Neurologic System

1. Neurologic System Adapted from Mosby’s Guide to Physical Examination, 6th Ed. Ch. 22

2. Development 1st year of life • Myelinization of the brain and nervous system “Any intruding event (infection, trauma, or biochemical imbalance), that upsets brain development and growth during this time, can have profound effects.” *Brain growth continues until 12-15 years

3. Motor maturation proceeds in a cephalocaudal direction • Control of the head and neck develops first • Followed by trunk and extremities • Motor development is a succession of integrated milestone • Many may be developed simultaneously • Orderly sequence to development • Considerable variation in timing exists

4. Developmental Milestones • See Table (Musculoskeletal)

5. Infant Exam

6. Infant Cranial Nerve Evaluation CN II, III, IV, & VI • 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 • Gazes intensely at close object or face • Focuses on and tracks an object with both eyes • Doll’s eye maneuver (CN VIII)

7. CN V • Rooting Reflex • Touch one corner of the infant’s mouth • Infant should open its mouth and turn its head in the direction of 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

8. CN VII • Observe the infant’s facial expression when crying • Note ability to wrinkle the forehead • Symmetry of the smile

9. CN VIII • Acoustic Blink Reflex • Clap your hands about 1 ft. from 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

10. CN VIII (continued) • 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

11. CN IX, X • Swallowing and gag reflex

12. CN XII • Coordinated sucking and swallowing ability • Pinch infant’s nose • Mouth will open and tip of tongue will rise in a midline position

13. Observation • Coordinated sucking and swallowing (cerebellum) • Hands are usually held fisted for the 1st 3 months (but not constantly) • After 3 months they open for longer periods • Observe for spontaneous activity • Symmetry • Smoothness of motion

14. Posture and movement • Rhythmic twitching • Facial, extremity, trunk musculature • Sustained asymmetric posturing • Paroxysmal episodes… associated with seizure activity

15. Sensory function • Withdrawal of limbs to painful stimulus

16. Reflexes • Patellar reflex present at birth • Achilles and brachioradial reflexes appear at 6 months • Use a finger to tap the tendon • Interpret findings as for adults *NOTE: ankle clonus is common

17. Babinski sign • Positive – fanning of toes and dorsiflexion of the great toe • Retained until 16-24 months of age

18. Primitive Reflexes Present in the newborn • Yawn • Sneeze • Hiccup • Blink at bright light and loud sound • Pupillary constriction with light • Withdrawl from painful stimuli • As the brain develops, some primitive reflexes are inhibited • more advanced cortical functions and voluntary control take over

19. Primitive Reflexes • Used to evaluate posture and movement of the developing infant • Appear and disappear in a sequence corresponding with CNS development

20. Palmar Grasp (birth) • Infant’s head midline • Touch palm of the infant’s hand from the ulnar side • Note the strong grasp of your finger • Sucking facilitates the grasp • Strongest between 1-2 months • Disappears by 3 months

21. Plantar Grasp (birth) • Touch the plantar surface of the infant’s feet at the base of the toes • Toes should curl downward • Strong up to 8 months

22. Moro (birth) • 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

23. Placing (4 days) • Hold the infant upright under the arms • 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

24. Stepping (birth-8 weeks) • 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

25. Asymmetric Tonic Neck (by 2-3 months) 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 • Diminishes around 3-4 months and 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

26. Galant (birth-4 weeks) • 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

27. 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

28. Landau (birth-6 months) • 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

29. Parachute (4-6 months) • 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

30. Neck Righting (3 months; after Tonic Neck disappears) • Infant supine • Turn head to the side • Observe the infant turn its whole body in the direction the head is turned

31. Child Exam

32. Cranial Nerve Examination CN II • Snellen E or Picture Chart may be used to test vision • Visual fields may be tested; child may need the head immobilized

33. CN III, IV, and VI • Have child follow an object with eyes; immobilize head if necessary • Move the object through the cardinal points of gaze video

34. CN V • Observe the child chewing; note bilateral jaw strength • Touch forehead and cheeks with cotton • watch the child bat it away

35. 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

36. CN VIII • Observe the child turn to sounds (bell or whisper) • Whisper a commonly used word behind the child’s back and have him or her repeat the word • Refer for audiometric testing

37. CN IX and X • Elicit gag reflex

38. CN XI and XII • Instruct older child to stick out the tongue • Instruct older child to shrug the shoulders or raise the arms

39. Observation • Observe the child at play • Gait • Fine motor coordination • Beginning walker: wide-based gait VIDEO • Older child: feet closer together, better balance VIDEO

40. Observe skill in reaching for, grasping, and releasing toys VIDEO • No tremors or constant overshooting movements should be apparent • Coordination skills (heel-to-toe walking, hopping, and jumping) • Modify into a game

41. Three Penny Games • Ask child who is standing 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 child balance a penny on the nose and dorsum of each extended hand • Tests Romberg

42. Deep Tendon Reflexes VIDEO • Use same technique as adults • Responses should be the same • May use finger instead of reflex hammer (less threatening)

43. Light Touch • Ask child to close eyes and point to where you touch • Discriminate between rough and soft Vibration • Tuning fork; “buzzing” sensation

44. Superficial pain • not routinely tested in kids due to their fear of needles and sharp objects

45. Graphesthesia (cortical sensory integration) • Use geometric figures • Draw each figure twice and ask the child if the figures are the same or different *May need practice session with eyes open

46. 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

47. 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

48. Heel walking Soft Sign Finding • Difficulty remaining on heels for a distance of 10 ft Latest Expected Age of Disappearance • 7 years

49. Tip-toe walking Soft Sign Finding • Difficulty remaining on toes for a distance of 10 ft Latest Expected Age of Disappearance • 7 years

50. Tandem gait Soft Sign Finding • Difficulty walking heel-to-toe, unusual posturing of arms Latest Expected Age of Disappearance • 7 years