MINISTRY OF HEALTH OF UKRAINE

Ukrainian Medical Stomatological Academy

”Approved”
at the meeting of the Department of Pediatrics №1
with Propaedeutics and Neonatology
“ ___” ___________ 20__ year
Protocol No._____ from________
Chief of the department, assoc. prof.
______________ S.M. Tsvirenko

Methodical instructions for independent work of

students during preparation to practical (seminar) сlasses
and on the classes

Discipline Propedeutics of Pediatrics

Module № 2 Anatomical and physiological features,
methods of examination and semiotics of
diseases in children
Topic of the class Anatomical and physiological features of the
nervous system in children. Violation of
embryogenesis as the basis of congenital
anomalies of the nervous system. Methodology
of clinical neurological examination of children.
Course ІІІ
Faculty Foreign students training faculty

Poltava- 2019
 I. Relevance of the topic. Knowledge of anatomical and physiological
characteristics of the nervous system in children is important for understanding the
changes that may cause pathology of the development of the nervous system in
children. The ability to provide correct neurological examination in children
condition will allow the student to detect symptoms and syndromes of the nervous
system violation that will facilitate early detection of the disease and further
establishing the correct diagnosis.

II. The training aims of the classes: to master the knowledge of

embryogenesis and morphological and functional peculiarities of nervous system in
children. Summary of embryogenesis of the nervous system as the basis of
congenital anomalies. The embryogenesis of nervous system and congenital
anomalies of the nervous system.
III. 1. Student has to know:
 The main principles the nervous system embryogenesis.
 Morphological and functional peculiarities of nervous system in children.
 The congenital anomalies of the nervous system.
 Methods of physical examination, inspection, palpation of the nervous system
in children of different ages.
2. Student has to be able:
 To use the knowledge about of embryogenesis and morphological and
functional peculiarities of nervous system in children.
 To interrogate of the sick children in different age periods and their parents.
 To use the knowledge about morphological and functional peculiarities of the
nervous system in children.
 To collect anamnesis for a patient with diseases of the nervous system.
 To conduct an objective examination of the nervous system taking into
account the child's age characteristics.

III. Interdisciplinary integration processes:

Disciplines To know To be able

1. Previous disciplines  The main  Students should be able to
- Medical ethics and principles of use the main principles of
 deontology Medical etiquettes Medical etiquettes and
and deontology deontology
- Human Anatomy
 The main rules of  Students should be able to
- Medical Histology communication use the knowledge about
between the doctor the anatomical structure
and patient, doctor of the nervous system
and parents  Students should be able to
 Anatomical use the knowledge about
structure of the the histological structure
nervous system of the nervous system
 Histological
structure of the
nervous system
 Students should be able to
interrogate of the children
in different age periods
 The main rules of
and their parents
communication
 Students should be able to
between the doctor
use the knowledge about
2. Following disciplines and patient, doctor
embryogenesis and
- Pediatrics; and parents
morpho-functional
 The
- Children's surgery; peculiarities of the
embryogenesis and
- Children's inflection nervous system in
morpho-functional
children
diseases peculiarities of
 Students should be able to
nervous system in
use examination,
children
palpation and percussion
of the healthy and sick
children of different age
periods

