Paediatric Neurological Examination

1/13/2020 Paediatric Neurological Examination - OSCE Guide | Geeky Medics
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PAEDIATRIC NEUROLOGICAL EXAMINATION – OSCE GUIDE
Thom Finnerty · Clinical Examination · January 1, 2020
Paediatric Neurological Examination – OSCE Guide
Table of Contents 
Examining the neurological system is different in young children compared with older
children and adults. The components of the complete exam are extensive and usually
cannot be performed in a classical fashion. This approach may be carried out on a
cooperative school-aged child – but always be mindful of keeping the examination fun.
Observation is key. Make the most of every opportunity to examine the child. See how they
play, taking into account handedness and motor de cits. These observations, especially in
younger children, will ultimately give you the best insight into their daily functioning and
paint a broad picture of their neurological function.
Tips include:
Using items such as a tennis ball, small toys (including a toy car), bells, bubbles and an
object that will attract the child’s attention (like a pinwheel).
Be mindful to postpone uncomfortable tasks until the end, such as head circumference,
fundoscopy and sensory testing.
You can access the Paediatric Neurological Examination OSCE Mark Scheme here.
https://geekymedics.com/paediatric-neurological-examination-osce-guide/ 14/40
Introduction
Wash your hands

Introduce yourself to both the parents and the child
Explain what the neurological examination will involve
Gain consent from the parents/carers and/or child before proceeding.
 Today I’d like to perform a neurological examination, which

will involve me testing the nerves that supply di erent
parts of the body.
 Are you happy for me to carry out the examination?
General Inspection
With toddlers – the initial phase of observation is best done with the child in the parent’s
lap. Through minimising apprehension, assessment of higher cortical function, muscle tone
and tendon re exes becomes easier.
Higher cortical functions
Observe the child during play:
A ention span
Gross and ne motor coordination
Problem-solving abilities
Observe for age-appropriate milestones (see our guide on Developmental Milestones)
General inspection 1
Cranial Nerves
Testing in infants is often by observation for speci c movements and responses, which is
ultimately less reliable. In older children, it may be possible to formally assess at least
some cranial nerves, however, this very much depends on the exact age of the child, their
current state and the environment. We have provided a guide to each of the cranial nerves
below, however, it is unlikely you will be able to carry out a complete neurological
assessment in one sitting with most children.
Olfactory nerve (I)
The olfactory nerve is responsible for the sense of smell.
Assessment
Test the ability to detect a smell with eyes closed (i.e. chocolate).
This is not checked in small children or infants.
Olfaction can be impaired after closed head injury and in infants with arhinencephaly-
holoprosencephaly.
Optic Nerve (II)
The optic nerve is responsible for vision and afferent pupillary light re exes
Testing visual acuity
Infant – observe the infant reach for objects of varying size

>6 months old – observe reaching for scraps of paper less than 5mm in size when
placed on a dark background
Older children – standard recognition of letters, numbers or shapes on a Snellen chart
(see our guide to visual assessment)
Visual elds
Introduce objects into the peripheral eld of vision as the child focuses on an object
held directly in front of them.
Note if the child becomes aware of the peripheral object (e.g. turning head towards it).
Pupillary re exes
To best see pupillary re exes the room should be dimly lit.
Direct pupillary re ex (afferent CN II, efferent CN III):
Shine a light into the pupil and observe constriction of that pupil.
Sluggish reaction or lack of constriction may suggest pathology (optic nerve, brainstem,
drugs)
Consensual pupillary re ex:
Again shine a light into the pupil, but this time observe the contralateral pupil.
A normal consensual response involves the contralateral pupil constricting.
Lack of a normal consensual response may suggest damage to one/ both optic nerves or
damage to the Edinger-Westphal nucleus
Fundoscopy
Often dif cult, requiring patience. If in doubt, it is often best to arrange for a specialist to
do this examination using equipment designed speci cally for children.
Assess for red re ex:
Position yourself at a distance of around 30cm from the child’s eyes.
Looking through the ophthalmoscope and ensure the light is directed into the pupil.
Observe for a reddish/orange re ection in the pupil.
An absent red re ex may indicate the presence of cataract, or in rare circumstances
neuroblastoma.
Move in closer and examine the eye with the ophthalmoscope::
1. Move in closer whilst maintaining the red re ex and examine the retina with the
ophthalmoscope. You may need to change the focus wheel to account for the difference in
glasses prescription between the child and yourself. Approach from an angle slightly
temporal to the child.
2. Begin by identifying a blood vessel and then follow the branching of this blood vessel
towards the optic disc (the branches point like arrows towards the optic disc).
3. Assess the optic disc (colour/margin/cupping).
4. Assess the retinal vessels for pathology (e.g. arteriovenous

