deceleration of head growth

    • between 5-48 months of age

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Generalized Seizure Disorder

  • Episodic, sudden, involuntary contractions of a group of muscles

  • Excessive discharge of cerebral neurons

    May be caused by:

    • Systemic disease

    • Head trauma

    • Toxins

    • Stroke

    • Hypoxic syndromes

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  • Affects 1% of the population

  • 75% new cases develop during childhood and adolescence

    Disturbances in:

    • Consciousness

    • Behavior

    • Sensation

    • Autonomic functioning (urinary and fecal incontinence)