V. The content of the topic

Anatomic-and-physiological peculiarities of nervous system in children
- Rather big sizes of a brain (1/8 weight of body, in adult - 1/40)
- Jellies consistence of brain, high contents of water, low contents of
protein and lipid
- Underdevelopment of sulci and convolutions of brain till 7 years old
- Poor differentiation between gray and white matter
- Big nucleus of nerve cells, absence of dendrites and also functionally
underdevelopment
- Myelination of nerve fibers is not finished; therefore speed of nerve
impulse is low. Myelination of intracranial nerves comes to end by 3-4 months, of
pyramid ways by 2-3 years, of vagus nerve - by 3-4 years
- High permeability of blood-brain barrier
- The spinal cord in newborns is relatively long, ends at level of 2-3
lumbar vertebra, in adult at level of L1-2 that it is necessary to take into account at
lumbal puncture
- Myelination of peripheral nervous system does not finish
- It is observed sympathicotonia in children of early age, in 3-4 years -
vagotonia, then balance establishes
Anatomical and physiological features of the nervous system in children of early
age
Brain:
 pyramid cells do not have a peculiar form; they do not have pigment;
 underdevelopment of dendrites in nerve cells;
 the centers of the cortex are not formed; the cortex acquires adult type of
cytoarchitectonics in 1-2 years old children;
 in newborn hemisphere is poorly developed, only the main furrows are formed,
which have a small height and depth; temporal development is better
developed at birth;
 brain tissue is rich in water;
 the gray and white matter are poorly differentiated.
Spinal cord:
 is more mature than the brain, with age only the number of nerve cells
increases;
 relatively longer;
 does not have physiological thickenings;
 completely fills the dorsal canal until the 5th month of fetal development.
Peripheral nerves:
 myelination of fibers does not complete (first afferent fibers are myelinated,
then efferent)
  intracranial nerves are myelinated to 3 months of age;
 peripheral nerves are myelinated up to 3 years of age, vagus nerve - up to 4-7
years.
Analyzers:
 visual - up to 2-3 months of age observed physiological photophobia,
physiological nystagmus, physiological hyperopia, good accommodation from
6 months of age, the child distinguishes colors well;
 auditory - the perception of sounds in the newborns is reduced, since the drum
cavity is filled with air; From 2 months of age the child differentiates sounds;
From 7-8 months of life coordination of auditory and visual analyzers takes
place;
 olfactory - in newborns the of sensitivity is reduced, they perceive only strong
smells; From the 4th month the child differentiates several smells;
 test sensation - in newborns the receptor field is wider and above the threshold
of sensitivity; From 3 months of life the child differentiates several taste
sensations; delicate taste sensation is improved at the young school age.
Sensitivity:
 tactile - determined from the 7th month of the fetal period, better developed on
the face, soles, hands;
 temperature - the high threshold of sensitivity, the child perceives cold better;
 painful - poorly developed, formed until the 6th day after birth, has high
threshold;
 deep (vibrational, muscular-articular sensitivity, feeling of pressure, weight) -
is formed up to 2 years of life.
Vegetative nervous system:
 both departments have been functioning since birth sympathicotonia in
early age, balance from 4 years;
 norepinephrine predominates in the blood of newborns;
  with age there is a transition from generalized vegetative reactions to local,
specialized reactions;
Spinal cord fluid:
 color and transparency - colorless, transparent, up to the 14th day of life
xanthromia, transparent;
 protein - in newborns 0,33-0,8 g / l, from 14 days to 3 months 0,2-0,5 g / l;
in 6 months - 0,18-0,33 g / l;
 cytosis in 1 μl - in newborns 3/3 - 30/3, predominantly represented by
lymphocytes, single neutrophils may be present; older than 6 months - 3/3 -
20/3, predominantly lymphocytes;
 Pandy test - up to 14 days of life from + to ++, after 6 months (-);
 sugar - in newborn 1.7 - 3.9 mmol / l, older than 6 months - 2.2-4.4 mmol/l.
Unconditioned reflexes of newborn:
1. oral segmental automatism: sucking, search (Kussmaul), trunk, Babkin (palm-
mouth)
2. spinal segmental automatisms: grappling (Robinson), Moro (covering), support,
automatic step, crawling (Bauer), Galant, Perez;
3. myeloencephalic posotonic reflexes: labyrinthine tonic, symmetrical cervical
tonic, asymmetric cervical tonic;
4. mesencephalic constitutional automatism: labyrinthine adjusting reflex, simple
cervical and trunk adjusting reflexes.
Objective examination of nervous system
1. Inspection. Pay attention at the form of a head and the sizes of a skull, a
condition of seams and fontanels, presence of stigma of dysembriogenes. Many
violations of nervous system define position of the patient in bed - forsed or passive.
Pathological positions:
- Opisthotonus - characteristic for tetanus
- The position of « gun dog » - on one side with drawn to stomach legs and the
thrown back head, - is characteristic for meningitis
2. It is necessary to estimate behavior of the child, correspondence to age his
psychological development.
3. The consciousness of the child can be clear or broken: stupor, sopor, coma
4. Muscular tone. Attributes of the raised muscular tone are adjusting positions
of hands, opisthotonus. Indirect attributes of muscular hypotonia are faults in posture,
expressed lordosis and kyphosis, protruding stomach.
In infants test on traction carries out. Child lies on a back. Doctor pulls up him
for hands. In the beginning child straights his hands, and then bends them. In
muscular hypertonia there is no first phase, in hypotonia - there is no the second
phase.
5. Research of function of craniocereberal nerves. It is necessary to define
fields of vision, volume of movement of eyeballs, convergence, divergence, reaction
of pupils on light, vision, color sensitivity, hearing, taste, sense of smell
6. Research of tactile, pain, temperature sensitivity
7. Research superficial (abdominal, cremaster, plantar) and tendon reflexes
(knee, Achilles, biceps, triceps-reflexes)
8. Coordinators tests: stability in Romberg’s position, finger-nose, knee-heel
tests
9. Condition of vegetative nervous system: demographics
10. Pathological reflexes: symptoms of latent spasmophylia, meningeal signs.

