pediatric neuro assessmentvudthuvhjj.pptx

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1. PAEDIATRIC ASSESSMENT

2. Subjective assessment Informant : mother /father Name : Age / sex : Domain : if patient is above 5 years of age right/left/mixed/not established Address : Date of birth : Date of assessment : Parent’s education : Father’s occupation :

3. Family cycle : Chief complain : History :

4. Prenatal history (24 th /26 th week of gestation upto birth) Age of mother at time of delivery : (<20 & >35 at high risk ) Consanguineous marriage : seroius birth defect, MR, genetic disease ( spina bifida, cystic fibrosis) Maternal infection : ( TORCH), gastro intenstinal genitourinary tract infection , rubella -(hydrocephalus) Genetic origin : Previous fetal abortion & reason for same : 3-4 abortion or miscarriage - ^se risk of premature birth, LBW h/o radiation exposure : radio/ chemotherapy h/o teratogenic drug during delivery : high risk for CP Metabolic disorders in mother like diabetes mellitus or thyroid –hypothyroidism-birth defect

5. - Gestational diabetes – macrosomia, low blood sugar, jaundice dysfunction Anaemia : spina bifida & LBW h/o PIH & Eclampsia : brain damage, reducing fetal growth LBW premature Maternal hypoxia : Brain damage h/o trauma to mother during pregnancy: blunt abdominal trauma, penetrating trauma, falls, –Bain injury- spastic cp (intracranial hemorrhage to child) Mental trauma : depression – neuro chemical changes

6. Perinatal history (during birth) Premature / postmature /at full term birth Forceps / vaccum / C.S. /normal delivery (trauma during delivery ) Birth asphyxia : - leads to delayed onset of first respiration (at the end of first 2 mins after birth) - hypercarbia - hypoxia - blood supply decreased - heart function affected - hypoxic ischaemic encephalopathy (results in s CP and any cognitive and developmental impaiments )

7. Grades of HII Severe: - immediate stupor/coma after birth & require mechanical ventilation - seizures and severe apnea in last12-24 hrs - severe hypotonia - absence of spontaneous movement & reflexes - mortality rate is high & survivor has significant neurological problems Moderate : - lethargic & difficult to arouse during first 12hrs of life - h/o acidosis & hypotension at delivery - require resuscitation at delivery and adequate ventilation -MV is short term 7

8. - seizures & apnea are less likely to occur -muscle tone & level of arousal may improve 2-3 days Mild : - asphyxia before delivery - recover well and require minimal Ventilation - lethargic – hyperactive — irritable --- exaggerated responses to stimulation - moro response is hyperactive - muscle tone is normal 8

9. APGAR score :

10. Interpretation 0-3 : severe depressed 4-6 : moderately depressed 7-10 : excellent condition The  Apgar score  is done routinely 60 seconds after the birth of the infant and then is repeated five minutes after birth. In the event of a difficult resuscitation, the  Apgar score  may be done again at 10, 15, and 20 minutes

11. Presentation of baby : breech : damage to the umblical cord –lack of O2 –brain damage Low birth weight: according to WHO : ≥ 2500g is normal 2500g -1500g is LBW 1500g -1000g is VLBW <1000g is ELBW that is due to young age multiple pregnancy –twins , triplets-CP

12. Previous LBW Poor nutrition Hypertension Alcohol abuse Lead exposure Smoking Air pollution It results in mortality, growth retardation, infection, cognitive impairment

13. NICU stay : reason :-premature delivery :-respiratory distress :- infection :- hypoglycemia

14. Postnatal history (up to 2-3 years of age) H/o of jaundice : disappear within 2-3 weeks that is normal, but if it persists more than 3weeks due to high billirubin concentration results in deafness, CP, Kernicterus, other form of brain damage

15. h/o infection : most commonly occurs within first four weeks of life due to LBW , premature birth h/o trauma :includes brachial plexus injury head and brain injury hemorrhage , hematoma

16. h/o epilepsy : The brains of newborn babies are sensitive to seizures in the first week of life. Some babies will continue to have seizures as they get older, but some babies will never have any more.  cause : hypoxic–ischaemic encephalopathy. It may be responsible for 80% of all seizures in the first 2 days of life.  Duration : The duration of neonatal seizures is usually brief (10 s to 1–2 min) and repetitive with a median of 8 min in between each seizure Subtle seizures (50%) Tonic seizures (5%) Clonic seizures (25%) Myoclonic seizures (20%) 16

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18. Past Medical/ Surgical History : Past Drug History: Educational History: Socio-economical History: Family history: Any siblings or in maternal/ paternal side suffering from any disease eg ., spinal muscular atrophy , DMD, alzheimer’s disease, epilepsy, stroke, parkinson’s disease, macrocephaly Till 5 th generation & clinically upto 3 rd generation. 18

19. On observation How child coming to department : wheelchair, assistive device, walking Posture : standing, sitting, supine scoliosis, kyphosis torticolis head and neck control Attitude of limb : Facial expression : down syndrome, facial palsy Head size : micro/ macrocephaly

