Neurological Exam in Children - Paediatric Neurology

Paediatric Neurology

Neurological Exam in Children

General (ALWAYS do these)

·        Are they well or unwell (esp toxic)

·        Growth:

o  Weight, height, and head circumference

o  Head exam: 

§  Anterior and posterior fontanels (while upright). Anterior closes ~ 18 months, posterior ~ 4 months 

§  Sutures, shape of head,

§  Check for shunts (subcutaneous tubes behind the ears),

o   Auscultation over closed eyes and temporal are for bruit

·        Dysmorphic features 

·        Neurocutaneous stigmata: marks on skin, port-wine stains, Care-au-lait spots, use Woods lamp to look for depigmented lesions if fair skinned

Higher cortical function

·        Ask questions appropriate to child‟s age

·        State

·        Attention: serial sevens, repeat numbers

·        Memory:

o   Dependent on attention, processing and storing, ability to access and ability to communicate 

o   Immediate (repeat numbers), recent (3 items at 5 minutes but not visual things), remote (old teachers name)

o   Object permanence

o   Visual: geometric reconstruction

·        Reading and spelling

·        Speech: dysphasia and dysarthria

·        Draw a man

·        Following instructions

·        Behaviour

·        Right left discrimination (crossed)

·        Name objects – visual agnosia

·        Construction of complex geometric figure

·        Cortical sensation

·        Abstract thought

·        Looking for: 

o   Frontal lobe disturbances: personality changes, irritability, lethargy, sphincter incontinence, primitive reflexes such as rooting, grasp re-emerge 

o   Temporal lobe disturbances: altered ability to read, write and understand speech, memory dysfunction 

o   Parietal lobe dysfunction: sensory perception abnormalities, 2 point discrimination, graphesthesia, stereognosis, apraxia

Cranial Nerves

·        1: Olfactory: don‟t often test unless abnormalities in the same area. Rarely impaired. Check each nostril separately. Use chocolate, mint or vanilla essence.

·        2: Optic

o   Visual Acuity: 

§  Babies: fix and follow, optokinetic nystagmus, blink reflex (50% of 5 months, 100% by 1 year) 

§  Toddlers: offer toys of different sizes.  Look in books for smaller and smaller things

o   Visual Fields:

§  Screen first: objects in the periphery – make sure they can‟t follow your arm to your hand

§  If suspicious: test with wiggly finger („look at my nose and grab the finger that wiggles‟)

o   Optic disc:

§  Very important

§  Use low light and small aperture

§  Get mum or dad to make funny faces behind you

§  Stay still and wait for optic disk to come into view 

§  Look for venous pulsations – take pulse to get rhythm. If still can‟t see them, push lightly on orbit – if veins collapse then OK. If no pulsations then ? ­ICP.

o   Pupils

·        III, IV and VI: Oculomotor, Trochlear and Abducens

o   Ptosis: nerve II and sympathetic.  One eye doesn‟t open as much as the other

o   III: down and out

o   IV: Up and out

o   VI: in

o   Sun-setting: paralysis of upward gaze = pressure on quadregeminal plate

o   Get them to follow an object past the limit of head turning – don‟t hold head

o  Hold them to your stomach and spin around with their head out.  Nystagmus is normal

o  Dolls eye

·        V: Trigeminal 

o  Motor: temporalis – bulk, power, clenching, chewing. Get them to bite on a wooden spatula while you pull it away

o  Sensation: test from out of sight with feather

o  Reflexes: jaw and cornea (only if unconscious or other signs point to a problem)

·        VII: Facial

o  Taste: anterior 2/3: very hard in children

o  Lacrimation and salivary glands

o  Motor:

§  Tickle nose with tissue (try and get them to wrinkle face up)

§  Close eyes/mouth open: look for asymmetry of facial creases 

§  Watch when crying – emotional movements less affected than voluntary ones (helps localised to UMN/LMN)

·        VIII: Vestibulochoclear

o  Ask parents 

o  Testing: whisper words (ice-cream, Wiggles) – rub fingers next to other ear (® white noise)

o  Spinning

·        IX and X:

o  Symmetry of uvula and palate movement

o  Swallowing

o  Gag: only if really necessary

o  Taste on posterior tongue: too hard

o  Voice: nasal „b‟, „d‟ and „k‟, hoarse

·        XI: Accessory shrug shoulders, turn heads with resistance 

·        XII: Hypoglossus: stick out your tongue at me – bulk, fasciculation, power. Poke tongue through cheek and feel it

Motor

·        Observe:

o  Abnormal movements: ticks, seizures, chorea, etc

o  Bulk

o  Scars

o  Contractures

o  Symmetry (eg small thumb nail on one side – contra-lateral parietal lesion)

o  Posture: eg frog leg posture in hypotonia, fisting

·        Tone:

o  Must be relaxed.  Lie on back and shake arms and legs to a song

o  Range of movements: passive and active

·        Power:

o  Functional: Observe, including: 

§  Gait: walking forward and backward, running, hopping, tandem gait (eg heal-to-toe), on tiptoes, on heals, on insides and outsides of feet (Fog test). Look for dystonic posturing of hands while they do this. 

§  Proximal weakness: up steps, Gower‟s sign, wheelbarrows, play ball, push-ups. Gower‟s: lie on back – tell them to get up as quick as they can when you say „go‟. Muscular dystrophy will roll onto front then climb up legs. 

§  Handedness 

o  Formal strength testing (grade 5 down to 0): Pull a toy, push me away, crazy glue (pretend to stick their finger to their nose and then try and pull it away), resistance, squeeze fingers

o  Pronator sign

o  Remember:

§  Proximal weakness: myopathy

§  Distal weakness: neuropathy (except myotonic dystrophy)

Reflexes

·        Must be relaxed, be patient

·        Hit your hand, not the child

·        Test ankle jerk on the sole

·        Swing with gravity, don‟t bash

·        Use distraction (look over there…) and reinforcement: clenched teeth (chewing sticky lolly)

·        Check for clonus 

·        Primitive reflexes (go at various ages): Moro, ATNR (atonic neck reflex) – turn head suddenly ® extend arm on that side, Babinski

Sensation

·        Difficult

·        Test from out of range

·        Test with a broken spatula: show them sharp and dull and then always use sharp

·        Touch, pain, vibration, proprioception

Cerebellar

·        Gait: Walk along a line on the floor – should be able to do it well by 6

·        Rhomberg

·        Finger nose: reach for toys (make sure they stretch)

·        Foot tapping

·        Rapid alternating movement

·        Hands outstretched with eyes closed, look for drift