Symptoms of latent spasmophylia

- Chvostek’s symptom - spasm of mimic muscles of the face at percussion in
points of output of trigeminal nerve
- Trousseau’s symptom - spasm of muscles of hand (a hand of obstetrician) at
squeezing of neurovascular bundle in the field of humerus
- Lust’s symptom - spasm of muscles of foot (back assignment) at squeezing of a
shin
Meningeal symptoms. Child is laying on a back
- rigidity of occipital muscles - at passive bending of a neck the child fills pain
- Top Brudzinski’s symptom - similar actions lead to bending of the lower
extremities in knee and hip joints
- Medial Brudzinski’s symptom - bending of legs in knee and hip joints at
pressing on pubic area
- Lower Brudzinski’s symptom - at lifting one leg another has bent
- Kerning’s symptom - impossibility of unbending in a knee joint of the bent in
hip joint leg (check up simultaneously with lower Brudzinski’s symptom)
11. Studying unconditioned reflexes of newborn: sucking, swallowing, trunk,
corneal, conjunctive, search, grasp and tonic reflex of hands, reflex of crawling,
support, automatic walking, Moro’s, Gallant’s and Peres’.
VI. The materials of methodical provision of class
1. Materials for self-control for the preparatory stage of the class:
Test tasks (examples):
1. The weight of newborn brain relative to body weight is:
A. 2,5%

B. 5%

C. 10%

D. 15%

E. 20%

2. Brain myelination comes to end in:

A. 1-2 years

B. 2-3 years

C. 3-5 years

D. 1 month

E. 6 months

3. Feature of cerebrospinal fluid in the newborn are:

A. Elevated level of protein, minor lymphocytic cytosis
 B. Pandey negative reaction, the presence of a small amount of red blood cells

C. Xantochromia, low protein level

D. Low amount of protein, increasing amount of glucose

E. Positive Pandey test, neutrophilic cytosis

4. The spinal cord in newborn ends at the level:

A. L 1-2

B. L 2-3

C. L 3-4

D. T 11-12

E. 12 T-L 1

5. Variants of hyperkinesia are:

A. atetosis

B. tremor

C. tic

D. myoclonus

E. all mentioned

6. Specify the age (in years), when appears cervical and lumbar thickening of the
spinal cord?
A. 1-2

B. 3-4

C. 5-6

D. 8-10

E. 12-15
7. The reason of predilection to toxic forms of infectious diseases in young children?
A. large size of the lateral ventricles