20. Disuse atrophy : Drooling of saliva : inflammation of mucus membrane of mouth , facial palsy , CP Involuntary movements : tics: repetitive involuntary movements like eye binking , lips smacking, shoulder shrugging due to ADHD/ ANXIETY/OCD/side effects of drugs/toxins/ infection/ neurodegenerative disorder chorea: continuous movement like writhing or dancelike movements due to metabolic derangements hyperthyroidism, hypo/hyper glycemia / hypo/hyper natraemia , hypocalcaemia dystonia : abnormal sustain contraction of muscle leads to unusual twisting movt due to HI brain injury myoclonus : sudden jerky movts due to affection of cortex/ brainstem/ basal ganglia/ spinal cord Tremors : juvenile parkinsons , shuddering attack : shivering movements ocuurs daily for several seconds without loss of consciousness due to immature brain or metabolic derangements like hyperthyroidism; toxins 20

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22. Epilepsy: Skin changes : neurofibroma , Café au lait spots, shagreen patches are lesions seen in children with tuberous sclerosis. Gait : scissoring gait (spastic cp), ataxic gait, toeing gait (foot drop), External applience : orthosis , 22

23. On Examination 1. Vitals 24

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25. Anthropometric measurement: Head circumference Chest circumference Height Current body weight

26. Head circumference Using a non stretchable tape, the maximum circumference of the head from the occipital protuberance to the supraorbital ridges on the forehead is recorded. The crossed tape method, using firm pressure to compress the hair, is the preferred way to measure head circumference Head growth is rapid, especially in the first half of infancy. It reflects the brain growth during this period. The head growth slows considerably thereafter. Beginning at 34 cm at birth, the head circumference increases approximately 2 cm per month for first 3 month,1 cm per month between 3-6 month and 0.5 cm per month for the rest of the first year of life. New born’s head is about half of the body length in cm plus 10cm.

27. Method of recording head circumference. Note the crossed tape method

28. ll. Chest circumference The chest circumference is measured at the level of the nipples, midway between inspiration and expiration. The crossed tape method, as recommended for head circumference measurement, is used for measuring chest circumference . The circumference of chest is about 3 cm less than the head circumference at birth. The circumference of head and chest are almost equal by the age of 1 yr. Thereafter, the chest circumference exceeds the head circumference.

29. lll . Height Length is recorded for children under 2 yr of age. Hairpins are removed and braids undone. Bulky diapers should be removed. The child is placed supine on a rigid measuring table or an infantometer . The head is held firmly in position against a fixed upright head board by one person. Legs are straightened, keeping feet at right angles to legs, with toes pointing upward. The free foot board is brought into firm contact with the child's heels Length of the baby is measured from a scale, which is set in the measuring table. Measurement of length of a child lying on a mattress and/ or using cloth tapes, is inaccurate and not recommended.

30. Standing height . For the standing height, the child stands upright. Heels are slightly separated and the weight is borne evenly on both feet. Heels, buttocks, shoulder blades and back of head are brought in contact with a vertical surface such as wall, height measuring rod or a stadiometer . The head is so positioned that the child looks directly forwards with Frankfort plane (the line joining floor of external auditory meatus to the lower margin of orbit) and the biauricular plane being horizontal. The head piece is kept firmly over the head to compress the hair

31. IV. Current Body Weight The weight of the child in the minimal light clothing is recorded accurately on a lever or electronic type of weighing scale (Fig. 2.4). Spring balances are less accurate. The weighing scale should have a minimum unit of 100 g. It is important that child be placed in the middle of weighing pan. The weighing scale should be corrected for any zero error before measurement. Serial measurementshould be done on the same weighing scale .

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33. 2. Gross motor examination Milestone achieved Mode of transition

34. Developmental milestone Gross motor milestone Fine motor milestone Language Social

35. Gross motor milestone Motor development progresses in an orderly sequence to ultimate attainment of locomotion and more complex motor tasks thereafter. In an infant it is assessed and observed as follows. Head control Pull to sit Ventral suspension Supported sitting

36. Head control Supine and pull to sit The infant is observed in supine and then gently pulled to sitting position. Control of head and curvature of the spine is observed. In the newborn period, the head completely lags behind and back is rounded (Fig. 1). Starting at 6 weeks, the head control develops and by 12 weeks there is only a slight head lag. The spine curvature also decreases accordingly (Fig. 2).The child has complete neck control by 20 weeks (Fig. 3). This can be ascertained by swaying him gently 'side-to-side‘ when sitting. At this age, the baby loves to play with his feet, and may take his foot to mouth as well. Infant lifts head from the supine position when about to be pulled at 5 months (Fig. 4).

37. 2: Pull to sit; no head lag at 4 months 1.Pull to sit; complete head lag in a newborn

38. Fig. 3: Pull to sit; flexes the head on to chest at 5 months Fig. 4: Infant lifts head from the supine position when about to be pulled at 5 months

39. Ventral suspension The child is held in prone position and then lifted from the couch, with the examiner supporting the chest and abdomen of the child with the palm of his hand. Up to 4 weeks of age, the head flops down (Fig. 5). At 6 weeks, the child momentarily holds head in the horizontal plane and by 8 weeks, he can maintain this position well (Fig. 6). By 12 weeks, he can lift his head above the horizontal plane (Fig. 7).

