NEUROlogic Examination in Infants and Children PDF

**OUTLINE** I. **Introduction** II. **Neurologic Evaluation** a. Developmental Assessment III. **Neurologic Examination** a. Instruments In Neurology b. Main Components c. Phases IV. **Head** a. Shape b. Fontanels V. **Mental Status Examination -- INFANTS** a. State Of Conscious...

**OUTLINE** I. **Introduction** II. **Neurologic Evaluation** a. Developmental Assessment III. **Neurologic Examination** a. Instruments In Neurology b. Main Components c. Phases IV. **Head** a. Shape b. Fontanels V. **Mental Status Examination -- INFANTS** a. State Of Consciousness -- Neonates and Infants b. Levels Of Consciousness c. Glasgow Coma Scale VI. **Mental Status** VII. **Cranial Nerves** a. CNI b. CN II c. CN III IV, VI d. CN V e. CN VII f. CN VIII g. CN IX, X h. CN XI i. CN XII VIII. **Motor Examination** IX. **Sensory Examination** X. **Reflexes** a. Deep Tendon Reflexes b. Cutaneous/ Superficial Reflexes XI. **Cerebellar Tests** a. Sweat Test b. Toilet Training c. Sphincteric Tone XII. **Developmental Reflexes** a. Moro Reflexes b. Tonic Reflexes c. Palmar Reflexes d. Plantar Reflexes e. Landau Reflexes f. Placing Reflexes g. Parachute Reflexes XIII. **Summary** XIV. **Additional Information** +-----------------------+-----------------------+-----------------------+ | **LEGEND** | | | +=======================+=======================+=======================+ | ⭐ | 🖊️ | 📖 | | | | | | Must | Lecture | Book | | | | | | Know | *\[lec\]* | *\[bk\]* | +-----------------------+-----------------------+-----------------------+ **OBJECTIVES** - To discuss the proper method of performing the neurological examination to infants and children. - To discuss the relevance of abnormal neurologic findings that may be seen in infants and children. I. **INTRODUCTION** - Challenge in logical deduction. - 🖊️ When we say children, less than 7 years old or babies up to 7 years old. - 🖊️ Beyond 7 years old we can do the traditional neurologic examination. - Process requires a clear plan for each step. - **GOAL** is to answer the following: - Does the child have a neurologic disorder? - If so, where is the lesion? - What pathological conditions are most likely to produce lesions at these sites? - For your level, we try to answer the first question. - 🖊️ We must determine if there is a presence/absence of neurological condition or not. - This is verified by doing your neurologic exam. II. **NEUROLOGIC EVALUATION** - ⭐ Clinical history is STILL the cornerstone of neurologic assessment. - Developmental Assessment is one of the most important in neurological evaluation. - 🖊️ Any abnormalities in developmental milestones is a **red flag** for neurological problems in children. - 🖊️ Earliest clue for neurologic problem are developmental delay or regression - ⭐ Normal variations exist depending on the child's age. - ⭐ A finding may be normal for neonates but may already be abnormal in infants or older children. - 🖊️ Example is eliciting Babinski reflex, which is normal in neonates, but abnormal after 3 months of age and onward. **A**. **DEVELOPMENTAL ASSESSMENT** - ⭐Physical and motor development follows a **cephalocaudal principle.** - **Figure 1. Five Domains of Developmental Assessment** - 🖊️ Five Domains of Developmental Assessment includes - **Gross Motor** - assess motor development for strength from head control, walking and crawling - **Fine Motor Domain** - for older children, like writing, grasping objects. - **Expressive Language** - speaking or speech and words, - **Receptive language** - understanding, like comprehension, name calling - **Social and Adaptive Skills** - with cognitive skills such as smile, laughing, eye contact - Is the child/infant related to the environment properly at specific age? - **Parental recollection** of milestones is important to determine if a condition is: - Isolated or Global Delay - **Isolated:** [only 1 domain] is affected - **Global:** [2 or more domains] are affected - Static - From birth - Etiology: congenital, intrauterine, or perinatal - Regression - 🖊️ loss of any developmental skills - 🖊️ Presence or Absence of developmental regression because it is a dead lag for neurological problem - Etiology: - **Structural** - like tumors - **Metabolic** - **Functional** - such as seizures - **Problem**: May be difficult for some parents to recall events. **SCREENING SCHEME FOR DEVELOPMENTAL DELAY** **Figure 2. Screening Scheme for Developmental Delay: Upper Range** - 🖊️ You can ask them these developmental landmarks to determine if the patient is developing properly or not. - One of the red flags is developmental regression. - 🖊️ You can use the developmental milestones as a marker to approximate the age of the patient that came to your clinic for evaluation. - For Example, without even asking, if the patient was able to walk with minimal support, or did he respond to name calling and say 1 -- 2 words then you can suffice that the patient is approximately 1 year of age. - It helps gain a rough estimate of the patient's approximate and developmental age. - 🖊️ Remember that the developmental milestone is an integral part of evaluation, and you cannot separate the two. - In history taking in pediatrics, you must remember you have to take the history of your developmental milestone. - 🖊️ If the patient is not able to perform a developmental milestone 1-2 months after the expected range, then you would expect a problem in the neurological evaluation. III. **NEUROLOGIC EXAMINATION** **A. INSTRUMENTS IN NEUROLOGY** - Measuring tape - Stethoscope - Penlight - Transparent ruler (mm) - Ophthalmoscope - Otoscope - Tuning fork/bell - Tongue blades - Cotton wisp - Small pellet and empty vial - Straight pins - Reflex hammer - Pencil/crayons - Toys (cars) - Page of figure-stimuli - BP cuff - 🖊️ Check autonomics in baby - 🖊️ In infants and children, we can be more creative and use a neurohammer that is masked to look like a toy, use a more colorful measuring tape, use cotton buds to test for sensation, use colorful bells to check for hearing, use colored blocks to check for visual tracking of the patient. Even in younger children, you can use objects to approximate the visual acuity. - 🖊️ If your patient can't read, you can use illustrations to determine if his/her vision is intact. **B. MAIN COMPONENTS** - Head examination - Special test done on children and infants - Level of Consciousness - Cranial Nerve examination - Somatic Motor examination - Sensory examination - Superficial and Deep Modalities - Cerebellar Function - Deep Tendon Reflexes - Superficial Reflexes - Special test done on children and infants - Nerve Root Stretch tests - Special test done on children and infants **THINGS TO NOTE DURING EXAMINATION** - ⭐Just one part of the physical exam. - Should encompass a systematic survey of all functions from the cerebrum to the peripheral nerve and muscle. - Should be correlated with clinical history and developmental milestones. - Start by using CLINICAL OBSERVATION as soon as the patient and parents enter the clinic and continue while taking the history. - For older children, the standard neurologic exam method for adults is applicable (with some exceptions). - 🖊️ Exceptions like when your patient has neurodevelopmental abnormalities such as Autism Spectrum Disorder or Intellectual Disabilities then you must adapt accordingly. - No strict rules in performing a neurologic exam. - Important to obtain trust and cooperation. - Do not "attack" the child. - Most (if not all) information could be gained by OBSERVATION - "Catch-as-catch-can" procedure - 🖊️ Hinuhuli mo kung kailan nila gagawin. - (catch nga beh, di ba?) - 🖊️While playing tinitignan mo si patient tapos pag nakita mo na ginawa nila, then you can record it in your chart. - 🖊️Perform the manipulative procedures last. **C. PHASES** - The neurologic exam in children is quite different when doing it in adult because in adults, usually they can follow instructions. - There is no specific order in performing the neurologic examination in children. You do them in phases. **PHASE 1** - Examiner should be playful, non-frightening, non-threatening - 🖊️Examine the patient already when the patient come in the clinic. - v Continuously observe the child, while doing clinical history - Examine the: - Cranial nerves - 🖊️ Such as visual tracking - Head and neck - Movements - Sensation - 🖊️Presence and Absence - Deep tendon reflexes - 🖊️Do playing by doing DTR - Heart & Lungs - 🖊️ While engaging with the child, you can do heart and lung examination **PHASE 2** - The infant is undressed. - Child on the examination table. - 🖊️We can do more invasive examination - Test coordination and balance. - Confirm motor landmarks and developmental reflexes. - Abdominal exam **PHASE 3** - 🖊️We do the more invasive procedures last. These procedures can bring anxiety to the patient and should therefore be placed last. - Head circumference - Fundoscopy - Examination of oral structures - Lower cranial nerves IV. **HEAD** - Document the following: - Size - 🖊️ Directly correlated with brain development. - 🖊️ Size small = brain is also small - Shape - Suture - Fontanels - ⭐ Head circumference measurement is important**.