Neonatal Neurological Examination (1)-1.pptx

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1. Neonatal Neurological Examination Dr Anu Thukral DM (Neonatology) Asst Professor AIIMS, New Delhi [email protected]

2. Learning objectives Which neonates mandate comprehensive neurological evaluation? When should it be done? How should it be done? Neonatal neurological evaluation

3. Which Neonates? Newborn has had any antecedent condition which mandates a thorough neurolgical examination Newborn has a directive physical sign during normal physical examination

4. When should it be done? The examination should ideally be done two third way in-between feeds when the infant is more likely to be in optimal state Preterm infants who are on continuous feeding : any time. Serial examinations

5. How should be neurological examination be done? Gestational age assessment Neurological evaluation change with maturation Certain disorders are characteristic of infants preterm AGA infants /SGA infants Different disorders have different impact on the central nervous system

6. Sequence of examination General examination Level of Alertness (Higher mental functions) Cranial Nerves Posture Tone assessment (Active and Passive) Reflexes (Superficial, Deep and Primitive) Head and Spine

7. Most sensitive marker of the integrity of central nervous system Time of last feed Recent painful experience (like venepuncture) Gestational age Environmental stimuli. How to elicit? Persistent gentle shaking, perioral stimulation, mild pinching, shining a light or ringing a bell. Higher Mental Functions: ( i )Alertness

8. Higher Mental Functions: Alertness Preterm Neonate < 28 weeks: difficult to identify period of wakefulness > 28 wks: arousable after stimulation > 32weeks stimulation not required (clinical sleep wake cycles) Term neonate Vigorous crying Increased wakefulness

9. Levels of alertness (Volpe) Level of alertness Appearance Arousal response Motor response Quantity Quality Normal Awake Normal Normal High level Stupor Mild Sleepy Diminished (slight) Diminished (slight) High level Moderate Asleep Diminished (moderate) Diminished (moderate) High level Severe Asleep Absent Diminished (severe) High level Coma Asleep Absent Absent Low level

10. (ii) Behaviour The NBAS (27 behavioural responses and 20 reflex items); 20 minutes to administer Prechtl and Brazelton behavioural scale State Eyes Respiration Gross body movements Vocalisation/ cry 1 Closed Regular - - 2 Closed Irregular + - 3 Open Regular - - 4 Open Irregular + - 5 Open/ closed Irregular + +

11. (iii)Habituation Soft light (at the frequency of approximately 1/ sec) Blinking response diminishes in intensity after 3-5 exposure Similar observation (startle or optical blink) is noted with repetitive auditory stimuli e.g. bell tinkle or hand clap.

12. (iv)Consolability The neonate may get consoled- 1.Spontaneously 2.Talking 3.Putting a hand on abdomen 4.By being picked up & held 5. May not get consoled.

13. (v)Cuddlability The infants response should be assessed when the infant is held when alert. Normal response is that the infant cuddles and clings to the examiner when alert.

14. Cranial nerve examination Optic nerve Response to light: 26 weeks- consistent blink response 32 weeks- persistent eye closure until light is removed 32 weeks – Onset of visual fixation. This matures over the next 4 weeks. 34 weeks – 90% of infants can track a fluffy ball 37 weeks- turning of the eyes to soft light. Term gestation- Visual fixation and following well developed. Colour perception: Demonstrable at nearly 2 months, even newborns follow coloured objects, preferably red. Visual discrimination: From 35 weeks onwards, newborns are able to recognise patterns

15. Cranial nerves examination Pupillary Reflex: Look for pupillary size & reaction. Size in preterm infants is 3-4 mm; it is slightly wider in full term infants. 29-32 weeks, pupil starts reacting to light. Visual acuity: Visual acuity of newborn infants has been estimated to be around 20/150. Fundus examination: Normal optic disc appears pale grey-white with diminished vascularity Retinal hge normal in 20-40%

16. 3 rd , 4 th , 5 th Cranial Nerve Eye position, eye movement and movement elicited by dolls eye maneuver. Eyes of a newborn are slightly disconjugate at rest Doll’s eye movement: 25 weeks. Spontaneous roving eye movements: 32 weeks Movements of full term infants are jerky and do not become smooth till the third month of life.