40. Fig. 5: Ventral suspension; unable to hold neck in the line with trunk at 4 weeks Fig. 6: Ventral suspension; head in line with the trunk at 8-10 weeks

41. Fig. 7: Ventral suspension; head in line with the trunk at 12 weeks

42. Prone position At birth or within a few days, the newborn turns the head to one side. At 2 weeks, the baby lies on the bed with high pelvis and knees drawn up (Fig.8). At 4 weeks, the infant lifts the chin up momentarily in the midline. The infant lies with flat pelvis and extended hips at 6 weeks (Fig. 9). By 8 weeks, face is lifted up at 45° (Fig. 10) and by 12 weeks, the child can bear weight on forearms with chin and shoulder off the couch and face at 45° (Fig. 11). At 6 months, he can lift his head and greater part of the chest while supporting weight on the extended arms (Fig. 12). Between 4 and 6 months, he learns to roll over, at first from back to side and then from back to stomach. By the age of 8 months, he crawls (with abdomen on the ground) and by 10 months, creeps (abdomen off the ground, with weight on knees and hands) (Fig. 13).

43. Fig. 8: The infant lies on the bed with high pelvis and knees drawn up at 2 weeks Fig. 9: The infant lies with flat pelvis and extended hips at 6 weeks

44. Fig. 11: In prone: face, head and chest off the couch at 3 months Fig. 10: In prone: face lifted to about 45° at 8 weeks

45. Fig. 12: In prone: weight on hands with extended arms at 6 months

46. Sitting By the age of 5 months, the child can sit steadily with support of pillows or the examiner's hands (Figs 14 and 15). At first the back is rounded but gradually it straightens (Figs 14 and 15). He independently sits with his arms forward for support (tripod or truly 'sitting with support') by the age of 6-7 months (Fig. 16). Steady sitting without any support generally develops at around 8 months (Fig. 17). By 10-11 months, he can pivot in sitting position to play around with toys (Fig.18)

47. Fig. 14: Sitting; back rounded but able to hold head at 8 weeks Fig. 15: Sitting; back much straighter at 4 months

48. Fig. 16: Sitting with support of hands at 6 months Fig. 17: Sitting without support at 8 months Fig 18 :Pivoting; turns around to pick up an object at 11 months

49. Trunk and neck tone are evaluated by assessing (a) head control in the sitting position, (b) head lag while the infant is pulled to the sitting position, and (c) the posture of the head and trunk in ventral suspension Head control in the sitting position is elicited by placing the infant into a sitting position and holding it there by encircling the infant’s chest with the examiner’s hand, then allowing the head either to fall forward (head control 1) or backward (head control 2). The infant’s ability to raise the head to vertical is noted. Head lag is elicited by grasping the infant’s wrists and gently pulling the infant from the supine toward the sitting position. The response of the head to this maneuver is noted. Posture of the head and trunk in ventral suspension is tested by suspending the infant in the prone position by a hand under the chest. Posture of the head in relation to the trunk is scored and the amount of flexion in the arms is also noted. The diagram most resembling the position of the trunk should be circled and any deviation of head or limb posture from the diagram in the proforma should be drawn on the diagram.

50. Interpretation In babies born preterm, corrected age rather than postnatal age is used for determining developmental status till two years of age. For example, a child born at 32 weeks gestation(gestational age) seen at 12 weeks of age (postnatal age/chronological age) should be considered as a 4-week-old ( corrected age ) child for development assessment.

51. While drawing any conclusions about development, one should remember the wide variations in normality. For example, let us consider the milestone of standing alone. The average age for attainment of this milestone in a WHO survey was 10.8 months Retardation should not be diagnosed or suggested on a single feature. Repeat examination is desirable in any child who does not have a gross delay. Factors such as recent illness, significant malnutrition, emotional deprivation, slow maturation, sensory deficits and neuromuscular disorders should always be taken into account.

52. At times, there can be significant variations in attainment of milestones in individual fields, this is called dissociation. For example, a 1-yr-old child who speaks 2-3 words with meaning and has finger thumb opposition (10-12 months), may not be able to stand with support (less than 10 months). Such children require evaluation for physical disorder affecting a particular domain of development. A child having normal development in all domains except language may have hearing deficit.

53. Table gives the upper limits by which a milestone must be attained. A child who does not attain the milestone by the recommended limit should be evaluated for cause of developmental delay.

54. Rolling -see for preferable side -Bilateral rolling present or not -Rolling full or partial -After rolling upper limb can be out by baby Sitting -rounded/ring sitting W sitting Sacral sitting

55. Standing -Observe transition -Symmetry -Wt. bearing status -Position of feet(medial /lateral/flat feet) -Knee flexed/ recurvatum -Spine -Head & neck

56. Mode of transition Prone pivoting Creeping Crawling Buttock dragging

57. Fine motor examination This primarily involves the development of fine manipulation skills and coordination with age. Prehension grip Reach : Good/fair/poor Grasp : Good/fair/poor Placement : Good/fair/poor Release : Good/fair/poor

58. Precision Grip Lateral : Good/fair/poor Spherical : Good/fair/poor Cylindrical : Good/fair/poor Hook : Good/fair/poor

59. Hand function examination Hand to mouth : Good/fair/poor Bilateral hand : Good/fair/poor Midline coordination : Good/fair/poor

60. Motor examination Muscle tone Reflexes Oromotor examination : - Articulation -speech 4) Fall examination : -frequency -direction

61. Muscle tone Tone is defined as the resistance of muscle to passive elongation or stretch. Tonal abnormalities are categorized as hypertonia (increased above normal resting levels), hypotonia (decreased below normal resting levels), or dystonia (impaired or disordered tonicity).