** - Should be done at every visit for up to 3 years of age. - Take note of the rate of head size increase: - Pre-term \> Term - 🖊️ Especially during neonatal period; pre-term infant has a faster head size rate - 🖊️We must plot this in a normal curve such as the one in figure 3. \ **Figure 3. Birth to 36 months: Boys** **Head circumference-for-age and Weight-for-length percentiles** - 🖊️Can be done until 21 years of age; normal trajectory showing a normal head growth. - Microcephaly if the head size is below the p2 2nd percentile of the graph, it is the upper limit of the measurement. - 🖊️ Above 97 percentile, macrocephaly. **A. SHAPE** **Figure 4. Head Shapes** - 🖊️Plagiocephaly - Flattening of the skull. - This can be seen in normal infants but more prominent in hypotonic infants because they are less mobile. - If you see this, you assume that the patient is always lying down. - 🖊️ Brachycephaly - More developed posteriorly than anteriorly - It is usually an indication of early cranial fusion. - 🖊️Scaphocephaly - Formed by premature closure of sagittal sutures, in which the anterior fontanelle is small or absent. - Results in a long, narrow, wedge-shaped cranium. - 🖊️Craniosynostosis - occurs when all sutures close prematurely. **B. FONTANELS** - ⭐ Take note of the closure. - Anterior fontanel - May close between by 9-18 months - 🖊️ Persistence may indicate hydrocephalus - Posterior fontanel: - Closed by 6-8 weeks old - Persistence may suggest hydrocephalus or congenital hypothyroidism - Check if depressed, pulsatile, or bulging. - May indicate certain conditions such as dehydration (🖊️depressed), increased intracranial pressure (🖊️pulsating, bulging).  **Figure 5. Normal Skull of the Newborn** **V. MENTAL STATUS EXAMINATION - INFANTS** - Assessment of level of arousal and interaction with environment - For neonates, level of alertness is affected by: - **Time of the last feeding, room temperature, and gestational age** - **Pre-term infants** (\< 28 weeks) -- do not have consistent periods of alertness - 🖊️ Usually seen asleep - **Term infants** -- have established sleep-wake patterns - 🖊️ Ask for the sleeping pattern -- usually asleep at night, regularly asleep at night etc. - **Child** - Observe the play behavior 🖊️ for infants \>6 months of age - Recall personal information (informal) 🖊️for children beyond 3 years of age - Recall 3 objects -- (formal -- cognition and immediate memory) 🖊️for children 7 years old and above -- cooperative - Level of Consciousness/Sensorium - Plays special significance to organic brain injury - Observe/Ask waking and sleep patterns. - Observe play activity and sleep. - Check self-awareness and the environment. - Observe response to visual, auditory, and tactile stimuli of the environment. - 🖊️ For this it is possible to detect a neurodevelopmental problem early on. - For example, they are not responsive to any auditory or visual stimulation still at 1 or 3 years of age, this might be an early sign of autism spectrum disorder. - Response to conversation -- ask name, age, point to parent, etc. - 🖊️You can also ask their name to test for immediate recall and learning, point to parent and recognition of others. - Response to pain - 🖊️Indicates an intact sensory pathway; In patients with autism, they usually have a lesser pain threshold and usually do not ignore pain stimulation. **A. STATE OF CONSCIOUSNESS -- NEONATES & INFANTS** **Figure 6**. **State of Consciousness -- Neonates & Infants** - Deep Sleep - Regular breathing - Eyes closed and no eye movements. - No spontaneous movements except startles - Light Sleep - Eyes closed - Rapid eye movement often observed under closed lids - Low activity level and sucking movements can occur - Breathing may irregular - Drowsy - Eyes may be open, but dull and heavy lidded, dazed look, closed, or fluttering eyelids - Variable activity level, responses often delayed and motor activity at a minimum - Can be waking up or may go back to a deeper sleep state - Alert - Bright-eyed look and their motor activity will be minimal - Able to focus their attention on visual or auditory stimuli - 🖊️ Usually, you prefer them alert and quiet looking into the faces of caregivers and the examiner. - Active Alert - Eyes open, considerable motor activity - Brief fussing vocalizations - 🖊️Fussy and irritable babies - Crying - Intense crying which is difficult to break through - High motor activity - 🖊️ This makes it difficult to do any neurologic exam at this point in time. **B. LEVELS OF CONSCIOUSNESS**  **Figure 7. Levels of Consciousness** - 🖊️There are certain levels of consciousness in adults and children. - Normal waking state is normal awake level. - In elevated stimulation, you can either have insomnia, euphoria, mania or irritability, and height of stimulation is seizure. - In contrast for CNS depression, you can have normal sleep pattern, or they can be lethargic, stupor, and coma. - 🖊️ We will focus on the depressed sensorium - Commonly seen in the emergency room and in the clinic. - Somnolence/Lethargy - Arouses spontaneously at times or after normal stimuli but drifts off inappropriately. - The sensorium functions adequately when aroused. - 🖊️But after the stimulation, the patient will drift back to sleep. - Stupor - Appears to be asleep but arouses from vigorous verbal stimuli. - May awaken spontaneously for brief periods, but sensorium clouded. - Shows some spontaneous movements and follows some brief commands. - Coma - No spontaneous movements or arousal. - May or may not respond to central pain. - Reflexes may or may not be present. - Breathing impaired or absent. **C. GLASGOW COMA SCALE** **Figure 8. Glasgow Coma Scale** **(correction above is from the live lecture, 13-14)** - 🖊️It is important to utilize the Glasgow coma scale. You have certain changes (Adults vs Pediatric) in the response levels. - 🖊️ For infants, usually the best verbal response for \< 2 years old, you can have smiles, follows object, and interact with environment - For 2 years and 5 years old, you can use appropriate word use for the situation as compared to the adult. - For 7 years and above, the best verbal response is already the orientation to time, place, and person. - 🖊️ If your patient is in deep sleep, you do not tell me that the patient is GCS 3. - When you do a Glasgow coma scale, it means a significant or pathological impairment in the level of consciousness. - (Natulog lang, GCS 3 na agad?) - 🖊️If your patient has a GCS between 13 to 14, there is a mild cognitive impairment. - For a score between 9 and 12, there is a moderate impairment. - For severe or impending coma and stupor, the score is between 3 and 8. - The GCS 3 means deep coma and it implies poor prognosis. VI. MENTAL STATUS {#vi.-mental-status.ListParagraph.TransOutline} ================= - Higher Cognitive Function - Infants - Elicits expected social/adaptive milestones for age - Observe play behavior and activity - Would they recognize their care giver? - Would they play peek a boo? - Able to feed themselves? - Would they be able to interact with other children? - Or achieve certain developmental milestone - Older children \> 2 years of age - Attention span - Orientation to time, place & person - Memory -- immediate, recent & remote - Fund of information - 🖊️ Ask age-appropriate questions, you can't ask them who the current president of the Philippines is. - Where are your eyes? Where is your nose & mouth? - Insight, judgment & planning - Calculation -- 🖊️ask them to count 1-3 - School Performance - Language -- 🖊️ 1 ½ year old should know at least 10-20 words - For children \> 3-4 years of age - Does the patient converse normally? - Articulation - Comprehension - Repeat words - Name objects - For infants - Elicited from developmental milestones review - Babbling, response to name calling - 12 months - "mama' or "papa", etc. **FIGURE 9. Developmental Milestones According to Age** - **Praxis** - **For older children** - Learned acts - Combing - Hair brushing - Tooth brushing - Cutting with Scissors - Laterality - 🖊️ By 3 years of age, you can determine their hands for dominance, laterality, or hand preference. VII. CRANIAL NERVES {#vii.