Paediatrics: Neurology Examination: children aged <5 years who can’t walk

Examination: children aged <5 years who can’t walk

Observe and note the following:

·  Developmental stage. Can they see, hear, or move?

·  Do they vocalize?

·  Are they dysmorphic? Are their orthoses, e.g. wheelchair, visible?

Examination

Don’t rush to get the child’s clothes off as you will frighten them. Examine the following:

·  Skin for neurocutaneous stigmata;

·  Spine;

·  Fundi;

·  Head circumference (when they like you, or at the end of the examination if you haven’t managed to break the ice).

·  Check for dysmorphic features.

Cranial nerves (II, III, IV, VI)

·  Check visual acuity. Will they fix on a small toy or large object, e.g. toy, face, bright light? If they do not fix are they pupil responses, i.e. is the child blind? Will they follow it?

·  Are their eyes symmetrical with a full range of movement, when following small and large toys?

·  Other cranial nerves.

·  Will they respond to a quiet, moderate, or loud sound (VIII)?

·  Elicit a smile, or wait to see if there is a grimace (VII).

·  Ask about or watch their swallow (IX, X).

Neuromuscular and peripheral examination

·  Observe their best motor function: antigravity movement; rolling over; lifting head up; sitting up; or pulling to stand.

• Place your little fingers in their hands while lying supine. Do they have a primitive grasp reflex? Then pull them up off their bed, watching for head lag, which would imply low tone, reduced power, or both.

·  If child has head control, see if they can sit with or without support.

·  Pick them up under their armpits. Do they slip through your hands (a sign of hypotonia)?

·  Then assess their parachute and moro reflexes.

·  Power: observe the movements and pattern of any paucity.

·  Tone: gently manipulate joints, but take care to avoid trauma.

·  Reflexes: use an adult tendon hammer and elicit the reflexes, but place your thumb over the tendons.

·  Co-ordination: if age-appropriate, assess fine motor ability by presenting an attractive target for them to take or grasp with either a primitive or pincer grasp.

Sensation is difficult to access in children with mental age <2. A clue to an abnormality may be inferred from other signs (e.g. skin, peripheral motor system)