62. An examination of tone consists of (1) initial observation of resting posture and palpation, (2) passive motion testing, and (3) active motion testing. For documentation in the medical record, tone is typically graded on a 0 to 4+ scale: 0 No response (flaccidity) 1+ Decreased response ( hypotonia ) 2+ Normal response 3+ Exaggerated response (mild to moderate hypertonia ) 4+ Sustained response (severe hypertonia ) Spasticity is assessed by Modified Ashworth Scale .

63. Tone is best examined by assessing resistance to passive movement with the subject at rest. Low tone or hypotonia can be focal, axial ( i.e.,central or truncal ), appendicular (in the limbs), or generalized. Increased tone or hypertonia is generally either focal or generalized. Hypertonia can be classified as spastic, where the greater the velocity of passive movement the higher the observed tone, or rigid, where the tone is uniform and not velocity dependent. The assessment of tone can be somewhat subjective and can be influenced by the state of the patient. A resting or sleeping child can have lower tone than while awake. In general, the normal flexed posture of a newborn and relatively increased tone decreases with age until about6 months and then plateaus.

64. In newborns, there are certain generalities which can help to describe or indicate abnormal tone. For example, when pulling a newborn’s arm gently across the chest toward the opposite shoulder, there should be increasing resistance felt as the elbow approaches the midline. If the elbow crosses the midline without excessive force, this is an indication of decreased tone , and this is sometimes referred to as a positive “scarf sign.” In infants, axial tone can be evaluated by holding the patient in a ventral suspension and observing the position of the child draped over the arm. Infants with normal tone should make some attempt to lift the head and keep the back arched. Additionally, one can raise the infant from supine to sitting by pulling on the arms and observing for any abnormal head lag (no lag by 6 months of age), a sign of axial hypotonia and neck weakness.

65. Limb tone Limb tone is assessed by noting the tone of the limbs in the supine position and in ventral suspension and by the response to traction of the upper and lower limb with the infant lying in the supine , head in the midline (Fig. 2). To elicit arm traction the arm is pulled slowly to a vertical position by the wrist . The resistance and the angle of flexion at the elbow is noted when the shoulder lifts from the surface ..

66. Leg traction is elicited by raising the leg into vertical position by gentle traction on the ankle. The resistance to this maneuver and the angle of flexion at the knee are noted when the buttock becomes elevated. Both arm and leg traction are tested separately in each limb.

67. Assessment of tone patterns It is important that the items assessing tone are evaluated not only individually but also compared to each other in order to identify possible patterns of distribution of tone (Fig. 4). This will help to establish, for example, whether the infant has generalized hypotonia or only poor axial tone (reduced trunk and head control). While the former may also be associated with systemic illness, central nervous system(CNS) involvement, and neuromuscular disease, the latter is more often a marker of CNS involvement.

68. Predominance of extensor tone compared to flexor tone This is assessed comparing ventral suspension and head lag or neck flexor and extensor muscles in the two items assessing head control. Relative increase in the neck extensor muscles compared to the flexor ones is often associated with hypoxic–ischemic lesions, meningitis, or increased intraventricular pressure.

69. Differential distribution of tone in upper and lower limbs. This is assessed comparing tone of upper and lower limbs (Fig. 5). Abnormal patterns of leg tone are often observed in infants with breech presentation. If noted in a quiet infant at any gestation it should raise the suspicion of CNS pathology. This sign can be associated with a number of conditions , such as the onset of an intraventricular hemorrhage or periventricular leukomalacia , and is often observed in full-term infants with hypoxic–ischemic encephalopathy who have severe basal ganglia lesions on brain MRI.

70. Relatively tight popliteal angle compared to leg traction. This is assessed comparing popliteal angle and leg traction (Fig. 6). A tight politeal angle associated with relatively poor resistance on leg traction can be observed in infants with breech presentation. A disproportionately tight popliteal angle compared with the rest of the leg tone is frequently found in association with germinal matrix or intraventricular hemorrhages.

71. Reflexes Reflex assessment includes : Deep tendon reflexes Superficial reflexes Visceral reflexes Primitive reflexes Pathological reflexes

72. Ulnar reflex– stimulus: Strike ulna above wrist. Response: Extension and ulnar deviation of wrist.

73. Reflex Grading: reflexes are graded on a 0 to 4+ scale: 0 Absent, no response 1+ Slight reflex, present but depressed, low normal 2+ Normal, typical reflex 3+ Brisk reflex, possibly but not necessarily abnormal 4+ Very brisk reflex, abnormal, clonus

74. Although deep tendon reflexes can be tested at any age, the triceps reflex is particularly difficult to elicit in neonates. Tendon reflexes can also be difficult to achieve in babies because of their constant motion and light weight, and thus nonspecific movements as well as movement due to the hammer itself can be interpreted as a reflex response. In addition, their small size makes for a small target; the biceps tendon and patellar tendon require a precise hit from the hammer, which can take practice or repeated trials.