nipping/neovascularization/haemorrhages).
5. Finally, assess the macula by asking the patient to look directly into the light:
Drusen are typically noted in macular degeneration

A cherry-red spot is typically noted in central retinal artery occlusion
Oculomotor, Trochlear & Abducens nerves (III, IV, VI)
Functions of CNII, CNIV and CNVI
III: Eyelid elevation, eye elevation, ADduction, depression in ABduction, efferent to pupil
IV: Depression in ADduction
VI: Eye abduction
Inspect for ptosis
Look for evidence of eyelid asymmetry suggestive of ptosis

Causes include sympathetic paralysis from lesions of cranial nerve III, Horner’s
syndrome, myopathies, myasthenia gravis and structural eye lesions (e.g. neuro broma).
Assess extraocular eye movements
Test horizontal, vertical and oblique planes of eye movement (drawing an imaginary “H”
and asking the child to “follow my nger” achieves this)
Tested by assessing the child’s ability to track brightly coloured soft toy or soft light
Abnormal eye movement ndings:
Down and out – paralysis of the inferior oblique muscle (III)

Laterally – paralysis of medial rectus (III)
Upwards – paralysis of inferior rectus (III)
Down and inwards – paralysis of superior rectus (III)
Upwards and out – paralysis of superior oblique (IV)
Inwards – paralysis of lateral rectus (VI)
Opsoclonus: Occult neuroblastoma – chaotic bursts of eye movements, often associated
with myoclonus
Up gaze paresis: Parinaud syndrome
Impaired down gaze: Niemann Pick Type C disease
Oculomotor apraxia: Delayed initiation of eye movement and jerky pursuit movements.
Seen in Joubert syndrome or oculomotor apraxia-ataxia syndrome.
Trigeminal nerve (V)
The trigeminal nerve provides facial and corneal sensation, in addition to motor
innervation to the muscles of mastication.
Assess sensory function
Assess response to light touch over the 3 divisions of the face using a piece of cotton
wool
In a baby, the presence of the rooting re ex con rms intact facial sensation
Assess the corneal re ex (afferent V, efferent VII) – this is rarely performed in practice
Assess motor function
Ask the child to open their mouth against resistance

Jaw jerk re ex (tests sensory and motor function) – rarely performed
Facial nerve (VII)
The facial nerve provides motor innervation to the muscles of facial expression and is
also involved in taste sensation.
Inspection
Inspect the child’s face for asymmetry

Compare the nasolabial folds to identify subtle asymmetry
Assess motor function
It is dif cult to formally assess the power of the facial muscles, particularly in children.
Instead, observe their facial expressions for any asymmetry (e.g. when smiling, crying
etc)
In older children, you may be able to ask them to copy your facial expressions (e.g.
blowing out your cheeks, showing teeth, screwing up eyes, wrinkling forehead)
Vestibulocochlear nerve (VII)
The vestibulocochlear nerve is responsible for balance and hearing.
Assessment
Infants: Make a soft sound close to the ear (i.e. rustling of paper). The child should show
an ‘alerting response’.
>5-6 months: Localise the sound to a speci c quadrant.
School-age children: Softly whispering a number approximately 30 cm from the ear.
Rinne and Weber’s can also be used.
Vestibular function: Poor head control, truncal unsteadiness, gait ataxia, nausea,
vomiting and horizontal nystagmus may indicate vestibular system dysfunction.
See our guide to hearing assessment for more details
Glossopharyngeal, Vagus nerve (IX, X)
The glossopharyngeal (IX) and vagus (X) nerves have various functions including:
IX: Sensation from soft palate, taste bres

