Paediatrics: Neurology Examination

Examination

This is the most useful tool in assessing children with neurological disor-ders. Nevertheless, it is neglected and often thought difficult. With a few simple tricks it is both easy and enjoyable for doctor, child and parent.

Children with mental age >4 years who can walk

Older children can undergo the full ‘adult’ neurological examination by making it a game. Pay particular attention to their:

·  affect;

·  gait and spine;

·  head size;

·  skin: neurocutaneous stigmata.

Children able to walk with a mental age <5 years

Such children can be examined by stealth, then moving onto a game.

Observe the play and note:

·  Gait, watch how they walk, narrow/normal/wide based, heel/toe strike, walk in a straight line ‘on a tight rope’, turn quickly around (cerebellar function); symmetric or asymmetric, do they perform the Gower’s manoeuvre (assessing proximal muscle strength).

·  Visual acuity, hearing, speech.

·  Behaviour,

·  Movements.

Examine:

·  Skin, spine, and head circumference.

·  Co-ordination (taxis) and formation of movement (praxis) by simple games. ‘Take this bread from my hand’, ‘Pretend to open a door’.

Cranial nerves (II, III, IV, VI)

·  Look at the child’s eyes. Do they fix and follow?

·  Move an interesting toy and watch child’s eye movements. Get the child to look at you. Will they look left or right when the toy comes in from each side of their visual field? Is there a squint, is it the common type—non-paralytic—where they can move the eyes fully, but with asymmetry?

·  Get a carer to stand behind you and wiggle their nose. Ask the child to ‘see if you can count how many times daddy wiggles his nose’, then look at their fundi by asking them to look at daddies nose and ask him to keep the child gaze on her.

Other cranial nerves

·  Watch the facial movements (VII).

·  Say something with your hand covering your mouth and see if the child responds appropriately (VIII).

·  Does the child dribble excessively? Ask a carer or watch them swallow and listen to their articulation of speech (IX, X).

·  Children love to stick out their tongues and shrug their shoulders (XI, XII).

Neuromuscular and peripheral examination

Children who can walk, run, jump, hop, and spring up form the ground well are very unlikely to have an abnormality of the peripheral neurologi-cal system that will be identified on further examination. However, if there is an abnormality do the following.

·Remove clothes as far as underwear if the child is happy.

·Look at the gait. Where does the foot strike? Heel or toe? Is it waddling, asymmetrical, is there abnormality of posture?

·Observe the muscle bulk and joint positions with particular reference to scoliosis, lordosis, hip flexion, ankle inversion, or eversion.

·Assess the upper limbs for joint ranges, tone, and power, by having a game with the child. Laugh and keep praising them. Use an adult tendon hammer and elicit the reflexes, but place your thumb over the biceps and brachioradialis.

·Have another game as you assess the same in the lower limbs.

·Try to categorize the pattern into increased or decreased tone. Is it mainly unilateral; or bilateral, but mainly in the legs, or in all four limbs, and possibly the bulbar muscles?

Sensation

If indicated assess sensation by asking them to close their eyes and say ‘Luton’ every time they feel your touch. Note that children do not like closing their eyes with a stranger, so reassure them by doing it first on daddy, then with eyes open (briefly), finally with their eyes closed. Move around dermatome by dermatome, but move irregularly when you will touch them, otherwise they may say they can feel it by guessing when the next touch is likely to come.