Child Neurologic Examination F.Ahmadabadi MD Child Neurologist ARUMS 2014 Oct 22

History: Characteristics: Frequency Duration Static, progressing, or improving Acute, subacute, or chronic ROS Birth history Gestational age, complications during pregnancy (including infections), maternal drug use, Apgar scores, problems during delivery e.g. meconium, and feeding difficulties

History Cont… PMHX: Medications Developmental milestones immunization status, accidents, chronic medical problems Medications when discussing szs, include previous AEDs and response Developmental milestones Family history: Epilepsy, Neurocutaneous syndromes, Migraines, Neurodegenerative disorders

General Physical Exam 1. Height, weight, blood pressure, and head circumference. 2. General appearance, including dysmorphology. 3. Skin exam 4. Location of the hair whorl 5. Quality of scalp hair 6. Exam of the midline of the back and neck 7. Presence of unusual body odor 8. Hepatosplenomegaly

Principles of Neurologic Examination of the Child 1. Use items such as a tennis ball, small toys (including a toy car), bell 2. Do not wear a white coat. 3. Postpone uncomfortable tasks until the end, such as head circumference, funduscopy, corneal and gag reflexes, and sensory testing. 4. Make the most of every opportunity to examine the child. 5. Examine the younger child in the parent's lap. 6.Always listen to the mother. It is okay to assess the child as sicker than the mother feels.

Neurologic Exam Mental state- Humans have an alerting reflex in the vertical position—the same reflex we utilize in newborns when we tilt them upwards so that they open their eyes Cranial Nerves fundoscopic examination     pupils     extra ocular movements Motor Sensory Reflexes Deep tendon reflexes, Superficial reflexes Cerebellum Gait

1.Mental Status Humans have an alerting reflex in the vertical position—the same reflex we utilize in newborns when we tilt them upwards so that they open their eyes Note these Patient’s activity as you enter the room, such as chatting, sleeping, posturing, etc. Stimulus required to awaken patient, such as calling her name, pinching, etc. Patient’s best mental state seen, such as chatty conversation, sluggish answers, semi-purposeful movements, etc. Patient’s activity when you stop stimulating her.

Consciousness Spell "WORLD" backwards Four Part Command Oriention Memory

2.Cranial Nerves I (Olfactory) nerve. Not routinely tested II(Optic)nerve Fundoscopy:Disk-Hemorrhage Disc sharpness refers to the sharpness of the distinction between the yellow optic disc and the pink retina. When the disc is elevated, the vessels may be noted to course downwards as they traverse over the optic disc. Disc color and retinal vessels. Spontaneous venous pulsations (SVPs.) While acute papilledema may take 48 hours or more to manifest itself, the first sign is usually loss of SVPs. PERRL means Pupils Equal, Round, Reactive to Light Visual acuity. If the visual acuity can be demonstrated to be normal through a pinhole, glasses, the near card, or the distant chart, then the acuity disturbance it is unlikely to be of primary neurological origin. Visual fields

Comparison of Nl and Abn Retin Normal Retin PAPILLEEDEMA Your Text Here

III (oculomotor), IV (trochlear), and VI (abducens). Cranial Nerves Cont… III (oculomotor), IV (trochlear), and VI (abducens). VI Controls the lateral rectus (abducts the eye) IV Controls the superior oblique (pulls the eye down and in) III Does all other extraocular movements

Cranial Nerves Cont… V. (trigeminal) nerve function includes Facial sensation Corneal sensation (the afferent limb of the corneal reflex) Muscles of mastication (masseter)

Cranial Nerves Cont… VII (facial) nerve Facial movements Taste on anterior 2/3 of tongue Chordae tympani which dampens loud sounds. Loss of this function causes hyperaccusis

Cranial Nerves Cont… VIII (cochlear) nerve IX (glossopharyngeal) Hearing testing IX (glossopharyngeal) X (vagal) nerve Gag reflex XI (spinal accessory) nerve Sternocleidomastoid (turns head to the opposite side) Trapezius (shrugs shoulder) XII (hypoglossal) nerve Tongue protrusion forward and to the sides. Tongue fasciculations seen in anterior horn cell disease.

3.Motor Examination Pronator Drift. This is a superb and sensitive test for upper motor neuron weakness. First, the child extends his arms palms down. Then, the eyes are closed, and a few seconds later, the child turns his arms palms up. During this turning maneuver, a child with upper motor neuron weakness may pull the elbow down and in.

Motor Examination (Cont…) Screen for upper extremity weakness by testing the triceps and drift For the lower extremities, the extensor hallicus and ankle dorsiflexors are the best screening tests for upper motor neuron lesions.

Motor Examination (Cont…) Functional motor tests, such as getting up from the ground, using stairs, and gait testing have several uses. 1.They may be the best way to pick up proximal weakness. 2.They may be the only way to gain the cooperation of younger children. 3.Functional tests can often be used as developmental landmarks. These include the parachute

Extra pyramidal Movements Athetosis Ballismus Chorea Dystonia Tremor

Muscle Tone Distinguish between the peripheral muscle tone (the tone of the extremities) vs. truncal tone (which includes pelvic tilt, posture, tendancy to fall through the examiner’s hands, and jaw tone).

Posture and muscle tone 1) Resting posture -observing the infant undressed.). Hypertonia in the extremities decreases after 3 months of age, with the upper extremities then the lower extremities. At the same time, tone in the trunk and neck increases. 2) Passive tone The scarf sign is where the arm is pulled across the chest and if the elbow passes the midline, then hypotonia is present. 3) Active tone - traction response up to 3 months of age The infant's hands are held with the examiner's thumbs in the infant's palms, and the fingers around the wrists. The infant is slowly pulled to a sitting position Normally the elbows flex and the neck raises the head. If hypotonia is present, then the head lags backward, then as the erect position is assumed, the head then drops forward. If hypertonia is present, the head is maintained backwards. 4)Vertical suspension 5)Horizontal (ventral) suspension (Landau reflex)

Reflexes Superficial Deep(Patella-achillus-…)

4.Primitive reflexes Moro reflex infant opens his hands, extends and abducts the arms, and then brings them together, followed by a cry Tonic neck response -Abnormal responses occur when this response is sustained or if it occurs differently when the head is turned to the right or left Palmar and plantar grasp reflexes The palmar grasp reflex should disappear by 6 months; the plantar by 9 to 10 months. Parachute response A normal response should be seen at 8 to 9 months and consists of arms extended and hands open. Reflex placing and stepping responses This reflex disappears at about 4 to 5 months of age

5.Gait Along with Fundoscopy and the Drift, Gait is an essential test in medically stable patients. Heel walking (This is particularly difficult in upper motor neuron diseases.) It is easier to observe if done while the child walks towards you. Toe walking Easier to observe if done while the child walks away from you. Tandem walking Running, including rapid turns, is an even better test.