-cranial-nerves.ListParagraph.TransOutline} =================== +-----------------------+-----------------------+-----------------------+ | Table 1. Cranial | | | | Nerves | | | +=======================+=======================+=======================+ | **Cranial Nerves** | **Function** | **Evaluated by** | +-----------------------+-----------------------+-----------------------+ | **I** | Smell | Simple odors -- | | | | | | | | behavioral response | +-----------------------+-----------------------+-----------------------+ | **II** | Visual Acuity & Field | Colored ball or | | | | | | | | blocks in visual | | | | field | +-----------------------+-----------------------+-----------------------+ | **III** | Extra-ocular | Observe tracking | | | movements | | | | | | | | Lid elevation | | | | | | | | Pupillary response | | +-----------------------+-----------------------+-----------------------+ | **IV** | | Response to Light | | | | | | | | Vestibular response | +-----------------------+-----------------------+-----------------------+ | **VI** | | | +-----------------------+-----------------------+-----------------------+ | **V** | Mastication | Chewing, sucking | | | | | | | Facial Sensation | Corneal reflex | +-----------------------+-----------------------+-----------------------+ | **VII** | Facial Expression | Symmetry of the | | | | | | | Taste | nasolabial folds, | | | | | | | | forehead, eye | | | | | | | | closure | +-----------------------+-----------------------+-----------------------+ | **VIII** | Hearing/Coordination | Tuning fork | | | | | | | Spatial Orientation | Musical toy, noise | | | | | | | | makers | | | | | | | | Caloric test | +-----------------------+-----------------------+-----------------------+ | **IX** | Swallowing | History of feeding, | | | | | | | Voice | sucking, quality | | | | | | | | of cry, gag reflex | +-----------------------+-----------------------+-----------------------+ | **X** | | | +-----------------------+-----------------------+-----------------------+ | **XI** | Head Movement | Observe in supine & | | | | | | | | prone position | +-----------------------+-----------------------+-----------------------+ | **XII** | Tongue Movement | Symmetry of the | | | | | | | | tongue, | | | | | | | | protrusion, atrophy, | | | | | | | | and fibrillation | +-----------------------+-----------------------+-----------------------+ **A. CN I -- OLFACTORY NERVE** - Special sensory group - Use mild, aromatic non-irritating substances - Soap, coffee, toothpaste, lemon oil, vanilla - Can be tested as early 32 weeks AOG - note the change in behavior or change in respiratory or heart rate **FIGURE 10. Olfactory Nerve Evaluation** **B. CN II -- OPTIC NERVE** - Test visual acuity and field - Infants - Use bright colored balls or blocks and move it his field of vision - Place two objects in front of patient's field of vision - Patient will look from one object to the other - Single object testing - Object from behind to the peripheral visual field - Visual field - Confrontation test **FIGURE 11. Optic Nerve Evaluation.** **FIGURE 12. Visual Field Deficits** - Visual acuity and field - "E" Snellen chart - For 2-4 years of age - Snellen or Jaeger Charts - For older children \>4 years of age **FIGURE 13. Snellen Chart vs "E" Snellen Chart** - Do Fundoscopy - Record color, size, degree of swelling/ elevation of the optic disc - Check retinal vessels - Check Size, regularity, arterial-venous nicking, hemorrhages, exudates - Normally, 8-12 vessels course over disc margin - Darker arterioles - 2/3 the size of lighter venules **FIGURE 14. Fundoscopy Findings** **C. CRANIAL NERVE III, IV, VI -- OCULOMOTOR, TROCHLEAR AND ABDUCENS NERVE** - 🖊️CN III usually is the efferent for pupillary light reflex meaning your optic nerve is the one sensing the light input, but the motor component is your CN III. - Describe the size and shape of pupils - Direct and consensual pupillary reaction to light - 🖊️When you say reactivity to light reflex, there is direct pupillary reaction to light and there is consensual pupillary reaction to light. - 🖊️ When you shine a light on one pupil, you observe in the contralateral side and the pupil will contract at the same time and you call that the consensual pupillary light reflex. **FIGURE 15. Different Pupillary Reaction** - 🖊️ As a review, miosis is the pupillary constriction and mydriasis is pupillary dilation - a unilateral dilated pupil is an ominous sign - Indicates CN III paralysis and can indicate anisocoria which may indicate an impending brain impingement or herniation. EXTRAOCULAR MUSCLE (EOM) {#extraocular-muscle-eom.TransSub-subtopic2} ------------------------ - Check for pupillary accommodation with convergence. - Extraocular muscles movement - Check for paresis, nystagmus, or abnormality of smooth pursuit, malalignment. - Check for ptosis, lid lag, or retraction. - Use brightly colored toys for the child to follow.  **Figure 16. Eoms And Their Corresponding Actions** - These are the muscles involved in the innervation used in your examination. CRANIAL NERVE PALSY {#cranial-nerve-palsy.TransSub-subtopic2} ------------------- **FIGURE 17. Cranial Nerve Palsy** - 🖊️Based on primary gaze and exam findings, you can determine if it is right nerve palsy. - For example, in **3rd nerve palsy** of the right eye, - At midline gaze, the defected (right) eye is already turned to the right, - When the gaze shifts to the contralateral (left) side, the defected eye of the patient is unable to adapt. - 🖊️For the **4th nerve palsy** of the right eye, - The defected (right) eye turns upwards and outwards at midline, and turn to one side, there is no obvious squint or any strabismus. - But when you shift the gaze to the left side, the right eye elevates more medially and there is diplopia. - 🖊️ In **6th nerve palsy** of the right eye, - At midline gaze, you note that the defected (right) turns medially, - When the gaze shifts to the right, the right eye is unable to fully adduct to lateral part (lateral rectus palsy). - When the gaze shifts to the left, both eyes of the patient an adduct with no obvious squint. **D. CRANIAL NERVE V -- TRIGEMINAL NERVE** SENSORY {#sensory.TransSub-subtopic2} ------- - Sensation over the entire face and corneal. - 🖊️ You can test this by blowing into the cornea or by lightly stroking the forehead, cheek, and mandibular area. MOTOR {#motor.TransSub-subtopic2} ----- - Check Function → Chewing/ Sucking - Check Masseter and Temporalis muscles as the patient bites down. - Test jaw opening, protrusion, and lateral motion against resistance. - 🖊️Is the patient able to bite down or are there any problem with resistance to manipulation? **FIGURE 18. Three (3) Innervations of Trigeminal Nerve and Examination** **E. CRANIAL NERVE VII -- FACIAL NERVE** SENSORY {#sensory-1.TransSub-subtopic2} ------- - Taste - Special sensory group - Taste on anterior 2/3 of the tongue - Ageusia -- loss of taste - 🖊️During the COVID period, you might encounter terms such as ageusia which is the loss of taste as part of the problems of patients with COVID **FIGURE 19. Bell's Palsy** - 🖊️The main defect is a unilateral hemiparesis in this child. - You can differentiate if the patient has stroke versus peripheral nerve palsy. - If the patient has complete immobilization of the eyebrow and forehead, then usually that is a peripheral nerve involvement. - If there is only a problem with the 1/3 of the face and they can still lift their eyebrows and forehead, then it is most probably a supranuclear problem. - 🖊️The facial nerve has double innervation in the brain. - ⭐ If the stroke happens in the brain, there is still innervation of the ipsilateral side preserving the muscles of the eyebrows and forehead. - ⭐ Again, If peripheral (facial nerve palsy), there is complete paralysis. If stroke (central facial nerve palsy), then only the lower 1/3 of the face nasolabial fold). You can see this in infants and young children. MOTOR {#motor-1.TransSub-subtopic2} ----- - Evaluate facial movements. - Check for asymmetry at rest and with movement. - 🖊️Sensory is mainly innervated by CN5, the motor component is the main function of the facial nerve (Corneal Reflex) - Check for: - Eyebrow elevation - Forehead wrinkling - Eye closure - Smiling - Whistling - Lip pursing **F. CRANIAL NERVE VIII -- VESTIBULOCOCHLEAR NERVE** FOR INFANTS {#for-infants.TransSub-subtopic2} ----------- - 