Neurological assessment of child

Pediatric Neurology examination explained in details with Developmental Milestones and Anthopometry

1. Neurological Assessment of Child Presenter :Dr Fakir Mohan Sahu AIIMS BHUBANESWAR Dept of Neurosurgery 23/03/2021

2. Outlines History Anthropometry/ Development assessment Examining of head / Dysmorphic Child The neurological examination HMF Cranial Nerves Motor system Sensory system Reflexes Signs of meningeal irritation Cerebellar signs Pearls on examining infants and Older Child

3. Introduction The CNS in a children is a dynamic, developing and maturing system A daunting task to assessment of CNS Special tricks and adoption of “play attitude” is mandatory History is often imprecise as child cannot explain or express

4. Normal Neurologic Growth and Development W hat additional questions are important for a complete pediatric neurology history? – Antenatal – Perinatal – Neonatal Complications – Neurodevelopment – Immunizations – Behaviour – Family History – Social History

5. Key points in History Presenting symptom Onset: Sudden/ Subacute/ Insidious Evolution: Improving/Slow Progression/Rapid progression Any symptom of raised ICP/Seizure/LOC Development before onset of symptom Mental status- Alert/ irritable/ lack of interest/ drowsy/ stuporous/ comatose Feeding History/Family history/ Consanguinity Etiological history- Perinatal events/trauma/drugs toxin/infections if any

6. Principles and art of Examination Pre-requisite/ Essential tools Setting- well lighted room, colourful comfortable, warm hands Position 0-3 months – Examination table 3mont – 1 yr - Mothers lap 1-3 yr -Standing / Mothers lap After 3 yr - Examination table Adolescent girl - Female attendants

7. General Physical Examinations General appearance/Posture/ nature of disability/ Build and Nutrition Handedness(established around 3 years of age) Anthropometry Skull and Spine- Size /shape /sutures/ fontanels/ spinal deformities Skin and Appendages –Neuroectodermal dysplasia: Adenoma sebaceum /café –au-lait/ shagreen Patch/ Swelling Vitals Sign- Anaemia/Cyanosis/ Icterus/ Clubbing/ LN pathy / Organomegaly

8. Neurocutaneous markers 1. Cafe au lait spots 2. Ash leaf patch 3. Litsch nodules 4. Axillary and inguinal freckling. 5. Facial angiofibromas . 6. Cutaneous neurofibromatosis. 7. Multiple unqualified fibromas . 8. Shagreen patch. 9. Adenoma sebacum . 10. Hypo / hyper pigmented Macules 11. hairy tuft at sacrum. 12. Facial angioma /Port wine stain

9. Neurofibromatosis

10. Tuberous Sclerosis

11. Sturge Weber Syndrome

12. PHACE Syndrome • Female predominance Consists of • P osterior fossa malformation • H aemangiomas ipsilateral to the aortic arch • A rterial anomalies • C oarctation of the aorta, apalsia or hypoplasia of carotid arteries, aneurysmal carotid dilatation, aberrant left subclavian artery • E ye abnormalities- glaucoma, cataracts, microphthalmia, optic nerve hypoplasia.

13. Myelomeningocele Dermoid cyst Lipoma Sacrococcygeal Teratoma Hairy Nevus Spinal dysraphism Encephalocele

14. Moro’s Reflex Grasp reflex Rooting reflex Asymmetric tonic Neck reflex Placing Reflex

15. Lindau reflex Parachute reflex

16. Developmental screening Gross motor Development Fine motor/ Visual Social/ Adaptive and language Development Red Alerts

17. Red Alerts Lack of Social smile by 2 months Absence of stable head control by 4 months Inability to recognize the mother by 6 months Inability to sit when pulled to sit by 6 months / independent sitting by 8 months Lack of creeping by 9 months Inability to stands without support by 1yr Inability to walk without support by 18 months Lack of pincer grasp by 1 yr Absence of syllabic babbling by the age of 1 yr Failure to make meaningful sentences by 3 years