75. Superficial reflexes A. Skin Reflexes Anal reflex– stimulus: Stroke the perianal area or insert gloved finger into rectum. Response: Contraction of the sphincter ani . 2. Cremasteric reflex– stimulus: Stroke inner thigh. Response:Testicular elevation. 3. Gluteal reflex– stimulus: Stroke buttocks. Response:Contraction of buttocks.

76. 4. Interscapular reflex– stimulus: Stroke skin of interscapular space. Response: Scapulas draw inward. 5. Plantar reflex– stimulus: Stroke sole of feet. Response: Plantar flexion of toes. 6. Upper and lower abdominal reflexes– stimulus: Medially stroke each side of abdomen above and below the umbilicus. Response: Umbilical deviation toward the stimulus.

77. children aged 1 or older, a normal plantar reflex produces a plantar flexion of the large toe, while an upward or extensor response is considered abnormal. An extensor response of the toe in non-infant is evidence that this otherwise spinally mediated reflex is not suppressed by information from the cortex . + Babinski's sign = dorsiflexion of the great toe and fanning of the toes. Can be normal up to 1 year of age so symmetry is the important feature to look at below 1 year. May be seen after a seizure.

78. B. Mucous Membrane Reflexes 1. Corneal reflex– stimulus: Touch cornea with wisp of cotton. Response: Blinking. 2. Gag reflex– stimulus: Irritate pharynx with tongue blade. Response: Gagging. 3. Sneeze reflex– stimulus: Irritate nasal membrane. Response: Sneezing. 4. Uvular reflex– stimulus: Phonation of “ Ahh ” or irritation of posterior third of tongue with tongue blade. Response:Uvular elevation.

79. VISCERAL REFLEXES Pupillary Reflexes Accommodation reflex– stimulus: Patient looks at distant object, then near object. Response: Pupillary constriction and ocular convergence. 2. Consensual light reflex– stimulus: Shine light into opposite eye. Response: Pupillary constriction. 3. Ciliospinal reflex– stimulus: Pinch neck. Response: Pupillary dilation. 4. Light reflex– stimulus: Shine light onto retina. Response:Pupillary contraction.

80. B. Blink Reflex stimulus: Unexpected, abrupt movement of object toward eyes. Response: Blinking or eyelid closure. C. Oculocardiac Reflex stimulus: Pressure directly over closed eyes. Response: Slowing of heart rate.

81. Primitive reflexes present from the time of birth These are the patterns seen in early stages of development which disappear later on or with advanced age. These responses are essential for normal progressive motor development There are some children who may skip some movements but these are not abnormal However not overcoming these primitive reflexes at the right time should be definitely considered as abnormal.

82. Initially lower centers such as spinal cord control these movements but later on higher centers like midbrain and cortex take control over them and dominate the lower ones integrating them for various voluntary functional task, Disappearance of certain primitive reflexes does not mean they are abolished but means that they have been take over by stronger reflexes at higher level in the CNS.

83. According to Dubowitz et al., 1999, Eliciting primitive reflexes has been regarded as an important component of the neurological assessment of the newborn. However, in our experience, reflexes cannot reliably identify infants with neurological abnormalities, as abnormal reflexes can be observed in normal infants and normal reflexes can also be found even in grossly abnormal infants. We have therefore decided to retain only the reflexes that we considered to be the most useful for our purpose.

84. These primitive reflexes are classified according to the level at which they are controlled. accordingly we have four levels at which these reflexes are regulated: Spinal cord Brain stem Midbrain Cortex Automatic reaction/reflexes

85. Primitive reflexes

86. Musculoskeletal examination ROM Muscle strength : In infants and young children , strength testing is typically performed while observing functional movements. For example, symmetric and age appropriate reaching, crawling, or cruising suggest normal strength. Of note, asymmetry in reaching or demonstration of a hand preference before about 1 year of age may be a sign of pathologic weakness in the non-preferred arm or hand.

87. Contracture Tightness Deformity Bony abnormality Muscle atrophy or hypertrophy

88. Sensory examination Superficial : Touch Pain Temperature Pressure Deep: Proprioception Vibration Kinesthesia

89. Sensory examination The sensory examination includes evaluation of the primary modalities of pain, temperature, touch, proprioception , and vibration sense. Formal sensory testing can be done typically after 5–6 years of age. A complete sensory examination can take a long time to perform in a healthy subject. In reality, the sensory exam is usually tailored to a specific area of concern where a deficitis already suspected, as it will seldom reveal an abnormality which has not been previously self reported.

90. Sensory testing in newborns and infants is usually limited to basic testing while assessing for motor output as a potential response to a stimulus. For example, an infant will usually withdraw a limb in response to a tuning fork. This procedure also provides temperature and touch stimulation and trial-to-trial variability in infant testing is common. Noxious stimuli such as nail bed pressure, pinching of the skin, or pinprick should also elicit a cry or withdrawal. Light touch or tickling will also usually precipitate a withdrawal of the foot, for example. Again, a sensory exam is most sensitive when there is a specific area of concern for neurologic injury.