🖊️ Usually can grossly test for hearing by using noise makers or rattles - Infants will turn their heads or tilt their heads towards the source. - Check for ability to hear tuning fork, finger rub, watch ticking, whispered voice in each ear. - ⭐ Air-bone conduction test (Rinne) - Usually a normal, the air conduction time is more than bone conduction. But if the bone conduction is more than air conduction, then it might indicate a conductive hearing loss. - ⭐ Sound lateralization test (Weber) - Subpoint A more formal form of testing is you utilize your tuning fork. This is your Weber test. Any lateralization on the ipsilateral is a probable conductive hearing loss on the same side or a probable sensorineural loss on the contralateral ear. - Do Otoscopy  **FIGURE 21. Weber and Rinne Test** DIZZINESS {#dizziness.TransSub-subtopic2} --------- - 🖊️Another function of your vestibulocochlear nerve is the presence of balance. - Test for positional nystagmus and vertigo. - 🖊️ The main problem you can elicit is in dizziness. - You can demonstrate positional nystagmus and vertigo - You can elicit this with your Epley maneuver test. - Epley Maneuver test - 📖 The Epley maneuver or repositioning maneuver is a maneuver used by medical professionals to treat one common cause of vertigo, benign paroxysmal positional vertigo (BPPV). - 📖 The maneuver works by allowing free-floating particles, displaced otoconia, from the affected semicircular canal to be relocated by using gravity, back into the utricle, where they can no longer stimulate the cupula, therefore relieving the patient of bothersome vertigo. **FIGURE 22. Epley Maneuver Test** **G. CN IX, X -- GLOSSOPHARYNGEAL & VAGUS NERVES** MOTOR: FOR INFANTS {#motor-for-infants.TransSub-subtopic2} ------------------ - Observe while the baby is swallowing the milk. - Note quality of the cry and voice - Check for hoarseness or stridor - Elicit the gag reflex - (LAST MANEUVER) **FIGURE 23. Glossopharyngeal & Vagus Nerve Evaluation for Infants** MOTOR {#motor-2.TransSub-subtopic2} ----- - Check for elevation of the palate-uvula with phonation ('aah') - ⭐ Phonation -- role of CN X - Check palatal & uvula position at rest - ⭐Check for symmetry and deviation as it may indicate weakness - Gag & Pharyngeal reflex **FIGURE 24. Glossopharyngeal & Vagus Nerve Evaluation** **\ ** **H. CN XI -- SPINAL ACCESSORY NERVE** - Observe head movements - Check shoulder shrug (Trapezius) - Check head rotation against **FIGURE 25. Shoulder Shrug** **I. CN XII -- HYPOGLOSSAL NERVE** - Examine bulk & power of tongue - Atrophy, deviation from midline with protrusion - Check for involuntary movements - Tremors, flickering (fibrillation, fasciculations)  **FIGURE 26. Hypoglossal Nerve Evaluation** VIII. MOTOR EXAMINATION {#viii.-motor-examination.ListParagraph.TransOutline} ======================= - Infants -- OBSERVATION - Check symmetry of movements - Check movements during play - Blanket test -- 8 mos. Old - Check fine motor movements - Check muscle tone - Scissor sign **FIGURE 27. Motor Examination in Infants** - \(2025) ✐ One indication is how they grasp objects, and it usually changes over time. - At 4 months, this is more of a general grab - At 6 months, note that the index finger is more utilized - The pincer grab is achieved by 9 months  **FIGURE 28. Difference Of Hypertonia and Hypotonia** - \(2025) ✐ Hypertonia there is mostly stiff limbs, high muscle tone, difficulty moving, and muscle spasms. - Hypotonia is more of floppy limbs, low muscle tone, difficulty standing, and maintaining posture. +-----------------------+-----------------------+-----------------------+ | **Table 2. Components | | | | of Motor | | | | Examination** | | | +=======================+=======================+=======================+ | **Inspect** | **Palpate** | **Strength Grading** | +-----------------------+-----------------------+-----------------------+ | - Gait | - Atrophy | - Flexion | | | | | | - Involuntary | /Hypertrophy | - Extension | | movements | | | | | - Tenderness | - Adduction | | - Body Symmetry | | | | | - Spasticity | - Abduction | | - Atrophy/ | | | | Hypertrophy | /Hypotonia | | +-----------------------+-----------------------+-----------------------+ **FIGURE 29. Motor Strength Grading**  **FIGURE 30. Motor Strength Grading Illustration** IX. SENSORY EXAMINATION {#ix.-sensory-examination.ListParagraph.TransOutline} ======================= - ⭐ Superficial sensory modalities - Light touch over hands, trunk & feet - Temperature discrimination over hand, trunk & feet - Pain perception over hands trunk & feet - There are usually dermatomal levels or specific nerve innervations that you can check, and you should determine any problems in the sensation - You are obligated to do a level-by-level examination of pain and light touch to determine if there is any spinal cord problem. **FIGURE 31. Dermatomes** - ⭐ Deep sensory modalities - Test vibration perception at knuckles, fingernails & malleoli of ankles & toenails - Test position sense of fingers and toes, using the 4^th^ digits - Stereognosis - Romberg (swaying) test - Your deep sensory modalities such as your vibratory sense, position sense, stereognosis, and Romberg (swaying test), are good test to determine your posterior column. - This is usually done when you are suspecting lower motor or peripheral nerve or spinal cord problems X. REFLEXES {#x.-reflexes.ListParagraph.TransOutline} =========== MUSCLE STRETCH (DEEP) REFLEX {#muscle-stretch-deep-reflex.TransSubtopic1} ---------------------------- **Table 3. Motor Stretch Reflex Grading** ------------------------------------------- ---------------------------- 0 **Absent** \+ Present but **diminished** ++ **Normoactive** +++ **Exaggerated** ++++ **Clonus** - Clonus -- repetitive rhythmic contractions evoked by a stretch receptor  **FIGURE 33. Testing of Patellar Tendon Reflex (Top) Deep Tendon Reflex Tests (Bottom)** - The downward arrow (Bottom) indicates normal flexor toe response and there is an absence of a clonus. If the arrow points upwards it indicates repeated arm and leg movement and that is what you call a clonus. - Any presence of clonus in one part of the reflexes indicates spasticity and increased tone Jaw Jerk {#jaw-jerk.TransSub-subtopic2} -------- - ⭐ CN V afferent; CN V efferent  **FIGURE 34. Jaw Jerk Reflex** Biceps Reflex {#biceps-reflex.TransSub-subtopic2} ------------- - C5-C6 Triceps Reflex {#triceps-reflex.TransSub-subtopic2} -------------- - C7-C8 **FIGURE 35. Muscle Reflex Testing at C5-C8 level** - You're measuring certain spinal cord levels. - For example, your biceps reflexes test for your C5 and C6 segments. - Your triceps reflex tests for your C7 and C8 levels {#section.ListParagraph.TransSub-subtopic2} Finger Flexion Reflex (Hoffman) {#finger-flexion-reflex-hoffman.TransSub-subtopic2} ------------------------------- - C7-T1  **FIGURE 36. Finger Flexion Reflex** Quadriceps Reflex (Knee Jerk) {#quadriceps-reflex-knee-jerk.TransSub-subtopic2} ----------------------------- - L2-L4 **FIGURE 37. Knee Jerk Reflex** - Most utilized deep tendon reflex is quadriceps reflex or your knee jerk. - This is supplanted by your L2 to L4 level of your spinal cord, and it is what you call a simple reflex. Hamstring Reflex {#hamstring-reflex.TransSub-subtopic2} ---------------- - L5-S1  **FIGURE 38. Hamstring Reflex** {#section-1.ListParagraph.TransSub-subtopic2} {#section-2.ListParagraph.TransSub-subtopic2} {#section-3.ListParagraph.TransSub-subtopic2} Triceps Surae Reflex (Ankle Jerk) {#triceps-surae-reflex-ankle-jerk.TransSub-subtopic2} --------------------------------- - L5-S1-S3 **FIGURE 39. Triceps Surae Reflex** Toe Flexion Reflex (Babinski) {#toe-flexion-reflex-babinski.TransSub-subtopic2} ----------------------------- - S1-S2 - This is the lower response meaning if no more flexion of the toe upon stimulation of the plantar region and there is extension and fanning of the toe that is what you call a positive reflex or an extensor toe response.  **FIGURE 40. Babinski Reflex** CUTANEOUS/SUPERFICIAL REFLEX {#cutaneoussuperficial-reflex.TransSubtopic1} ---------------------------- - If you suspect spinal cord lesions, you can do skin-muscle (cutaneous/superficial) reflexes such as your abdominal skin-muscle reflexes or your umbilical migration test. - You do not do these routinely. - You do these if you suspect a SC lesion in the patient. Abdominal Skin-Muscle Reflexes {#abdominal-skin-muscle-reflexes.TransSub-subtopic2} ------------------------------ - Upper quadrants -- T8-T9 - Lower quadrants -- T11-T12 **FIGURE 41. Superficial Abdominal Reflex** Umbilical Migration Test (Beevor's Sign) {#umbilical-migration-test-beevors-sign.TransSub-subtopic2} ---------------------------------------- - Do in thoracic cord compression cases only  **FIGURE 42. Eliciting Beevor's Sign** Cremasteric Reflex {#cremasteric-reflex.TransSub-subtopic2} ------------------ - Afferent L1; Efferent L2 - (*2025*) Stroke the inner aspects of the thigh in a caudal--rostral direction and observe the contraction of the scrotum. - The reflex is normally present and symmetric - Cremasteric reflex is also done in newborn to determine presence or especially if they have presence or absence of congenital spinal cord lesion. - To determine the level of involvement - Commonly used is cremasteric reflex and your anal pucker test. **FIGURE 43. Cremasteric Reflex** Anal Pucker (S4-S5) & Bulbocavernosus Reflex {#anal-pucker-s4-s5-bulbocavernosus-reflex.TransSub-subtopic2} -------------------------------------------- - Do in sacral or cauda equina lesions - When you do these, it's just stimulating the anal region. - If they contract by doing pain stimulation, then they are intact in the S4 and S5 level Plantar Reflex {#plantar-reflex.TransSub-subtopic2} -------------- - Normal: Plantar flexion of the toes - Abnormal: Extensor toe sign/ Babinski sign (Afferent S1; Efferent L5-S1-S2) - Occurs after interruption of the UMN's to the lumbosacral cord - Remember that an abnormal response in older children is the extensor toe response or the Babinski sign. - Once this is present, you will assume that there is an Upper motor neuron lesion. - When you say an UMN lesion, there's a lesion at the level of the spine up to the brain. - Extensor toe response is NORMAL in infants until 12-24 months of age - We have to determine if it is sustained or unsustain. - Usually, the normal toe response in children is unsustain. - Meaning, if we do it repeatedly, the response goes weaker, and it becomes absent. - But if there is a real pathology in the upper motor neuron level, then the response is consistent and constant in response. **FIGURE 44. Plantar Reflex** {#section-4.TransSub-subtopic2} {#section-5.TransSub-subtopic2} {#section-6.TransSub-subtopic2} Nerve Root Stretching Tests {#nerve-root-stretching-tests.ListParagraph.TransSub-subtopic2} --------------------------- - Done in patients in disc or low back disease: - Straight-knee-leg raising test (Lasegue's Sign) - If there is pain in the back, there is confirmation of spinal cord compression **FIGURE 45. Straight-knee-leg Raising Test** Meningeal Irritation {#meningeal-irritation.TransSub-subtopic2} -------------------- - Nuchal Rigidity - Concomitant leg flexion (Brudzinski\'s sign) - Bent-knee leg raising test (Kernig's sign) - One of the most important tests that you should do in children is determine the presence or absence of meningeal irritation - This is a routine nerve root stretching test wherein you do a flexion of the neck to determine the presence or absence of nuchal rigidity - If there is flexion of the hips and knees in response to the neck flexion, then you call that a positive Brudzinski\'s sign. - If the patient complains of pain while doing your bent-knee leg raising test, then that is your positive Kernig's sign.  **FIGURE 46. Brudzinski's and Kernig's Maneuver** XI. CEREBELLAR TESTS {#xi.-cerebellar-tests.ListParagraph.TransOutline} ==================== +-----------------------------------+-----------------------------------+ | **Table 4. Cerebellar Tests** | | +===================================+===================================+ | Gait dystaxia | - Free walking for broad based | | | gait & tandem walking | +-----------------------------------+-----------------------------------+ | Nystag,mus | - Inspect and have patient | | | follow your finger through | | | fields of gaze | +-----------------------------------+-----------------------------------+ | Arm dystaxia and irregular | - Finger-to-nose | | alternating movement | | | | - Pronation-supination test | | | | | | - Thigh slapping test | +-----------------------------------+-----------------------------------+ | Overshooting | - Wrist slapping test | | | | | | - Arm-pulling test | +-----------------------------------+-----------------------------------+ | Leg dystaxia (other than gait) | - Heel-to-knee | | | | | | - Shin tapping test | +-----------------------------------+-----------------------------------+ | Hypotonia | - Inspect for rag doll postures | | | and rag doll gait | | | | | | - Passive movement of | | | extremities | | | | | | - Pendular quadriceps reflex | +-----------------------------------+-----------------------------------+ **FIGURE 47. Finger-to-Nose Test** - Finally, we do cerebellar test, we check for gait ataxia, nystagmus, and common test we use is finger to nose test and for children, we can even use a toy.  **FIGURE 48. Heel-to-Knee Test** - We can also check for over shooting, we can also check for leg dystaxia, and to test this we do your heel to knee test or shin tapping test and hypotonia is also a sign of a cerebellar hypo functioning. XII. AUTONOMICS {#xii.-autonomics.ListParagraph.TransOutline} =============== Sweat Test {#sweat-test.TransSub-subtopic2} ---------- - Povidone Iodine paint over cornstarch - Look for areas of sweating - Dry areas are abnormal **FIGURE 49. Povidone Iodine Paint Sweat Test** Toilet Training {#toilet-training.TransSub-subtopic2} --------------- - History of constipation, bladder control, and presence or absence of incontinence Sphincteric Tone {#sphincteric-tone.TransSub-subtopic2} ---------------- - Do rectal exam XIII. DEVELOPMENTAL REFLEXES {#xiii.-developmental-reflexes.ListParagraph.TransOutline} ============================ **Table 5.** ⭐ **Developmental Reflexes** ------------------------------------------- -------------------- ------------------ **Reflexes** **Appearance Age** **Disappear by** Adductor spread of knee jerk Birth 7-8 months Moro Birth 5-6 months Palmar grasp Birth 6 months Plantar grasp Birth 9-10 months Rooting Birth 3 months Tonic neck response Birth 5-6 months Truncal incurvature Birth 1-2 months Parachute 8-9 months Persists Landau 10 months 24 months - These are important because they are usually markers of normal development in children - There should be an expected appearance, present at birth, and they are expected to disappear at certain point during development - ⭐ Parachute reflex is the only developmental reflex that persists throughout life - Protective reflex when you are falling - Appear at 8-9 months, the time when they are trying to walk Moro Reflex {#moro-reflex.TransSub-subtopic2} ----------- - Infant in a supine position - Left head off by 30 degrees, then suddenly but gently let the head fall - Response: abduction and extension of the arms, hand opens followed by adduction of arms and crying - Check for the symmetry and rapidity of the response - Its persistence beyond 6 months of age or its absence or diminution during the first few weeks of life indicates neurologic dysfunction.  **FIGURE 50. Moro Reflex** Tonic Neck Reflex {#tonic-neck-reflex.TransSub-subtopic2} ----------------- - In supine position, turn head of the infant to one side - Extension of the arm and leg towards which the face is turned and flexion of the arm and leg on the side of the occiput (Fencing position) **FIGURE 51. Tonic Neck Reflex** Palmar Grasp Reflex {#palmar-grasp-reflex.TransSub-subtopic2} ------------------- - Place one object or finger in the palm from the ulnar side - Result: involuntary flexion of fingers and grasping of fingers.  **FIGURE 52. Tonic Neck Reflex** Plantar Grasp Reflex {#plantar-grasp-reflex.TransSub-subtopic2} -------------------- - (*2025*) Generally, the plantar grasp reflex is weaker than the palmar reflex. - (*2025*) The reappearance of the grasp reflex in frontal lobe lesions reflects the unopposed parietal lobe. **FIGURE 53. Plantar Grasp Reflex** Landau Reflex {#landau-reflex.TransSub-subtopic2} ------------- - Hold infant in prone position while in horizontal suspension ➡ Flex infant's head - RESULT: Flexion of leg to the trunk - (*2025*) Normally, a reflex extension of the vertebral column occurs, causing the newborn infant to lift the head to slightly below the horizontal, which results in a slightly convex upward curvature of the spine. With hypotonia, the infant's body tends to collapse into an inverted Ushape.  **FIGURE 54. Landau Reflex** Placing Reflex {#placing-reflex.TransSub-subtopic2} -------------- - Hold the infant in upright position - Bring the dorsi of the feet against the under edge of the tabletop - Upon contact, the infant will briskly flex the legs at the hips and knees to terminate contact with the table. - Often mistaken by parents that it is a sign that the infant can walk already. **FIGURE 55. Placing Reflex** Parachute Reflex {#parachute-reflex.TransSub-subtopic2} ---------------- - While holding the infant in horizontal suspension suddenly thrusting the infant in headfirst direction towards the floor - Response: arms extend and abduct slightly, and fingers spread as if attempting to break the fall  **FIGURE 56. Parachute Reflex** XIV. SUMMARY {#xiv.-summary.ListParagraph.TransOutline} ============ Neurologic examination in infants and children begins with OBSERVATION. Standard methods of the neurologic exam are done once the child is cooperative and able to follow instructions. Developmental milestones and reflexes are useful markers to monitor neurologic function in infants and young children. XV. ADDITONAL INFORMATION {#xv.-additonal-information.TransOutline} ========================= DEVELOPMENTAL ASSESSMENT {#developmental-assessment.ListParagraph.TransSubtopic1} ------------------------ With babies and small children, careful observation is particularly important. Take time to observe the baby when on its back and in other positions. When observing his spontaneous activity, we observe If the movement is symmetrical If stereotypical movements occur. We also watch for favorite position patterns or asymmetries and body postures, and position of the extremities.  Observe the movements of the baby. Are they symmetrical? This little girl hardly moves her left arm. She invariably grasps things with her right hand. Merely watching children play provides a great deal of information. A detailed examination is still needed here. A systematic neurological examination of a young child consists in the first place of an evaluation of social, fine motor, gross motor and intellectual development using the Denver Test.  Checking the functional integrity of the nervous system. Both aspects are interdependent. This is why when testing functional integrity, the psychomotor development must also be invariably considered. 🖊️EXPLANATION {#explanation.ListParagraph.TransSub-subtopic2} ------------- Neurological examination and developmental milestones or psychomotor development ng children is interdependent. They are closely related to each other. You cannot consider one without considering kung ano ang neurological development niya. So basically, the development of a child is closely related to its neurological status. When you are doing your clinical history, most of your neurological findings will be highly based on your developmental history. It is very important that you know kung ano ang appropriate developmental milestones in the child. So kapag nag history kayo, ang importante, we will emphasize, that you know the developmental milestones appropriate for age kasi hindi mo pwedeng gawin yung neurologic examination mo, for example, upon history, delayed pala yung baby, so will have to adapt yung neurological exam based on the development of the child. As stated in the lecture video, for example, by just observing the patient, you can gain most of the information that you need, just by observing the child. Another example, the video illustrated earlier, they were just playing, they already demonstrated handedness in the child. Based on the developmental milestones, kailan ba lumalabas and handedness? As early as 2 -- 3 years of age. Handedness is established at 3. So, kapag neurologic examination sa isang infant at 1 year old, tapos parang may preference na sya agad, that indicates / sign that you might be dealing with weakness on the contralateral side, yung hindi nya ginagalaw. So, yung weakness na yon, kailangan iconfirm through neurological exam Awareness of surroundings is as early as 1 month. Ano yung napapansin mo doon? Ano yung tinitignan mo doon? Follow objects or certain things pero ano yung importanteng finofollow? They perceive sound, specifically the face. If they acknowledge the face or kapag nagface si mommy, tumitingin sila, as early as that it is termed as regard (presence of regard). Regarding the face, pag sinabing regards, ibig sabihin, tumtingin sa mukha and they follow you, kapag kinakausap mo sila, they will follow you yung mata. They can also imitate you, yung ginagawa mo sa bibig. Pag nag-eelicit ka ng developmental milestones using the Denver test, you are actually doing an indirect neurological exam kasi tinigtignan mo yung cognition, fine motor skills at gross motor skills. pag nakuha mo na yung mga yon, makikita mo na for example, Gumalaw sa iyo yung mata nya, they follow you; you can already deduce yung vision, intact. Pangalawa, you can deduce yung Extra ocular muscles or EOMs niya kung full or equal yung movements nya. You can see it just by observing. So, sa neurologic exam ang kinoconfirm niyo lang is pupillary activity, symmetry, and the light pero alam niyo nakakakita na sya before doing the neurologic exam. Just by looking at the posture, you can already determine kung hypotonic or spasticity at the onset na tinitignan niyo pa lang siya. Position na nagsasabi na may hypotonia yung patient? RAG DOLL = Bigger children. Floppy infant, kasi kinarga mo na siya, walang head control. HEAD LAG = Maneuver Spasticity = Extended ang extremities, limitation with lower extremities Pag floppy infant, they don't move the extremities equally, nakahiga lang siya, legs flat on the floor, parang nakaflex against the abdomen. They are flex on the floor, nakalupaypay lang. Frog leg position = Hypotonia DO NOT ATTACK the baby Don't do active maneuvers at the start, just observe. 90% of the information can be obtained through general observation. Pag pasok pa lang ni patient sa clinic/examination room, tinignan or kinikilatis na siya kasi kapag alam niyo na yung age ni patient, you have an expected developmental milestone and alam mo na yung kayang gawin at specific age PSYCHOMOTOR DEVELOPMENT {#psychomotor-development.ListParagraph.TransSubtopic1} ----------------------- In healthy children, psychomotor development follows a specific pattern. Here's some milestones in the young child's development.  At the age of 1 month, most babies respond to a smile At the age of 1 month, follow objects with their eyes  By the age of 6 months, most babies can sit up. Starting at 6 months, the baby also begins to grasp the objects outside his reach. For this, he grasps the object between the thumb and all 4 fingers.  At 8 months, a young child begins to be shy and makes strange towards unknown person At 9 months, children begin to stand  Trying to take their first steps at 12 months By this time, they have also learned to use one word correctly  Also at 12 months, the child has learned to pick up small objects with thumb and 4 finger. This is called pincer grip. Their hands are by now quite well coordinated and they can transfer objects from one hand to the other. A child learns to undress before it is 2 years old, but it doesn't learn to dress until later. Up to 2 ½ years, children have learned combine 2 words meaningfully.  At 3 years, they can ride their tricycles The Denver developmental test is a screening test designed to test the psychomotor development of children under 5 years.  The test considers the development of social contacts, fine motor development and adaptation, as well as gross motor development, and language. The Denver test quickly provides the pediatrician with an idea whether the patient has developed normally. The result of the Denver test can be a criterion for deciding whether a more specialized examination is required. 