Script : Red
Additional notes: Blue
General Assessment
● First we observe while the patient is seated in the parent’s
lap. While talking to the parents, inspect the size of the head,
stance, body and note any asymmetry. Observe for any skin
lesion.
● Mental Status Exam
● Observe the patient and undress with permission from the
parents.
○ (Importance of seeing the child undressed: to see the
movement of both the arms and legs)
● Look at the waking patterns, if asleep assess the resting
posture, if awake introduce a noise and look at the facial
expression and the movement of the head.
○ Sensorium/Level of Alertness
○ Cognitive Functions
■ Demonstrate expected social behavior
■ Elicit developmental milestones??
■ Play behavior and activity
● Head
○ First we are going to inspect the head and look for any
signs of flattening of the occiput on one side (most
common), premature closure of sutures
(craniosynostosis)
○ Next is we palpate the sutures and check for any
premature closure as well as palpate the fontanelles
and note any bulging (indication of high pressure that
can be caused by edema eg hydrocephalus)
■ anterior fontanelle closure - 10-20 mos
■ posterior fontanelle - 3 months
○ Then we determine the circumference of the head using
a tape measure. We measure the occipitofrontal
circumference and this is done last because children
get restless if their head movement is restricted.
○ Head size
○ Fontanel
○ Sutures
○ Scalp swelling
○ Auscultation
○ Transillumination
● Spine – check for neural tube defects etc.
○ We observe the patient and look for any signs of spinal
and back deformities as well as search for any tufts of
hair, bulgings or openings along the spine.
● Cranial Nerves
○ CN I (menkes/swaiman)
■ note the change in behavior or change in
respiratory or heart rate
■ Functional by 5-7 months
■ It is infrequently accessed because it is functional
by 5-7 months of age.
■ By contrast, newborns do respond to inhalation of
irritants, such as ammonia or vinegar, because the
reflex is transmitted by the trigeminal nerve;
hence, this reflex is preserved in the infant with
arhinencephaly
■ (baka itanong) olfactory pathway: olfactory
receptors → collectively (CN1) → olfactory tract
→ olfactory cortex → olfactory information
○ CN II (bates)
■ We assess the visual acuity by using the optic
blink reflex, the newborn blinks in response when
shown a bright light at 1 month of age can fixate
on an object.
■ The newborn infant follows toward a light or a
bright object during an alert period
■ Visual acuity
■ Term infants → 20/150
■ 6 months → 20/20
■ 28 weeks old = (N) PM infant blinks
■ 32 weeks old = Eye closure maintained until light
source is removed
■ 37 weeks old = Turn head and eyes to source of
light
■ Ophthalmoscope examination is done at Phase 3
because it is invasive
■ We check for the Red retinal fundus reflex, failure
to see a red orange red reflex may indicate
congenital cataract, congenital glaucoma or
retinoblastoma. We also note retinal
hemorrhages.
■ For the ophthalmoscopic examination, with the
newborn awake and eyes open, examine the red
retinal (fundus) reflex by setting the
ophthalmoscope at 0 diopters and viewing the
pupil from about 10 inches. Normally, a red or
orange color is reflected from the fundus through
the pupil. A thorough ophthalmoscopic
examination is difficult in young infants but may be
needed if ocular or neurologic abnormalities are
noted. The cornea can ordinarily be seen at +20
diopters, the lens at +15 diopters, and the fundus
at 0 diopters.
■ Congenital glaucoma may cause cloudiness of
the cornea.
■ A dark light reflex can result from cataracts,
retinopathy of prematurity, or other disorders.
■ A white retinal reflex (leukokoria) is abnormal, and
cataract, retinal detachment, chorioretinitis
suggests intrauterine infection (salt and pepper
pigmentary changes, or should be suspected
■ Hemorrhages are commonly detected after
vaginal delivery, even in the absence of traumatic
delivery. Retinal hemorrhages may be found in a
large percentage of otherwise normal infants who
have no history of abnormal delivery and who later
prove to be neurologically normal.
■ They are usually small and multiple, and their
presence does not necessarily indicate intracranial
bleeding.