X: Palatal movement, vocal cords, cough
Assessment
Observe the child swallowing:
Observe the child drinking or eating

Dysfunction swallowing may present with salivary drooling, pooling of saliva and
coughing during feeding
Observe the movement of the so palate:
Observe the uvula and ask the child to say “AAH” (if possible)
Unilateral CNX lesions result in deviation of the uvula to the side contralateral to the
lesion
Listen to the child’s voice:
Hoarseness may be due to unilateral dysfunction of the recurrent laryngeal nerve (X)
Bilateral dysfunction results in a bovine cough
Gag re ex
Assesses both the afferent pathway of CN IX and efferent pathway of CN X

Be aware of this test, however, it is rarely performed in practice
Accessory nerve (XI)
The accessory nerve provides motor innervation to the trapezius and sternocleidomastoid
muscles, which assist with head-turning and shoulder shrugging.
Assessment
Test elevation of shoulders:
If the child is old enough, ask them to scrunch their shoulders up towards their ears
(demonstrate for them)
Test turning the neck against resistance:
If the child is old enough, ask them to look over their shoulder whilst you observe the
sternocleidomastoid muscle
Small child: When supine, gently push the head laterally while supporting the shoulder.
Hypoglossal nerve (XII)
The hypoglossal nerve is responsible for the movement of the tongue.
Assessment
Inspect the tongue when inside the mouth for fasciculations

Ask the child to stick out their tongue – unilateral lesion results in deviation of the
tongue to the affected side
Check whether the tongue can be equally protruded on both sides
Upper and Lower Limb Examination
This portion of the examination requires an assessment of muscle tone, strength, re exes
and sensation of the upper and lower limbs.
Upper motor neuron (UMN) lesions
Lesions result in loss of muscle strength and dexterity distal to the injury, hypertonia and
hyperre exia.
Due to the corticospinal tract crossing at the pyramidal decussation, UMN lesions will
present with contralateral de cits for lesions above the pyramids and ipsilateral defects
for lesions of the spinal cord.
Spinal cord lesions will also present with LMN ndings at the level of the injury due to
damage to the ventral root or ventral nerve at that level.
Lower motor neuron (LMN) lesions
Lesions result in muscle fasciculations and atrophy, loss of strength, decreased tone and
absent deep tendon re exes.
Inspection
Begin by inspecting the limbs for symmetry, muscle bulk and posture.
Look for any evidence of abnormalities:
Asymmetry at rest in infants – may suggest hemiparesis

Opisthotonus – persistent arching of the neck and trunk due to bilateral cerebral
cortical dysfunction
Abducted hips or ‘frog-legged’ posture – hypotonia
Making a st with the hand or holding the thumb adducted across the palm during quiet
wakefulness – suggesting corticospinal tract involvement
Tremor – rhythmic, ne amplitude exion-extension movements of the distal extremity
Myoclonus – quick, non-stereotyped jerks around a segment of the body
Athetosis – slow, sinuous movement of the distal extremity with pronation of the distal
extremity
Chorea – rapid, quasi-purposive, non-stereotyped movements of a segment of the body
that is generally proximal
Tics – highly stereotyped and repetitive movements
Muscle atrophy – may be segmental or generalised – neuropathy, myopathy or disuse
Pseudohypertrophy – bulky appearance of muscle with associated weakness