17. Cranial nerve examination 5 th nerve To assess the motor component assess the rooting and sucking reflex and assess muscle strength by allowing biting on finger. To assess the sensory component the facial sensation can be tested by response to pinprick. 7 th nerve The width of the palpebral fissure has to be noted. Presence of nasolabial fold Note the position of the angle of mouth The sucking reflex has to be assessed.

18. 8 th nerve Neonate shows a startle Test with a bell. From 28 weeks- startle or blinks in response. With maturation – subtle responses like cessation of breathing / change in RR/HR/ opening of eyes. 9 th / 10 th and 12 th nerve Pooling of secretions; also note the position of the soft palate; Observe a feeding session and assess the swallowing Gag reflex Active contraction of the soft palate with upward movement of uvula and posterior pharynx must be observed. 12 th nerve: size and symmetry of tongue movements/ fasciculations Cranial nerve examination

19. Motor system evaluation Quality, quantity and asymmetry Passive tone Active tone Reflexes Primitive reflexes

20. Motor system evaluation Quantity, quality and symmetry of movements: Slow twisting movements at 28-32 weeks Alternating flexor movements by 36 weeks. At birth, “writhing” movements that change to a “fidgety” pattern by six to nine weeks of age which resolve by 20 weeks. Absence of fidgety movements at a time when they should be present is predictive of subsequent long-term neurologic sequelae.

21. Passive Tone Rule of thumb This is assessed by observing the posture at rest and the resistance to movement. Make sure the head and the trunk are in the same axis. The measurement of different limb-angles diminishes as the muscle tone increases.

22. Passive tone assessment Posture Flappability Axial tone Normally ventral incurvation is much easier than dorsal incurvation, in central nervous system pathology the dorsal incurvation is increased much more than ventral incurvation. Appendicular tone

23. Passive tone assessment

24. Active tone assessment Righting reaction of lower extremities and trunk: With the baby in the standing position, assess the support of body weight and the righting of the trunk.. Righting reaction of the head: Neck extensors- With the baby sitting and the head hanging down on the chest, move the trunk slowly backward and observe the reaction of the head; this allows the tone of the extensor muscles on the back of the neck to be tested. Neck flexors - With the baby lying on the table, grasp the hands (or the shoulders if a very small premature) and pull him slowly to the sitting position, observing the position of the head in relation to the trunk. This enables the tone of the flexor muscles on the front of the neck to be checked.

25. Active tone assessment Stepping response can be obtained in infants born ≥32 weeks CA Vertical suspension measures the strength of the neonate's shoulder girdle. The examiner holds the infant in an upright position by placing the hands under the arms and around the chest with feet unsupported Head control − By 40 weeks CA, the infant has sufficient neck and truncal strength to maintain the head in line with the trunk for one to two seconds while being pulled from the supine to sitting position (figure 5). Ventral suspension measures the strength of the infant's trunk and neck. The infant is held in a suspended prone position in the air by placing a hand under the chest. A normal term infant will keep his/her head in the horizontal plane momentarily with flexion of both the upper and lower extremities

26. Reflexes An examiner's finger that is placed over the tendon to be tested can be lightly struck with a percussion hammer to elicit the reflex. Jaw Biceps Brachioradialis (supinator) Knee (patellar)

27. Superficial reflexes Abdominal reflexes Cremasteric reflex Anal wink reflex Corneal reflex Plantar reflex/ Babinski

28. Reflex How to elicit? What is normal? What is abnormal? Palmar grasp Appears: 28 wk Fully developed: 32 wk Disappears: 2-3 m Head in midline and arms semi flexed. Without touching the dorsal surface of the hand, place your index finger across the palm and apply gentle pressure. Preferably, both hands should be tested simultaneously.* Normal response All fingers should flex around the examiners finger with the strong grasp. After obtaining the grasp the fingers are drawn gently upwards. This elicits a reinforcement of the grip with progressive tensing of muscles from wrist to shoulder until baby hangs from fingers momentarily. Exceptionally strong and persistent grasp may be seen in spastic cerebral palsy or kernicterus. Asymmetry is noted in hemiplegia. Primitive reflexes

29. Rooting Reflex Appears: 32 wk Fully developed: 36 wk Disappears: 3-4 m The newborn's cheek is lightly stroked. Normal response Baby turns to find the expected mother's nipple Not turning to stimulus Primitive reflexes