○ CN III, IV, VI
■ Describe size and shape of pupils; check for
ptosis, lid lag or retraction
● First part involves observation; describing
the size, shape and symmetry of pupils. You
should also check if there is presence of
ptosis or nystagmus.
■ Direct and consensual pupillary light reflex
● Normal Report: Both pupils are briskly
reactive to light meaning constriction was
observed upon illumination.
■ Extraocular muscles movement
● With the use of a bright object, test the EOMs
and observe the patient’s gaze as he/she
follows the object.
● Normal Report: The patient was able to
follow the direction of the object indicating
intact EOMs
○ CN V (Source: Bates)
■ Motor: Test the rooting reflex by gently stroking the
perioral skin at the corners of the mouth and
sucking reflex observed when the baby is feeding.
Also take note of the strength of the suck.
■ Sensory: Not yet elicited on neonates
■ Tests for pain and sensation are imprecise at this
age, and the gross response of infants to stroking
and pinprick with withdrawal, crying, and change
in sucking rates may be the only information
possible. More sophisticated testing can be
devised during which heart and respiratory rates
are monitored (SWAIMAN'S)
○ CN VII (Source: Bates)
■ Motor: Observe the baby’s crying and smiling while
assessing the symmetry of the nasolabial folds,
forehead and even eye closure. Take note that
 cranial VII innervates all muscles of facial
movements and expression.
■ Sensory: Not yet elicited on neonates
■ Facial movements are readily observed during
crying.
■ Asymmetry should be carefully assessed to
determine whether it is related to an upper motor
neuron lesion (such as the so-called central
seventh nerve palsy causing contralateral lower
face weakness), a peripheral nerve lesion
(causing unilateral weakness of both the upper
and lower face), or a muscle problem such as
hypoplasia of the depressor anguli oris that causes
weakness of a lower lip and is also referred to as
asymmetric crying facies (SWAIMAN'S)
○ CN VIII
■ Use noise makers/rattles, infants will turn head or
tilt head towards the source, startle response or an
increase in their state of alertness.
■ CN VIII mediates hearing and vestibular function,
(BATES TABLE page 847) Test for acoustic blink
reflex or tracking in response to sound, by using a
noisemaker or rattle, neonate will turn their head
or tilt their head towards the source, startle
response or an increase in their state of alertness,
(Check both ears L&R). Patient respond well to
sound indicates intact cranial nerve VIII.
■ Normal: Startle/blink in response to sound, turn
head towards source
CN VIII: Hearing is normally present in term
babies, Neonates blink or startle with loud noise -
Blue book
- In a normal newborn, pause briefly during
sucking when bell is presented; after several
stimulations, the pauses stop as habituation
occurs (use of bell or other noise).
- No habituation occurs for neurologically
abnormal infants. - PD PEDIA Neuro
○ CN IX, X
■ Observe while baby is feeding milk
■ Note quality of the cry
■ Elicit the gag reflex
■ Has both sensory and motor function. For cranial
nerve IX (Glossopharyngeal Nerve), this usually
innervates the posterior ⅓ of the tongue. We
observe the uvula and soft palate when a neonate
cries as well as the gag reflex
● The uvula and palate usually elevates when
a neonate cries and if there is a vagal nerve
problem, the uvula will deviate toward the
UNaffected side (PD PEDIA NEURO)
● Sucking - tests for strength of masseter and
temporalis muscles (OSCE PD PEDIA)
● Swallowing dysfunction requires close
scrutiny to determine which cranial nerve or
nerves are involved (CN 5,7,9,10 and 11).
(SWAIMAN)
● For CN 10 (Vagus nerve), we don’t need to
make the neonate cough, hearing the
neonate cry loudly this signifies that the
neonate has an intact CN 10
● Apply gentle pressure to the trachea or
suprasternal notch to test for cough in
newborn (PD PEDIA NEURO)
● The quality and strength of the cry is a way
of looking at (CN IX) Cranial Nerves 9 and
(CN X) 10 function.(Neuro Exam - Newborn cranial
nerves - Embryology. (n.d.). Embryology.Med. Retrieved
November 10, 2020, from
https://embryology.med.unsw.edu.au/embryology/index.p
hp/Neural_Exam_-_Newborn_cranial_nerves)
● A neonate with generally depressed CNS
function often cries infrequently (SWAIMAN)
● Another way of testing this is we will give the
neonate a bottle of milk which will elicit
swallowing and gag reflex.