91. Cranial nerves examination Although the 12 cranial nerves can be individually evaluated in an order child upon request, in younger children these are often evaluated with observation of spontaneous or provoked responses

92. I: Olfactory Nerve CN I (olfactory) appears at 5 to 7 months of age. This nerve mediates the sense of smell. This nerve has little utility for testing in a child unless a deficit is somehow otherwise suspected. Disorders of olfaction are rare in paediatrics , and testing in this age group is unfruitful.

93. II: The Optic Nerve Visual field The best stimulus to check visual behavior is the primary caretaker's face. At birth, a baby can fixate and follow a moving person or dangling ring held 8-10 inches a way up to a range of 45°. This increases to 90° by 4 weeks and 180° by 12 weeks. At around 1 month, the baby can fixate on his mother as she talks to him. At about 3-4 months, the child fixates intently on an object shown to him(' grasping with the eye') as if the child wants to reach for the object .

94. Binocular vision begins at around 6 weeks and is well established by 4 months. By 6 months, the child adjusts his position to follow objects of interest, can follow rapidly moving objects by 1 yr. Later the child displays more maturity in vision by not only identifying smaller objects but also being able to recognize them.

95. Testing The ideal subject to test for tracking is a human face held 8–12 in from the child. An easy way to test for tracking is to hold the child in your outstretched arms, facing you, as you rotate him or her around. It is important to note that tracking at this age is likely due to involuntary responses and deep brain structures and does not necessarily involve higher cortical areas such as primary visual cortex. To check Visual fields in children less than a year of age ,Have one examiner attract the attention of the child to a toy/shiny metal object after which another examiner in back of the child brings another toy into the field of vision, noting the location at which the child turns his or her head towards this second toy

96. Visual field evaluation is not classically a test of optic nerve integrity, although it is reasonable to include a discussion of visual fields in this section. Visual field testing may identify focal retinal deficits as well as brain lesions involving any part of the visual pathway. In cooperative children (and adults), the best method is to position yourself at arms’ length away from the patient

97. The most direct evaluation of the optic nerve is to assess for pupillary light reflex, which requires the proper functioning of the optic nerve to transmit the light information which hits the retina and cranial nerve III which mediates the pupillary constriction. The direct response describes ipsilateral constriction of the pupil, while the consensual response is the constriction which also occurs in the contralateral eye. Pupillary light reflexes should be apparent by 32–35 weeks’ gestational age but can be difficult to assess in infants because the pupils are relatively small relative to the size of the iris at this age.

98. The pupils should be equally reactive to light and symmetrical within the orbits. Note eye position and movement on spontaneous eye opening. Asymmetry of pupil position implies a squint (strabismus) and mandates further assessment (for example by the ‘cover test’). The corneal reflex can be assessed by shining a bright light from a short distance (20-30cm) into the child’s eyes. The reflection should be central within the pupils when the child looks directly at the light. If the light reflection is not central it further suggests the presence of a squint.

99. -The blink reflex appears at about 3 to 4 months. Present in about 50% at 5 months and 100% of children at 12 months.

100. It is important to try and ensure the child is relaxed when examining the eyes. Acuity cannot be formally quantified in the neonate or infant. However, gross abnormalities can be elicited by assessing the child’s ability to fix upon faces, lights or brightly- coloured objects (e.g. Does the baby recognise and follow mother’s face? Does the infant reach for small building bricks to play with?). The parents may report that the child does not seem to respond to them as expected, which may arouse suspicion. In a young child, acuity may be assessed by asking the child to count your fingers.

101. Visual acuity - Vision chart - In a younger child, offer toys of various sizes

102. Optokinetic nystagmus Rotate a striped drum or draw a strip of cloth with black and white squares in front of the eyes Optokinetic nystagmus can be elicited starting 4 to 6 months of age Confirms cortical vision Supports the integrity of the frontal/parietal lobes and visual fields.

103. Funduscopic exam for appearance of the optic disk, macula, and retina Important signs on fundoscopy . Cataract Glaucoma – increased corneal diameter, corneal clouding Retinoblastoma – leukocoria Retinal haemorrhage – may indicate traumatic birth or non-accidental injury Retinitis – may indicate congenital infection Pale disc – may indicate congenital optic neuropathy Papilloedema

104. III/IV/VI: Oculomotor Nerve, Trochlear Nerve, and Abducens Nerve To formally test for the integrity of these nerves and the associated muscles, assess for full range of motion in the horizontal and vertical directions. Testing the “diagonals” increases the sensitivity of noting any deficits, because the extraocular muscles do not attach to the globe at perfect right angles. If limited range of motion or disconjugate gaze is noted in any direction, each eye can then be evaluated separately in an attempt to determine which eye is the abnormal one. In older children, inquiring about diplopia is important, as patient self-reporting can be more sensitivethan directional testing.

105. In the neonate or young infant, try gaining the attention with a toy or large coloured object and move this through the vertical and horizontal axes once the child has fixed it in his gaze. In older children able to follow commands it should be possible to assess eye movements by stabilising the head with one hand while asking the child to follow your finger.