30. Moro reflex Appears: 28-32 wk Fully developed: 37 wk Disappears: 3-4 m There are three ways: Baby in supine, head midline . Pull both arms to raise the shoulder slightly off the table . Release the arm allow the infant to fall on the table . Suspend the baby with supporting the trunk on one hand and head with the other and lower rapidly both the hands without flexing the head Head bang which is done for ill, spinal cord injury, ventilated incubator. With the infant supine, slap sharply on the mattress on either side of the infant. Normal response Symmetrical abduction of arms Extension of forearm, followed by adduction of arm and flexion of forearm Hands open completely and the infant cries or grimaces Infant habituates after 3 attempts in term and 10 attempts in preterms Failure to extinguish or non habituate Persistence beyond 4 months of age indicates poor cerebral function above the brain stem or absence of cortical inhibition. Asymmetric Moro reflex is seen in unequal muscle tone or weakness due to injury of humerus or clavicle.

31. Placing Fully developed: birth Disappears: 10-12 m Hold the infant with both hands under the arms and around the chest. Support the head with thumbs and jaw with index finger. Lightly touch the dorsum of infant feet to the sides of the table and lift him to draw the foot against the edge. Normal response Infant should flex the lower extremity enough to bring his foot up and place it on the surface. Asymmetrical, absent or weak response with poor movement of lower extremity. Marked extension after initial stimulus. Walking/ stepping Fully developed: birth Disappears: 10-12 m Hold the infant in the same position as described above; then hold him upright over a table with the sole of the foot presses against the table. Normal Response Reciprocal flexion and extension of legs -

32. Asymmetrical TNR Appears: 35 wk Fully developed: 1 m Disappears: 2-3 m Baby: lying supine, head in mid line, shoulder horizontal Head turned till jaw over either shoulder and held for 15 sec and released. Normal response: Mental extension, occipital flexion; arm and leg on the mental side extend and arm and leg on the occipital side flexes. If it occurs spontaneously, it is an active reflex. Sustained/exaggerated response i.e. failure to move out of position while head is held for 15 sec or after release Consistent failure to move an extremity Persistence of reflex beyond 6 months. Obligatory ATNR – infant cannot break the response while the head is rotated. Symmetrical TNR Fully developed: 4-6 m Disappears: Before crawling Support the child prone on your thighs while you sit on chair, passively flex the neck and observe the response and then extend the neck. Now observe the response again What is normal response? When the neck is flexed the arms flexes and the legs extends When the neck is extended the arm extends and legs flexes Persistence beyond 6 months is abnormal, In cerebral palsy, this reflex is overactive. If the head is lowered the arm flexes, leg extends and the infant falls on his face, hence is unable to crawl.

33. Parachute reflex Fully developed: 9 m Disappears: Throughout life Plantar grasp Appears: Birth Disappears: 9-10 m Landau Reflex Appears: 3 m Fully developed: 6-10 m Disappears: 9-10 m Truncal incurvation Appears: Birth Disappears: 1-2 m Primitive reflexes.......

34. Head and spine Size Shape Sutures Fontanelle Spine Transillumination

35. Neurological exam in sick neonate Level of Alertness Habituation Pupils, Dolls eye movement Posture AF Tone (Popliteal angle, fisting) Reflexes Head and spine

36. Preterm corrected Term When examined at term, preterm infants tend to have less flexor tone Head control in the sitting posture shows less extensor tone in the neck compared to full-term infants

37. Abnormalities of tone Increased Extensor tone in babies: HIE, Bilirubin encephalopathy, IVH, Meningitis, Raised ICP

38. Predictive ability of CNS evaluation for CP Tone abnormality of trunk, UL, LL Diminished cry for 1 day Weak/absent suck Diminished activity for more than 1 day 12-15 fold 21 fold rise 14 fold 19 fold Nelson K B . Collaborative Perinatal Project of NIH. Pediatrics 1979

39. Points to remember!! Standard format Ten minute examination Serial exam and not one would help Prognosis (Discharge Neuro exam) Early Intervention Normal from Abnormal

40. Remember! Persistent neurologic dysfunction is associated with an increased risk of permanent disability. The risk of cerebral palsy increases in infants with persistent hypotonia, weak cry, poor sucking, and decreased level of activity. Persistent asymmetric findings often are associated with an underlying abnormality Composites of neurologic findings are better predictors of outcome.

41. Thank you