Herczegfalvi Ágnes
Neurological Examination of Infants
SE II. sz. Gyermekklinika
Budapest, 2016-09-14.
The elements of a complete neurological
assessment
• Focused clinical history
Presumptive diagnosis,
• Physical examination
Differential diagnosis
• Detailed neurological and
examination plan for laboratory
We test the child’s: evaluation
mental status
motor skills
sensory skills
balance and coordination
• In some cases, developmental screening
reflexes , functioning tests
of the nerves are also
helpful
In infants and children
• the history should include information about
- prenatal exposures and
- symptoms and assessment of developmental milestones
• Observations of infants and toddlers during play (eg, while
stacking blocks or playing with an age-appropriate toy)- can
provide valuable information about
- the patient's attention span
- gross and fine motor coordination and
- problem solving abilities
• the higher cortical functions are also assessed with a series of
questions appropriate to the child’s age
General Physical examination
• 1. Height, weight, blood pressure, and head circumference. Developmental scales!!
• -Rule of thumb for head circumference is the 3 & 9 rule.
• AGE head circumference newborn 35 cm
3 month 40 cm
9 month 45 cm
3 yo 50 cm
9 yo 55 cm
• 2. General appearance, including dysmorphology.
• 3. Skin exam: neurocutaneous lesions (ash leaf spots (TS), cafe au lait spots (NF), angiomas
(SW), axillary freckling (?), adenoma sebaceum (?), or shagreen patches (?).
• 4. Location of the hair whorl (can signify presence of cerebral malformations) and appearance
of palmar creases (which genetic syndrome?)
• 5. Quality of scalp hair, eyebrows, and nails. Friable, kinky hair may signify Menkes kinky
hair disease that is associated with mental retardation and optic atrophy.
• 6. Exam of the midline of the back and neck for sacral dimples, tufts of hair, or other signs of
spinal dysraphism.
• 7. Comparison of thumbnail sizes and their convexity. Abnormalities may signify a growth
disturbance, which may be a sign of hemiparesis.
• 8. Presence of unusual body odor, which is present in some inborn errors of metabolism.
• 9. Hepatosplenomegaly .
• Rule of thumb guides*: At 1 year: 3 × birth weight 1-9 years: Age (years) × 5 + 17 ... At birth, head circumference exceeds chest
circumference by 2-3 cm
[Link] Cranial nerve
[Link]
Testing in infants is often by observation for specific movements
and responses and is less reliable
• The patient should be observed for abnormalities of posture and
movements, including asymmetry at rest, fisting of the
hand, frog-legged position suggesting hypotonia,
tremor, myoclonus or tics
• Muscle tone is the resistance felt upon passive movement of a
joint through its range of motion.
• Hypotonia is characterized by decreased resistance to passive
movement and hyperextension at the joints.
• Hypertonia can be either spastic in nature or characterized by
muscle rigidity.
• Sensory examination in young children is often imprecise, and only
gross deficits can be detected. In children > 5 -6 years sensory
function is evaluated in the same manner as in an adult.
3 stages of motor development in children.
the final stage does not have any
marked new developments, rather
it is characterised by the mastering
and development of the skills
achieved in the first two stages
the age of 2 years old,
his development has begun to level out
somewhat
This stage is marked by extremely rapid
growth and development, as is the 2nd stage
The Importance of Integrating Primitive reflexes
• Primitive (infant) reflexes are
repetitive, automatic movements that are essential for development
of head control, muscle tone
sensory integration and development.
• They form the basis of our postural, lifelong reflexes
• These primitive reflexes surface in utero and infancy and become
inhibited in sequential order during the first year (movements
become more practiced and controlled), and replacement
reflexes, called postural reflexes emerge. PR, are more
mature patterns of response that control balance,
coordination and sensory motor development
When a baby has been given the opportunity to develop freely and
naturally the primitive reflexes will integrate and no longer be
active. When the primitive reflexes remain active then many
difficulties can emerge
Types of Primitive Reflexes
• Moro Reflex: The Moro reflex acts as a baby’s primitive fight/flight reaction
and is typically replaced by the adult startle reflex by 4 months old.
• If a child experiences a retained Moro reflex beyond 4 months, he may
become over sensitive and over reactive to sensory stimulus resulting in poor
impulse control, sensory overload, anxiety and emotions and social
immaturity.
• [Link]
• Rooting Reflex: The rooting reflex assists in the act of breastfeeding and is
activated by stroking a baby’s cheek, causing her to turn and open her mouth
• Retention of the rooting reflex beyond four months may result in difficulty
with solid foods, poor articulation and thumb sucking.
• Sucking reflex
▶ 0:49
[Link]
Types of Primitive Reflexes
• Palmar Grasp Reflex: The palmer reflex is the automatic flexing of
fingers to grab an object and should integrate by six months.
If the palmer reflex is retained, a child may have difficulty with fine
motor skills, stick out tongue while writing and exhibit messy
handwriting
• Spinal Galant Reflex: The spinal galant reflex happens when the skin
along the side of an infant’s back is stroked, the infant will swing
towards the side that was stroked.
[Link]
This reflex helps with the birthing process and should inhibit between
3-9 months. If it persists, it may affect a child’s posture, coordination attention
and ability to sit still.
Types of Primitive Reflexes
• TLR: The tonic labyrinthine reflex (TLR) is the basis for head
management and helps prepare an infant for rolling over,
creeping, crawling, standing and walking.
This reflex initiates when you tilt an infant’s head backwards while placed on the
back causing legs to stiffen, straighten and toes to point. Hands also become
fisted and elbows bend. It should integrate gradually as other systems mature
and disappear by 3 1/2 years old.
If retained, the TLR can lead to poor muscle tone, tendency to walk on toes,
motion sickness and poor balance.
• Landau Reflex: assists with posture development and technically isn’t a primitive
reflex as it isn’t present at birth. It is when a baby lifts his head up causing the
entire trunk to flex and typically emerges at around 3 months of age. It is fully
integrated by one year.
If the landau reflex persists beyond this point, children may experience short term
memory problems, poor motor development and low muscle tone.
• [Link]
Types of Primitive Reflexes
• STNR: Also known as the crawling reflex, symmetrical tonic neck reflex
(STNR) is present briefly after birth and then reappears around six to
nine months. This reflex helps the body divide in half at the midline
to assist in crawling – as the head is brought towards chest, the arms
bend and legs extend. It should disappear by 11 months.
Developmental delays related to poor muscle tone, tendency to slump
while sitting, and inability to sit still and concentrate can result if the
STNR is retained.
[Link]
• ATNR: Asymmetrical tonic neck reflex (ATNR) is initiated when laying
babies on their back and turning their head to one side. The arm and
leg of the side they’re looking should extend while the opposite side
bends. This reflex serves as a precursor to hand-eye coordination and
should stop by six months.
• [Link]
• [Link]
Primitive Reflexes
• Cranial nerves
• [Link]
• Facial nerve exam.
• [Link]
• PEDIATRIC NEUROLOGICAL EXAMINATION
• [Link]
• Cranial nerves
• [Link]
• Normal tone
• [Link]
• Stepping reflex
• [Link]
Thank you