🖊️ EXPLANATION {#explanation-1.ListParagraph.TransSub-subtopic2} -------------- In Denver test when you are doing the screening titingnan mo lang ang 4 areas of domain ng development: Gross motor skills Fine motor skills Language (receptive & expressive language) Social adaptive skills. In language, ang receptive & expressive are indirectly correlated with intelligence. So those things, before your neurologic exam, important yung mga binanggit ko, even yung manner ng grip (that's why they mentioned it), because development follows caudal pattern (front to back, from center to outwards). For example, self-awareness then awareness to surroundings. So, importante na alam niyo yung developmental status ng pasyente niyo when you are doing your neurological exam para maipattern mo yung neurological exam sa development niya. For example, sa development niya cephalocaudal propagation. So, alam natin na, una, nakikita niya yung tao, aware siya na nadoon yung tao so tumitingin tingin siya Later, na-develop na yung parietal area niya. So alam na niya na yung tao na ito ay bago, Na-associate na niya ngayon na hindi ito yung normal na taong kilala ko kaya nagkakaroon sila later on ng stranger anxiety. Another example, nauuna yung development ng shoulders para magalaw ang arms and makakuha siya ng mga gamit palabas ng kanyang field of surroundings. Importante rin na mag develop ang kanyang limb girdle muscles bago siya makapaglakad Kaya nag-ccrawl muna sila bago sila makaupo at makatayo because they are developing those muscles regularly. Kapag alam niyo na lahat yun mas madali niyong magagawa ang neurological exam sa bata kasi paminsan-minsan may ginagawa kayo hindi naman appropriate for age. In preceptorials, ang hinahanap namin doon ay ang age appropriateness and kung paano ginagawa yung methodology depending on the age. Iba yung ginagawa sa infants, young children, and older children. Beyond 7 years old, normal adult neurological exam na yan. For example, hindi kayo magpapagawa ng gait testing sa 6-month-old infant kasi hindi naman siya naglalakad. Hindi rin kayo magpapa-test ng ambulation sa 9- month-old kailan niyo lang ittest ang ambulation? As early as 1 year old doon mo ichecheck yung ambulation. Kailan niyo naman i-chcheck yung awareness sa strangers at sa paligid niya? As early as 8 months of age Dapat meron na siyang stranger anxiety, so as early as that you can even determine any neurodevelopmental problems like autism. Again, I will emphasize development is closely related to your neurological exam FUNCTIONAL INTEGRITY {#functional-integrity.ListParagraph.TransSubtopic1} -------------------- In the following examples, particular attention is paid to methods which differs from used in adults. LEVEL OF CONCIOUSNESS {#level-of-conciousness.ListParagraph.TransSub-subtopic2} --------------------- Determining the level of consciousness can be difficult, especially in very young children. A first clue is provided by their social contact such as smiling or playing. In other words, the extent of their reaction to their surroundings. Older children are able to carry out orders and ought to be capable of answering questions that are appropriate for their age concerning orientation to person, time, and place CRANIAL NERVES {#cranial-nerves.ListParagraph.TransSub-subtopic2} --------------  In babies and small children cranial nerve function is usually assessed by observation. In school children the test is the same as for adults. A quick test of the visual field to exclude the homonymous or bitemporal hemianopsia can be performed in babies as young as 6 months  While the tester draws the attention to the front, an assistant move a dangling object from the back into the child's field of vision. We note when the child moves the eyes to the object and fixes on it. For a rough test of visual acuity, we can try placing an object the size of a pea while watching whether they want to grasp the object. But this excludes only major visual defects.  From about 4 years we can use the E-table to check for visual acuity. Bear in mind that many children find it difficult to distinguish between an E which points to the left and one that points to the right. Cooperation is better if the table is placed at a distance of only 4 meters instead of the usual 6  Tables of well-known objects can also be used to detect major visual defects. But visual acuity cannot be tested accurately in this way. Defective eyesight cannot be definitively assessed until the child starts schooling Examination of the fundus of the eye performed similarly in children as an adult, time must be taken, and movement must be restricted as little as possible. Should be done at the end.  To test the baby's eye movement, the examiner approaches the baby to a distance of approximately 30cm. Once eye contact has been made. The examiner slowly moves his head in various directions, which normally causes the eye to follow the examiner. Restricted movements and possible nystagmus should be noted. Small children can be interested in the light of a torch, which they like to follow with their eyes CN V and VII can be spontaneously assessed by the facial expression the baby makes.  The corneal reflex can be tested reliably in young babies. When assessing the child's hearing we make noises from the left and to the right. It is important that neither the hand nor the sounds instrument come to the babies' vision Producing shadows, vibration or drafts must also be avoided. A major hearing disorder can be excluded  For a small child, one can whisper orders which must be carried out. If there's the slightest suspicion of a hearing disorder a detailed audiological test should be ordered. A congenital hearing disorder ought to be diagnosed before 6 months  Examining a child's sense of balance is complex. Balance can be tested roughly if the child stands on a soft surface with closed eyes. To stand securely, an intact deep pressure sense in the soles of the feet is necessary. Balance can also be tested by having to stand on one leg, walk in tandem, and hop around on one foot. The stage of psychomotor development must also be considered  Vagus and glossopharyngeal nerve paresis, reflected in the absence of gag and palatal reflexes on the affected side. This test must be performed at the end of the examination. 🖊️ EXPLANATION {#explanation-2.ListParagraph.TransSub-subtopic2} -------------- Functional Integrity is basically a neurological exam. The video showed what and how general are the physical findings. Facial Asymmetry are directly observed when crying. (Pero wag mo pa-iyakin yung bata kung hindi umiiyak.) When testing CN V, ask the patient to drink directly on the bottle or ask the parent to breastfeed in front of you. The latching is one of the functions of motor component of CN V. When testing the sensory component, you can perform the Cotton Test. A better way also test this is by blowing on the side eye of the patient and the patient is expected to blink. When testing for CN VIII for hearing, as early as newborn there's already a screening here in the Philippines. If there is gradual hearing loss or conductive hearing loss you can perform a Bell test. Weber Test and Rinne test is not done during infancy. This is usually done for school age children. Inspect the ears to check if there is an obstruction like compacted cerumen. When testing CN IX and X, observe the swallowing of the patient. Do the Gag Test last. Ask the parents if there are episodes of choking when feeding. When testing CN XI, check and observe the head position. When testing CN XII, observe the tongue for early signs of fasciculation Sign of a lower motor neuron defect in children. Balance is not checked unless they are not able to achieve ambulation. This is checked beyond 1 year of age usually toddler (between ages of 1 and 3) Cerebellar are checked dependent on the age group. Nystagmus is the earliest sign. It might indicate a cranial nerve defect or a cerebellar defect. Meningeal Signs is done last by flexing the head of the patient. This may be difficult for young children MUSCLE STRENGTH {#muscle-strength.ListParagraph.TransSub-subtopic2} --------------- A child's strength can be tested playfully. For example, let the child pull your fingertips. Some children love pinching the doctor.  