18. Anthropometry Weight Length/ Height Head circumference Assessment of - Mid arm circumference/ Subcutaneous fat/ Arm span/ Obesity

19. Head Circumference Brain growth takes place 70% during fetal life, 15% during infancy and remaining 10% during pre-school years. Head circumference are routinely recorded until 5 years of age. If scalp edema or cranial moulding - measurement of scalp edema may be inaccurate until fourth or fifth day

20. Expected head circumference in children Head Circumference Growth Velocity Till 3 months 2 cm/month 3 months – 1 year 2cm/3 month 1 – 3 year 1cm/ 6 month 3 – 5 year 1cm/ year During first year there is 12 cm increase in head circumference , while 1 – 5 year age , only 6 cm gain occur in head size. Age Head circumference (cm) At birth 33 – 35 2 months 38 3 months 40 4 months 41 6 months 42 - 43 1 year 45 - 46 2 years 47 - 48 5 years 50 - 51

21. 10 cms / yr for boy

22. Head Examinations Size/ Shape/ Symmetry/Sutures Fontanels-Depressed/ Flat/ Buldged Six at birth Two large ant/post Anterior fontanel (2.5×2.5cm) closes by 12-18 mnths Posterior fontanel small at birth closes by 6 weeks Two Anterolateral/ two posterolateral

23. Abnormal head/ facies/ Dysmorphic child Hydrocephalus Microcephaly Dolichocephaly Brachycephaly Frontal bossing's Acrocephaly / Oxycephaly Trigonocephaly Plagiocephaly Caput quadratum/ hot cross burn appearance Flat Occiput/ Prominent occiput

24. Microcephaly Macrocephaly with frontal bossing Craniotabes Proptosis NF Down syndromes

25. Hydrocephalus

26. SCAPHOCEPHALY Trigonocephaly

27. PLAGIOCEPHALY Turricephaly

28. Higher Mental Function Level of Consciousness Alert Response to Voice Response to pain Unresponsive to any stimulus Coma Scale

29. Coma Scale

30. Higher Mental Function Emotional status- Assess behaviour/ perception and emotional liability/ hyperactivity/ attention/ distractibility/ impulsiveness Memory and Orientation Immediate/Recent/ Remote(above 5yrs) Time / Place / Person Name of school/ teacher/ father/ friends Ability to obey simple commands Tell a brief story and repeat the same Repeat no forward/ Backward 6yr repeat forward five digits and backward three digits, 10 yr six digits forward and four digits backward

31. Speech Aphonia/Dysphonia- Volume or intensity of speech affected A child is asked to blow out a candle or count 1 -100 Wernicke’s aphasia/ Broca’s Aphasia/ Dyslexia(slowness in reading, mirror image writing, reading from right to left) Disorders of Articulation- “Pa” “Ta” “Ka” Stammering/ lalling or baby speech Scanning and Staccatto speech/Slurred Spastic / Slurring dysarthria Nasal Speech Autism Spectrum disorders

32. Signs of Meningeal irritations Absent-infants <3 months/ malnourished child/ seriously sick pt. Early Sign Late Sign

33. Neck rigidity

34. Tripod Sign

35. Cranial nerve exam: Olfaction CN(I) Olfactory sensation as transmitted by the olfactory nerve is not functional in the newborn P resent by 5 to 7 months of age. Anosmia/ Parosmia

36. Cranial Nerve- Optic nerve(II) Visual Acuity- Infants Blinking response/ Turning of head towards light Above 3 yr – E Chart Field of vision tested after 3yrs(confrontation) Perimetry feasible after 8-9 yrs Colour vision above 3 yr Fundus exam Optic disc infant- pale Papilledema/Papillitis- elevated disc, blurred edges, obliteration of physiological cuff “E” chart

37. III, IV, VI CN Movements are complete in all directions by approximately 4 months of age, Acoustically elicited eye movements appear at 5 months of age . Ptosis/ Diplopia Head tilt Dolls eye movement Infant Depth perception using solely binocular cues appears by 24 months of age Stable binocular alignment and optokinetic nystagmus.

