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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
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
  • 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.

infant cranial nerve exam
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.

© 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.

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

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
  • Coordinated sucking and swallowing ability
  • Pinch infant’s nose
    • Mouth will open and tip of tongue will rise in a midline position
deep tendon reflexes
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.

sensory function
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
primitive reflexes
As a general rule… birth to 6 monthsPrimitive 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
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.

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
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
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
  • 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.

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
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.

  • 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
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
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)
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.

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
please demonstrate
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…
  • Observe the child at play
    • Fine motor coordination
    • Observe skill in reaching for, grasping, and releasing toys


*No tremors or constant overshooting

games you can use as tests
“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
    • 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
deep tendon reflexes32
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
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
cranial nerve examination
Cranial Nerve Examination


  • Snellen Eye Chart
  • Visual fields
    • child may need the head immobilized
CN III, IV, and VI
  • Cardinal planes of gaze
    • Have child follow an object with eyes
    • Immobilize head if necessary


  • Observe the child chewing; note bilateral jaw strength
  • Touch forehead and cheeks with cotton
    • watch the child bat it away
  • Observe the child’s face when smiling, frowning, and crying
  • Ask child to show teeth
  • Demonstrate puffed cheeks and ask the child to imitate
  • 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
CN IX and X
  • Elicit gag reflex
  • Instruct child to “stick out the tongue”
  • Instruct child to “shrug the shoulders”
neurological soft signs
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
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
  • 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
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
Visual tracking
  • Soft Sign Finding:
    • Difficulty following object with eyes when keeping the head still; nystagmus
  • Latest Expected Age of Disappearance:
    • 5 years
  • Soft Sign Finding:
    • Unable to identify common objects placed in own hand
  • Latest Expected Age of Disappearance:
    • 5 years
Right-left discrimination
  • Soft Sign Finding:
    • Unable to identify right and left sides of own body
  • Latest Expected Age of Disappearance:
    • 5 years
Hopping in place
  • Soft Sign Finding:
    • Unable to hop rhythmically on each foot
  • Latest Expected Age of Disappearance:
    • 6 years
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
Heel walking
  • Soft Sign Finding:
    • Difficulty remaining on heels for a distance of 10 ft
  • Latest Expected Age of Disappearance:
    • 7 years
Tip-toe walking
  • Soft Sign Finding:
    • Difficulty remaining on toes for a distance of 10 ft
  • Latest Expected Age of Disappearance:
    • 7 years
Tandem gait
  • Soft Sign Finding:
    • Difficulty walking heel-to-toe, unusual posturing of arms
  • Latest Expected Age of Disappearance:
    • 7 years
Finger-nose test
  • Soft Sign Finding:
    • Unable to alternately touch examiner’s finger and own nose consecutively
  • Latest Expected Age of Disappearance:
    • 7 years
  • Soft Sign Finding:
    • Unable to identify geometric shapes you draw in child’s open hand
  • Latest Expected Age of Disappearance:
    • 8 years
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
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
  • Inflammatory process in the meninges
    • Bacterial / viral


    • Fever
    • Chills
    • Nuchal rigidity
    • Headache
    • Seizure
    • Vomiting
    • Altered level of consciousness
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

  • 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
space occupying lesions intracranial tumors
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

Early Signs & symptoms:
  • Headache
  • Vomiting
  • Change in cognition
  • Motor dysfunction
  • Seizures
  • Personality changes

*Vary by location of the tumor

cerebral palsy
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
Signs include:
  • Delayed gross motor development
  • Altered muscle tone
  • Abnormal posture
  • Abnormal motor performance
  • Abnormal reflexes
rett syndrome
Rett syndrome
  • Progressive encephalopathy
    • Unknown cause
    • Affects girls between 6-18 months of age

*Develops after normal neurologic and mental development …

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
generalized seizure disorder
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
Affects 1% of the population
  • 75% new cases develop during childhood and adolescence

Disturbances in:

    • Consciousness
    • Behavior
    • Sensation
    • Autonomic functioning (urinary and fecal incontinence)