Fasciculations – ripple-like movements of the muscles that accompany degeneration of
anterior horn cells
Stereotyped hand wringing movements and bruxism – may be seen in Rett syndrome
Muscle tone
Muscle tone is assessed by passively taking the limb through a range of motion –
including the shoulder, elbow and wrist bilaterally in the upper limb and the hip, knee and
ankle bilaterally in the lower limb.
Spasticity
Felt as an increase in tone varying with the force applied and the velocity of movement
Often considered ‘clasp knife’ and tends to accompany pyramidal tract lesions
Rigidity
Increased tone that does not vary with velocity or position

Suggests an extrapyramidal lesion
Clonus
Position the child’s leg so that the knee and ankle are slightly exed, supporting the leg
with your hand under their knee, so they can relax.
Rapidly dorsi ex and partially evert the foot
Keep the foot in this position
Clonus is felt as rhythmical beats of dorsi exion/plantar exion (>5 is abnormal)
Sustained clonus is abnormal at all ages
Power
Much of this assessment may not be possible in the majority of young children, however,
we have provided it for older children who are capable of following instructions.
The assessment of muscle power in young children is less formal and involves comparing
the strength of their natural movements between sides.
The MRC scale for muscle power is used to formally score the strength of particular
muscle groups, however, it is less useful in the context of young children and therefore we
have not included details.
Upper limb power
Assess power one side at a time and compare like for like.

Remember to stabilise and isolate the joint when testing.
The following are a test of some of the main movements of the upper limbs, suf cient
to show most pathology.
Shoulders:
ABduction (C5) – “Don’t let me push your shoulders down”

ADduction (C6/7)– “Don’t let me pull your arms away from your sides”
Elbow:
Flexion(C5/6) – “Don’t let me pull your arm away from you”

Extension(C7) – “Don’t let me push your arm towards you”
Wrist:
Extension (C6) – “Cock your wrists back and don’t let me pull them down”
Flexion (C6/7) – “Point your wrists downwards and don’t let me pull them up”
Fingers:
Finger extension (C7) – “Put your ngers out straight and don’t let me push them down”
Finger ABduction (T1) – “Splay your ngers and don’t let me push them together”
Thumb ABduction (C8/T1) – “Point your thumbs to the ceiling and don’t let me push
them down”
Lower limb power
Assess one side at a time and compare like for like.

Remember to stabilise the joint whilst testing power.
Hip:
Flexion (L1/2) – “raise your leg off the bed and stop me from pushing it down”
Extension (L5/S1) – “stop me from lifting your leg off the bed”
ABduction (L4/5) – “push your legs out”
ADduction (L2/3) – “squeeze your legs in”
Knee:
Flexion (S1) – “bend your knee and stop me from straightening it”

Extension (L3/4) – “kick out your leg”
Ankle:
Dorsi exion (L4) – “keep your legs at on the bed…cock your foot up towards your
face…don’t let me push it down “
Plantar exion (S1/2) – “push down like on a pedal”
Inversion (L4) – “push your foot in against my hand”
Eversion (L5/S1) – “push your foot out against my hand”
Big toe:
Extension(L5) – “don’t let me push your big toe down”
Re exes
Upper limb re exes
For each of the re exes, ensure the child’s upper limb is completely relaxed
Hold the tendon hammer at the end of the handle and allow gravity to aid a good swing
onto your nger.
If a re ex appears absent: make sure the child is fully relaxed and then perform a
reinforcement manoeuvre – ask the child to clench their teeth together, whilst you hit the
tendon.
1. Biceps re ex (C5/6) – located in the antecubital fossa
2. Triceps re ex (C7) – place forearm rested at 90º exion – tap your nger overlying the
triceps tendon
3. Supinator re ex (C6) – located 4 inches proximal to the base of the thumb
Lower limb re exes
1. Knee jerk (L3/4)
2. Ankle jerk (L5/S1)
3. Plantar re ex (S1):
Run a blunt object along the lateral edge of the sole of the foot, moving towards the
little toe, then medially under the toes
Observe the great toe
Normal result = Flexion of the great toe and exion of the other toes
Abnormal (Babinski sign) = Extension of the great toe and spread of the other toes –
upper motor neuron lesion
Sensation
Sensory information is carried by 2 major pathways and should be tested systematically