38. Trigeminal(Vth) CN 1-Sensory :ophthalmic-maxillary-mandibular. 2-Motor:masseter - temporalis – pterigoid . 3-Reflexes:corneal reflex-jaw reflex

39. Facial (VII) CN Impaired motor function is indicated by facial asymmetry. The McCarthy reflex , ipsilateral blinking produced by tapping the supraorbital region, is diminished or absent in lower motor neuron facial weakness. Palpebral reflex , bilateral blinking induced by tapping the root of the nose, it can be exaggerated by upper motor neuron lesions. In hemiparesis or peripheral facial nerve weakness, the contraction of the platysma muscle is less vigorous on the affected side, This sign also carries Babinski's name. Failure to pull the affected side of the mouth backward and downward when crying. Sensory-----Ant.2/3 of tongue.

40. Vestibulocochlear(VIII) Cochlear part(hearing) At birth ---Moro reflex. Younger deviate to sound. Later Rinne s test+ Weber test. Vestibular part(Vertigo+ Nystagmus) C an be assessed easily in infants or small children by holding the youngster vertically so he or she is facing the examiner, then turning the child several times in a full circle. Clockwise and counterclockwise rotations are performed. The direction and amplitude of the quick and slow movements of the eye are noted.

41. Hearing development BERA

42. IX, X, XI CN Sensory ……loss of post 2/3 of tongue. Motor……pharyngeal O/E…. 1-gag reflex…absent in bulber palsy UMNL exaggarated in pseudo bulber palsy LMNL. 2-Uvula ….normally central & mobile. In unilateral lesion….uvula deviate to healthy side. In bilateral lesion…uvula is central but immobile. Spinal accessory N. Sternomastoid-ability to rotate head to healthy side. Trapezius-dropping of shoulder in affected side

43. Hypoglossal(XII) Hypoglossal N. ….. Deviation of the tongue to the affected side on protrusion.

44. Motor system Bulk Tone Power Deep/ Superficial reflexes

45. Muscle tone 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. UMNL =Pyramidal lesion….. spasticity(clasp knife) resistance on the start of movement. Extrapyramidal lesion….. rigidity(resistance is all over movement (cog-weal or lead)

46. Muscle power 1-Young child…….painful stimulation on the opposite side of the tested muscle. 2-Older child….ask to move against resistance. 3-Test every joint for its muscle group. 4-Grading of muscle power

47. Scarf sign Heel Ear Dorsiflexion toe

48. Involuntary movements Usually with extrapyramidal lesion. Chorea….sudden irregular purposeless dancing movement affect big proximal joint. Athetosis…slow twisting movement affect distal joint. Dystonia….slow twisting movement in trunk. Tremors….rapid alternating movement around small joint.

49. Incoordination 1st year ……grasp reflex & object transfer. -2nd year……button & unbutton. ->3years……U.L. 1- Finger to nose test 2-Finger to finger test 3-Dysdiadochokinesis…inability to perform rapidly alternating movement 4-Rebound test L.L. Heal to shin test Toe finger test Foot Tapping test Inco-ordination = ataxia.

50. Sensory system 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 Touch Pain & Temperature JPS

51. Pearls on examining infants and Older Child Accuracy depends upon the observational ability and intelligence Concerns of Parents/ Attendants Dietary/ Immunization/ Perinatal/ Developmental history Approach of examination Unstructured (unpleasant examination postponed to the end) Signs of meningeal irritation may be minimal or absent during first year of life (especially first 3 months) and in malnourished children

52. Pearls on examining infants and Older Child Primitive reflexes are present in birth disappear by 4-5 months Developmental screening is a must/ early markers of Cerebral palsy Deep tendons reflexes are normally brisk during infancy KJ  crossed adductor response/ Cremasteric reflex Plantar normally extensors up to 2yrs Fundus normally pale in infants/ Papilledema appears after 3 yrs

53. Thank You