106. In newborns, using the “doll’s eye” reflex can be used to assess horizontal eye movements. To perform this test, also known as the oculocephalic reflex , the head is turned somewhat quickly but gently to one side. The movement should result in a temporary deviation of both eyes in a direction opposite to the direction of turning. The doll’s reflex is typically present as early as 25 weeks of gestation

107. The doll’s eye response can be elicited by slowly turning the head from left to right. In the normal case, the eyes will not move with the head, essentially moving in the opposite direction to head movement. Asymmetry of this movement implies a lesion of the oculomotor or abducens nerve.

108. Look carefully for paralysis of ocular movement or nystagmus . Jerk nystagmus (containing a slow and fast phase) suggests vestibular dysfunction, while a pendular nystagmus suggests disease of the cerebellum or retina.

109. Weakness of the superior oblique muscle or trochlear nerve will result in a compensatory head tilt in many children, in order to prevent the diplopia which results from the abnormal elevation ( hypertropia ) of the affected eye. The most common cause of trochlear nerve damage is head trauma.

110. Incomplete abduction of an eye is usually due to weakness of the lateral rectus which is innervated by the abducens nerve. One cause of abducens injury is increased intracranial pressure due to brain edema or hydrocephalus. Also, Duane syndrome is a form of congenital abducens nerve malfunction (occasionally also involving other cranial nerves),which limits eye mobility but is typically benign and does not result in overt visual deficits. Horner’s syndrome is a constellation of findings, which include miosis (pupillary constriction), ptosis , and anhidrosis on the same side of the face, and is frequently caused by disruption of sympathetic innervation which ascends along the carotid artery. However, Horner’s syndrome can also arise from a central brain or spinal disorder.

111. Parinaud syndrome results in an impairment of upward gaze, often accompanied by eyelid retraction and pupillary abnormalities. Parinaud syndrome is the result of a lesion or compression of the pretectal area in the dorsal midbrain, which is a common location for pediatric neoplasms . Other causes of this syndrome include obstructive hydrocephalus or direct injury due to ischemia or hemorrhage.

112. V: The Trigeminal Nerve Facial sensation in older children can be tested by applying a stimulus such as light touch to each division of the trigeminal nerve: the ophthalmic branch of the forehead, the maxillary branch(the cheek), and the mandibular branch (the chin).

113. In infants, tickling or stroking the face, for example, with a cotton swab on one side of the nose, cheek, or lip, should elicit a rooting-like motor response toward the side of the face that was stimulated. The trigeminal nerve can also be tested by eliciting the corneal reflex . A very light touch to the cornea, such as with a wisp of cotton, should trigger a bilateral blink reflex. The sensation is mediated by the ophthalmic branch, while the motor response arrives via the facial nerve.

114. In neonates the muscles of mastication can be tested indirectly by evaluation of sucking strength and control and more directly by allowin the infant to bite on your fingers.

115. VII: The Facial Nerve In cooperative children, facial nerve integrity can be demonstrated by noting strong eye closure, wrinkling of the eyebrows,smiling , and strong puffing out of the cheeks. The face at rest can also be examined to evaluate for any asymmetry such as widening of the palpebral fissure or fl attening of the nasolabial fold which might suggest weakness, keeping in mind of course that some slight asymmetries may be normal. In infants and neonates, evaluating for facial symmetry at rest and while crying or smiling is usually sufficient.

116. Taste in older children can be tested by using a concentrated solution of salt or sugar, placed on the tongue with a cotton swab, and should be reported before putting the tongue back in the mouth to avoid detection with cranialnerve IX. Testing taste is usually done in order to help determine if a facial nerve deficit is due to problems with the nerve (i.e., a “peripheral 7th”such as due to a Bell’s palsy, in which case taste will be impaired) from a “central 7th,” where taste would be expected to be preserved.

117. VIII: The Vestibulocochlear Nerve Finger rubs or whispers can test for hearing acuity. If a deficit is observed,use a tuning fork (256 Hz) to perform the Weber and Rinne tests. In the Weber test, the tuning fork is placed at the vertex of the head. The sound should appear to come from the midline if hearing in intact. However, if one ear is abnormal, the sound will lateralize to the side of decreased hearing in cases of conductive hearing loss (i.e., a problem with the outer ear, eardrum, or ossicles ) but will lateralize to the normal ear in cases of sensorineural hearing loss arising from damage to the cochlea or eighth nerve.

118. The Rinne test is performed by holding the base of the vibrating tuning fork against the mastoid process of the abnormal ear. When the subject no longer perceives sound, the vibrating end of the tuning fork is then placed just outside the ear canal. If the tuning fork can now be heard, this signifies a “positive test” and suggests sensorineural hearing loss. If the tuning fork cannot be heard after removing it from the mastoid, the test is negative an suggests a conductive hearing loss . Note that in normal ears without hearing loss, the normal result is “positive.”

119. Children begin to clearly localize sound at about 6 months. Use a noisy toy or loud voice while observing patient reaction to evaluate hearing. In younger infants and newborns, a startle response or eye blink to loud or sudden sounds can evaluate for basic hearing ability. This reflex is present as early as 28 weeks. Vestibular dysfunction can manifest with diverse symptoms such as vertigo, nystagmus , emesis, and ataxic movements.