through examining Touch, Pain, Temperature, Vibration and Proprioception in the upper
limb and lower limb.
It’s easy to get bogged down in examining sensation. Check at least one modality each
from the dorsal columns and spinothalamic tracts. Demonstrate normal sensation on the
child’s sternum and ask them if it feels the same on the limb.
Much of the detailed assessment below is not possible in younger children and therefore
gross assessment of sensation should be adopted.
Light touch sensation
Light touch sensation assesses the dorsal/posterior columns and spinothalamic tracts.
1. Touch the child’s sternum with the wisp of cotton wool to con rm they can feel it
2. Ask the child to say yes when they are touched
3. Using the wisp of cotton wool, gently touch the skin
4. Assess each of the dermatomes of the upper and lower limbs
5. Compare left to right, by asking the child if it feels the same on both sides
Pin-prick sensation
Pink-prick sensation assesses the spinothalamic tracts.
Repeat the previous assessment steps, but this time using the sharp end of a neuro-tip.
If loss of sensation is noted distally, test for “glove” distribution of sensory loss
(peripheral neuropathy) by moving distal to proximal.
Vibration sensation
Vibration sensation assesses the dorsal/posterior columns.
1. Ask the child to close their eyes
2. Tap a 128 Hz tuning fork
3. Place onto the child’s sternum and con rm they can feel it buzzing
4. Place onto the distal interphalangeal joint of the fore nger/distal phalanx of the great
toe and ask them if they can feel it buzzing
5. If vibration sensation is impaired, continue to assess the bony prominence of more
proximal joints (interphalangeal joint of thumb → carpometacarpal joint of
thumb → elbow → shoulder)
Proprioception
Proprioception assesses the dorsal/posterior columns.
1. Hold the distal phalanx of the thumb/great toe by its sides
2. Demonstrate movement of the thumb/great toe “upwards” and “downwards” to the

child (whilst they watch)
3. Then ask the child to close their eyes and state if you are moving the thumb/great toe
up or down
4. If the child is unable to correctly identify the direction of movement, move to a more
proximal joint ( nger > wrist > elbow > shoulder)
Dermatome map
Gait
Observe the child walking (if able) – posture, arm swing, stride length, speed, symmetry,
balance and abnormal movements
Some common types of gait abnormality to observe for:
Ataxic: broad-based and unsteady. As if drunk. From cerebellar pathology or sensory

ataxia. Often won’t be able to tandem gait either. With sensory ataxia, the child will
watch their feet intently to compensate for proprioceptive loss. In a cerebellar lesion,
they may veer to one side.
High-stepping: (either unilateral or bilateral) caused by foot drop (weakness of ankle
dorsi exion). Also won’t be able to walk on their heel(s).
Waddling gait: shoulders sway from side to side, legs lifted off ground with the aid of
tilting the trunk. Caused by proximal lower limb weakness (e.g. myopathy).
Hemiparetic: one leg held stif y and swings round in an arc with each stride
(circumduction).
Spastic paraparesis: similar to above but bilateral – both are stiff and circumducting.
Feet may be inverted and “scissor”.
Cerebellar Examination
Cerebellar function should be assessed as part of a complete neurological examination.
If the child is unable to follow instructions – noting how a child reaches for and
manipulates toys can be used as a crude assessment of coordination.
See our Cerebellar Examination guide for more information (adapting it as appropriate to
the age of the child).
Neurological Examination of the Infant and Primitive

Re exes
See our guide to the Newborn Infant Physical Examination (NIPE), which covers basic
neurological assessment of the infant, including primitive re exes.
Cognitive Assessment
Younger children
Has the child met appropriate developmental milestones?