B. increased blood supply of brain

C. difficulties outflow of blood from the brain

D. high permeability of blood-brain barrier

E. all mentioned

8. Which of the symptoms is not abnormal for young children?

A. Kerning symptom

B. Brudzinsky top symptom

A. Brudzinsky medial symptom

C. Brudzinsky low symptom

B. Lesage symptom

9. There is white wide dermographics during the examination of a child. This

indicates about:
A. sympathicotonia

B. vagotonia

C. normotonia

D. dystonia

E. eutonia

10. Child is on his back, the doctor tries to straight his leg, which is bent in the hip
and knee joints. This causes pain and impossible. The child has positive symptom:
A. Kerning

B. Brudzinsky top
 C. Brudzinsky medial

D. Brudzinsky low

E. Lesage symptom
Standards of answers:
1 C 3 A 5 E 7 E 9 A
2 C 4 B 6 B 8 A 10 A

2. Materials for the control of the final part of class:

Situational tasks (examples):
Task 1. Child is in horizontal position on his back. The doctor bends the
leg of the child, in knee and hip joints, supporting it with one hand, and then
tries to straight the leg. That cause pain and impossible. What symptom doctor
checks?
Task 2. In the infectious department at Children's Hospital a 5 years old
child is admitted with complaints of severe headache, frequent vomiting without
prior nausea, fever, pain in eyeballs during last 3 days. At inspection condition
is grave, severe intoxication symptoms present. Position of a child is forced on
one side with thrown down head and brought to the abdomen legs. What
additional research needs to be done for diagnostic of the disease?
Task 3. The child is 6 months old. The parents have complaints restless
sleep of child, frequent awakenings, tremor of the hands and chin. Moth er
frequently was ill during the pregnancy. In neonatal period was established
diagnosis hypoxic - traumatic damage of the CNS. What research is needed to
the baby?
Standards of answers:
Task 1.
Kerning symptom
Task 2.
Lumbar puncture
Task 3.
Neurosonography

VII. Materials for the methodical providing of the independent work of the
students:

1. David Candy, Graham Davies, Euan Ross Clinical Paediatrics and Child
health. - Reprinted W.B. Saunders, 2006. – 838 pp.
2. Tom Lissauer, Graham Clayden Illustrated textbook of Paediatrics. – Mosby
International Limited. – 2003. – P. 588 pp.

VIII. LITERATURE
A) The main literature:
1. Kapitan T. Propaedeutics of children’s diseases and nursing of the child. –
Vinnitsa, 2012. – 763 pp.
2. Manual of propaedeutic pediatrics / Nykytiuk S.O., Balatska N.I., Galiyash N.B.,
Lishchenko N.O., Nykytiuk O.Y. – Ternopil: Ukrmedkniha, 2005. – 467 p.
3. Pediatry. Guidance aid / Edited by professor O.Tiazhka. – Kyiv, 2007. – P. 118-
127.
4. Nelson textbook of pediatrics.—18th ed. / edited by Robert M. Kliegman. Part
XXII. Nephrology // www.mdconsult.com
5. Clinical examination of the child. / OV Katilov, DV Dmitriev, KY Dmitriev and
others. - Vinnitsa, 2017. - p. 358-385
6. Introduction to pediatrics: Methods of examination of the child and semiotics of
childhood diseases: Tutorial for students / S. Ilchenko, K. Duka, T. Yaroshevska,
O. Korenyuk at al. - Dnepropetrovsk, 2013. - P. 158-165
7. Nelson textbook of pediatrics. – 21st ed./ edited by Robert M. Kliegman. Part
XXVI. The Nervous System // www.mdconsult.com

B) The scientific literature:

1. Dr. Mayoor K. Chheda Practical aspects of Pediatrics. – Bhalani Book Depot. –
2007 (Reprint). – 317 pp.
 IX. INFORMATION RESOURSES

1. The library of Ukrainian Medical Stomatological Academy.

2. The Internet.

Methodical instructions for practical class were prepared by the assoc. prof. of the
Department of Pediatrics №1 with Propaedeutics and Neonatology Soloviova H.O.