Standing on tip toe, test the strength of the calf and intrinsic muscles of the foot. In this boy, who has muscular dystrophy, we can observe the so-called Gower's Sign That is, in order to stand up, he first need to push himself up unto his legs or he would not be strong enough to rise MUSCLE TONE {#muscle-tone.ListParagraph.TransSub-subtopic2} -----------  An important fact to know in advance is that muscle tone and deep tendon reflexes very much depend on a child's state of activity. Among other methods, muscle tone can be judged by the child's posture when being pulled up into a sitting position. The so-called pull-to-sit test. You can feel to what extent the child himself is helping you. He pulls his arm in slightly towards his body and raises his head. At the end, he pulls up his legs  In this baby, a diminished muscle tone can be noted. Arms and legs lie flat on the blanket. Because of this lack of tone, the child can hardly be pulled up into a sitting position. Held in such position 🖊️ EXPLANATION {#explanation-3.ListParagraph.TransSub-subtopic2} -------------- Just by observing alam mo na kung paano yung motor strength, when you are examining motor tone and muscular strength To emphasize again, kailangan gising yung baby, di mo masasabi na hypotonic siya when asleep. In hypotonia, ang baby hindi naka flex on the abdomen naka flex siya on the floor tapos yung arms niya naka stay put din on the floor. You can see the weaknesses of the abdominal muscles and your intercostal muscles, so this is a sign of generalized hypotonia. Ang Gower's sign naman, kapag ginawa niya yun sa harap mo that is an indication of weakness in the proximal muscles. Question: Routinely ba ginagawa ang neurologic examination sa pediatrics or depende sa chief complaint? In general, kasama siya sa general survey di mo siya pwedeng iseparate pero pwede mo siyang hindi ilagay na in detail pag sa clinical practice. But dapat every clinical encounter you always do your neurological exam kasi baka hindi naman pinapansin ng magulang delayed na pala yung anak niya kasi akala niya normal. So as early age, pwede mo ng ma-detect ang sign of cerebral palsy, signs of developmental delay and it's our role as a general practitioner to screen this patient, to detect early development of children. Dapat habit na ito at kasama sa PE niyo na and at the back of your mind, you are already observing the child, so tinitingnan mo yung movement, tone, and awareness. In actuality, sa PE parang ginagawa mo na din yung neurological exam. Pag nakakita kayo ng hypotonic na infant may sloppy muscles, generalized yung kanyang weakness, mag-iisip ka na agad na may problem na siya sa brain kasi pwedeng early sign yan ng may cerebral palsy. Hindi pwedeng titigil lang kayo sa heart, abdomen, sa legs. Syempre when you examine the leg dapat tingnan mo din yung tone yung muscle hindi lang yung posture. Part na ng PE ang neurological exam so kasama talaga siya, you may not perform it, but you are actually doing it just by observing. Pag lagi mo yan ginagawa sa clinical practice parang kinoconfirm mo nalang yung inoobserve mo, May weakness ba talaga to? Malambot ba talaga siya? Symmetrical ba talaga yung movement niya? Meron ba talaga syang gag kasi lagi sya nasasamid? It doesn't really take additional of your time part na talaga siya ng PE. A detailed neurological exam takes 10-15 minutes if talagang you're looking for kung saan talaga siya may problem. As a general practitioner, dapat nagagawa nyo yung general screening in every checkup kahit sa well child. DEEP TENDON REFLEXES {#deep-tendon-reflexes.ListParagraph.TransSub-subtopic2} --------------------  A routine part of the examination involves testing the biceps tendon reflex. Corresponding to spinal cord segments C5 -- C6, the triceps tendon reflex for segments C6 -- C7. The radial reflex for segments C5 -- C6  The patellar reflex for segments L2 -- L4 The Achilles reflex for segments S1 -- S2  A particularity must be noted in babies. During the reflex test, the babies should look straight ahead because the asymmetric tonic neck reflex affects not only muscle tone but reflexes as well. If the reflexes are difficult to trigger, we can facilitate eliciting them with Jendrassik's maneuver in older children. Ask the patient to pull apart his fingers which are hooked together and elicit the reflex in that moment.  In children, the deep tendon reflexes of the lower extremities are livelier than those of upper ones. The area where they can be elicited is larger than the adults. The examination should determine whether the reflexes are present and symmetrical. Hyperactive reflexes may point to a lesion in the pyramidal tract. A full picture of pyramidal tract lesion also comprises of positive Babinski sign, spasticity, and sustained clonus. CEREBELLAR FUNCTION {#cerebellar-function.ListParagraph.TransSub-subtopic2} ------------------- The function of cerebellum is to coordinate the movements of individual muscle groups. The following test was used to examine this.  The finger to nose test can be used for children as young as 3. Usually with its eyes closed, the child is asked to put its 4 th finger to his nose. Not all children cooperate equally well. This test shows possible defects such as ataxia or intention tremor. The corresponding test for lower extremities is the heel-to-shin test. The child is asked to close her eyes and to slide her heel down along her shin. Both sides should be compared.  A 3-year-old child begins to imitate rapid alternating hand movements. At first the movement is slow, and the elbows and the other hand are involved as well. Children do not achieve the skill adults have until they are 10. In younger children, the degree of fine motion coordination can be assess with the help of Denver test appropriate to their age.  Many things can also be observed if we simply allow the child to play. In older children, we assess coordination by assigning them skill tests such as buttoning and unbuttoning  or placing a cap onto a pen 🖊️ EXPLANATION {#explanation-4.ListParagraph.TransSub-subtopic2} -------------- So basically, pinakita lang yung mga maneuvers na pwedeng gawin in children and in young children. We already emphasized when we do the basic procedures such as DTRs. For infants, pinakita yung isang developmental reflex, that we should be very careful of, asymmetric tonic reflex, which can affect your reflexes. Dahil kung saan sila tumingin, nagextend yung kamay, much more tonic, yung kabila, flex, and less tone. The rest of the maneuvers are still the same Reflexes in the lower extremities in infants are much stronger compared to upper extremities why? It is part of the cephalocaudal development. Mas mature yung upper extremities kaya kala natin mas malakas yung lower extremities, but poorly developed pa yung pyramidal tracts from lower extremities to the brain. Be very careful with that. Pag dating ng 1 year old dapat symmetrical na dahil nakakapaglakad na pero pag less than 1 year old, pwedeng LE\>UE. Remember Cephalocaudal Development SENSATION {#sensation.ListParagraph.TransSub-subtopic2} --------- Even in small children, the sense of touch and pain can be tested. We observe the child's reaction. Sensation deficits are very rare in children. GAIT {#gait.ListParagraph.TransSub-subtopic2} ----  A child's walking posture is examined as an adult. We know whether the child's limbs and its movements are coordinated. If some pathology is suspected, the child may also be asked to run. Walking on the heels or tip toes are also tested. During assessment, bear in mind the child's age and stage  This one-year-old child is still unsure, and his walk is broad based. Standing on one leg is not possible for a child until age 5 MENINGEAL SIGNS {#meningeal-signs.ListParagraph.TransSub-subtopic2} --------------- Because of the seriousness of meningitis, we should also cover the meningeal signs.  The signs of meningitis comprise of nuchal rigidity, a positive Lasegue, a positive Kernig, and a positive Brudzinski sign. When testing for nuchal rigidity, the examiner tries to flex the child's chin down to the sternum which is normally readily accomplished.  Shows the flexion being carried out only incompletely or not at all in meningitis because of the pain. For Lasegue sign, the examiner takes the stretched leg of supine child and flexes it at the hip joint. Normally a flexion of 70 -- 90 degrees is quite possible.  The Lasegue sign is positive if the hip flexion is restricted and painful. To exclude compensatory movements, the pelvis should be held down. The Kernig sign is based on a similar mechanism. The legs is first flexed 90 degrees at the hip and then stretched to the knee. If there is meningitis, the leg can no longer be straightened.  A further indication of meningitis is the Brudzinski sign, if the meninges are stimulated, raising the head can cause the legs to flex. Another indication is seen when the child has to support him/herself in a sitting position by placing its hands behind it and by drawing out its legs. 🖊️ EXPLANATION {#explanation-5.ListParagraph.TransSub-subtopic2} -------------- Kayang elicit sa children ang nuchal rigidity. Another sign of increased intracranial pressure or meningeal irritation in young infants is the integrity of the fontanel. Bulging fontanel can be normal in young children especially if it is pulsatile. Pero pag matigas,parang bola or kasing consistency ng skull may problem na. if it is patent. And you should know, kailan bukas at sarado yung anterior fontanel. REFERENCES {#references.TransOutline} ========== 1. Villaluz, M. M. G. (2023, August). Neurologic Examination in Infants and Children. Lecture. 2. Menkes, J. H., Sarnat, H. B., & Maria, B. L. (2006). Child Neurology (7th ed.). Lippincott Williams & Wilkins. 3. Batch 2024 Trans