Careful questioning of parents – a history of loss or plateauing of developmental
milestones is a red ag that should be investigated in greater detail.
See our Developmental Milestones guide.
Children aged >7 years:
The mini-mental state examination (MMSE) may be used, with modi cations available
for children of different ages/stages (e.g. MMSPE for preschool-aged children).
To Complete the Examination…
Ensure the child is re-dressed after the examination

Thank the child and/or parents
Explain your ndings to the parents and/or child
Ask if the parents and/or child have any questions
Wash your hands
Further clinical assessments to consider
Skin assessment – both the skin and the nervous system develop from ectoderm during
embryogenesis, so dermatological ndings can sometimes relate to underlying
neurological disease (e.g. Café au lait spots in neuro bromatosis and Ash-leaf spots in
tuberous sclerosis)
Assessment of the back – scoliosis or a patch of hair which may indicate an undetected
vertebral anomaly (e.g. spina bi da)
Cardiovascular examination – important if considering causes of loss of consciousness
or a thromboembolic source of stroke
Abdominal examination – important if considering metabolic diseases (e.g. hepatomegaly
in glycogen storage disorders)
Further investigations
Record a full set of vital signs

Plot the height and weight on a growth chart
Blood tests – FBC, U&Es, CRP, Autoantibodies
Lumbar puncture (e.g. meningitis, encephalitis)
Neuroimaging (CT/MRI)
EEG (seizures)
Nerve conduction studies

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1/13/2020 Paediatric Neurological Examination - OSCE Guide | Geeky Medics

Thom Finnerty · Clinical Examination · January 1, 2020

Paediatric Neurological Examination – OSCE Guide

Wash your hands

 Today I’d like to perform a neurological examination, which

 Are you happy for me to carry out the examination?

Higher cortical functions

Observe the child during play:

Observe for age-appropriate milestones (see our guide on Developmental Milestones)

Olfactory nerve (I)

The olfactory nerve is responsible for the sense of smell.

Optic Nerve (II)

Testing visual acuity

Infant – observe the infant reach for objects of varying size

To best see pupillary re exes the room should be dimly lit.

Direct pupillary re ex (afferent CN II, efferent CN III):

Consensual pupillary re ex:

Assess for red re ex:

Position yourself at a distance of around 30cm from the child’s eyes.

Move in closer and examine the eye with the ophthalmoscope::

3. Assess the optic disc (colour/margin/cupping).

4. Assess the retinal vessels for pathology (e.g. arteriovenous

Drusen are typically noted in macular degeneration

Oculomotor, Trochlear & Abducens nerves (III, IV, VI)

Functions of CNII, CNIV and CNVI

Inspect for ptosis

Look for evidence of eyelid asymmetry suggestive of ptosis

Assess extraocular eye movements

Abnormal eye movement ndings:

Down and out – paralysis of the inferior oblique muscle (III)

Trigeminal nerve (V)

Assess sensory function

Assess motor function

Ask the child to open their mouth against resistance

Facial nerve (VII)

Inspect the child’s face for asymmetry

Assess motor function

Vestibulocochlear nerve (VII)

The vestibulocochlear nerve is responsible for balance and hearing.

Glossopharyngeal, Vagus nerve (IX, X)

IX: Sensation from soft palate, taste bres

Observe the child swallowing:

Observe the child drinking or eating

Observe the movement of the so palate:

Listen to the child’s voice:

Assesses both the afferent pathway of CN IX and efferent pathway of CN X

Accessory nerve (XI)

Test elevation of shoulders:

Test turning the neck against resistance:

Hypoglossal nerve (XII)

The hypoglossal nerve is responsible for the movement of the tongue.

Inspect the tongue when inside the mouth for fasciculations

Upper and Lower Limb Examination

Upper motor neuron (UMN) lesions

Lower motor neuron (LMN) lesions

Look for any evidence of abnormalities:

Asymmetry at rest in infants – may suggest hemiparesis

Pseudohypertrophy – bulky appearance of muscle with associated weakness

Increased tone that does not vary with velocity or position

Upper limb power

Assess power one side at a time and compare like for like.

ABduction (C5) – “Don’t let me push your shoulders down”

Flexion(C5/6) – “Don’t let me pull your arm away from you”

Lower limb power