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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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Observation

  • 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

CN II, III, IV, & VI

  • 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.

CN V

  • 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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CN VII

  • 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.

CN IX, X

  • Swallowing

  • Gag reflex


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CN XII

  • 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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Placing

  • 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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Perez

  • 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)

Placing

Stepping (VIDEO)

Galant (VIDEO)

Perez

Asymmetric tonic neck (aka Fencer) (VIDEO)

Neck righting

Landau (VIDEO)

Parachute (VIDEO)

Doll’s eye (VIDEO)

Rooting Reflex (VIDEO)

DTR (VIDEO)

Please demonstrate…



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Observation

  • Observe the child at play

    • Fine motor coordination

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

      VIDEO

      *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

VIDEO

  • 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

    Vibration

  • Tuning fork; “buzzing” sensation

    Superficial pain

  • Not routinely tested in kids

    • Fear of needles and sharp objects


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Cranial Nerve Examination

CN II

  • 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

      video


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CN V

  • Observe the child chewing; note bilateral jaw strength

  • Touch forehead and cheeks with cotton

    • watch the child bat it away


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CN VII

  • 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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CN VIII

  • 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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CN XI and XII

  • 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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Motor-stance

  • 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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Stereognosis

  • 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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Graphesthesia

  • 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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Meningitis

  • Inflammatory process in the meninges

    • Bacterial / viral

      Signs/Symptoms:

    • 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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Encephalitis

  • 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)


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