120. IX and X: The Glossopharyngeal Nerve and Vagus Nerves The glossopharyngeal nerve and vagus nerves are often tested together. The glossopharyngeal nerve mediates taste and sensation to the pharynx , and the vagus nerve is responsible for many functions, among which is pharyngeal constriction ,palate elevation, and vocal cord movement. Symmetric palate elevation while saying “ ahh ” tests the integrity of the vagus nerve, while the gag reflex tests both the sensory function of the glossopharyngeal nerve and motor aspects of the vagus.

121. Cranial nerves IX and X are commonly assessed together as between them they mediate sucking and swallowing. Look at the position of the palate and uvula when the child is crying, or is otherwise open-mouthed. A unilateral droop of the palate or deviation of the uvula suggests a lesion of the vagus nerve. The uvula deviates away from the side of the lesion. Gently insert a finger into the neonate’s mouth. If cranial nerve IX (sensory) is intact the child should respond by trying to suck your finger.

122. Normal swallowing suggests that these nerves are intact, as they must work together for the proper coordination needed to swallow. It is also useful to ask the parents if there have been any difficulties with feeding as this may indicate an underlying cranial nerve lesion.

123. XI: The Spinal Accessory Nerve Difficult to assess directly in young children, although it will be possible to gain a general impression of the function of the muscles innervated by the accessory nerve (primarily the sternomastoid and trapezius ) by observation of the child and by the response to other parts of the examination. Inability to turn the head will be detected when eliciting the rooting response (trigeminal nerve).

124. In newborns, observe for proper neck strength with turning of the head. Isolated spinal accessory nerve lesions are rare, however, and routine testing in infants is rarely helpful unless there are other neurologic signs.

125. Hypoglossal (CN XII) Hypoglossal innervates the muscles of the tongue. Lesion of this nerve will contribute to dysfunction of sucking and swallowing. Again, it is important to establish if there have been any difficulties with feeding. If possible, observe the tongue for wasting, fasciculation or abnormalities of movement, which are indicative of a hypoglossal lesion. In the presence of a lesion , the tongue deviates to the side of the lesion on protrusion.

126. Tongue strength can also be tested by asking the child to move the tongue from side to side and also to push against the interior of the cheek with resistance applied from the outside the mouth. In any case of suspected nerve or muscle disease, or in infants with generalized weakness (e.g., in suspected spinal muscular atrophy), the tongue should be examined at rest while in the mouth for fasciculations. Tongue fasciculation can be an early indicator of neuromuscular disease. Be careful, however, as a protruding tongue will often have a normal tremor or movement that can be mistaken for fasciculations. In newborns the sucking reflex can be utilized to evaluate lingual tone and strength.

127. Balance / equilibrium Equilibrium responses occurs between 5 months and 21 months of age. The equilibrium reactions reach full maturity by approximately 4 years and persist for life. Equipment : assessed by – therapy ball - tilt board - scooter board - other moveable surface All this according to child’s body size. Balance check in – prone , supine , sitting , crawling standing

128. 1) equilibrium in prone / supine: Position : child in prone / prone with head in midline. Response : - lateral tilt to the right / left limbs on the upward side extension and abduction Concavity of spine towards the upside. - anterior tilt : all limbs extended and abducted concavity of spine posteriorly - posterior tilt : limbs extended and abducted concavity of spine anteriorly . 2 ) equilibrium in sitting : same response as supine and prone Rotation of the spine away from the wt shift. 3 ) equilibrium in Standing

129. Balance Functional reach test Pediatric berg balance scale

130. Indirectly , coordination of large muscles is considered in terms of whether the patient can walk and run normally , Go up and down stairs , Ride a tricycle or bicycle , Can stand in one leg , Can kick a moving / stationary ball, Can move in backward space.

131. Visual system tactile system Auditory system Vestibulo-proprioceptive system

132. Touch High sensitivity Avoids messy play Dislikes tags or certain fabrics Dislikes grooming Low sensitivity Hands are on everything

133. Auditory High sensitivity Distractible Covers ears Overwhelmed by loud noise Low sensitivity Not listening Slow to respond Turns the volume up too loud

134. Visual High sensitivity Squints Distractible Avoids eye contact Loses track on page, and lining up problems Leads to poor math and reading skills Low sensitivity Appears not to notice environment

135. Oral Smell / Taste High sensitivity Picky eater Gags easily Dislikes textures Low sensitivity Mouths items Over stuffs mouth Does not distinguish tastes or smells

136. Vestibular Balance / Motion High sensitivity Car sick Gravitational insecurity Fearful of heights at playground Sedentary Low sensitivity Fidgety On the go Constantly in motion

137. Proprioception Body Position High sensitivity (almost never) Low sensitivity Clumsy Bumps and pushes Poor posture Too much or too little pressure

138. Sensory Processing Disorder also affects Sensory Processing Disorder also affects Social skills Poor play skills Misread social cues Emotionally reactive Isolation Specific motor skills Academics Handwriting

139. Motor Planning Clumsy or uncoordinated Misses developmental milestones Appears to be “ Lazy”

140. Functional assessment Wee FIM PEDI