● If there is no spillage of milk, it means that the
neonate has an intact CN 10
■ CN XI (Spinal Accessory Nerve)
■ Infants – observe head movements
● Observe the head movements of the neonate
■ Cannot assess adequately during infancy
● Since muscles (SCM and Trapezius muscle)
are still underdeveloped
■ Ask for the consent of the mother to undress the
child until to the torso or ask the mother to do this
for the newborn. Once consent is given, ask the
mother to lift the newborn
■ When the mother lifts the baby, observe for the
symmetry the upper trapezius muscle (Bates) and
if there is no involuntary movements,
fasciculations or atrophy (difficult to assess) -
SWAIMAN, then CN 11 is intact
○ CN XII (Hypoglossal Nerve)
■ Examine bulk and power of tongue. Atrophy,
deviation from midline with protrusion
■ Check for involuntary movements
● We will examine the tongue using a gloved
finger and put it in the neonate’s mouth to
stimulate the mouth of the baby to open and
to protrude his tongue
● Once it is open, gently squeeze the
neonate’s cheeks to get a better visualization
of the baby’s mouth and observe for its
motility, size, shape and atrophy (OSCE PD-
PEDIA Neurological exam) and look at the
base (underside) and lateral margins of
tongue (SWAIMAN) for presence of
fasciculations since usually it is located here
■ Asymmetry or loss of tongue bulk may indicate
abnormalities of CN 12 or its nucleus (Swaiman)
● Sensory Examination
○ Perioral tactile sensation can be evaluated by the
rooting response in which gentle stroking of the cheek
results in the infant turning towards stimulus with an
open mouth ready to latch onto the object (UpToDate)
● Motor Examination
○ Assess the motor tone, observe their position at rest
and their resistance to passive movement. To further
assess the tone, apply gentle manipulation of the
infant’s limbs and note any spasticity or flaccidity.
○ When held in the vertical position, the hypotonic and
weak infant tends to slide through the examiner’s
hands. In the horizontal position, the hypotonic infant
droops over the examiner’s arms without raising head
or legs.
○ To test the arm traction, take the arm and gently pull
until the shoulder is slightly off the mat. There should be
some flexion maintained at the elbow.
○ For the arm recoil, the forearms are flexed for few
seconds, then fully extended, and then released. The
arms should return to the flexed position.
○ Tone of the shoulder girdle with the scarf sign; take
the baby’s hand and pull the opposite shoulder like a
scarf. The hand should not go past the shoulder and the
elbow should not cross the midline of the chest.
○ For the leg traction, hold the leg by the ankle and pull
upward until the buttock is lifted off the mat. The knee
should maintain a flexed angle.
 ○ To test leg recoil, the legs are fully flexed, then the legs
are quickly extended and released. The legs should
spring back to the flexed position.
○ To assess the popliteal angle. Flex the thigh fully, and
extend the leg at the knee. The angle between the thigh
and the leg is typically about 90 degrees. Extension of
the leg beyond 90 to 120 degrees would be seen in
hypotonia.
○ Source: SWAIMAN'S PEDIATRIC NEURO
○ Check videos here:
https://embryology.med.unsw.edu.au/embryology/inde
x.php/Neural_Exam_-_Newborn_positions_-
_vertical_suspension
● Reflex Examination (bates)
○ Tendon Reflexes
■ Biceps − Elbow flexed, tapping the biceps tendon in the
antecubital fossa leads to flexion at the elbow.
■ Knee (patellar) − Tapping the quadriceps tendon below
the patella leads to extension of the knee.
■ Ankle - slightly dorsiflex the ankle, strike the
achilles tendon
■ Alternative way is to grab the neonate’s malleolus,
then slightly dorsiflex the ankle
■ A rapid, rhythmic, plantar flexion of the foot can be
noted. up to 10 beats normal in neonate; this is
unsustained ankle clonus
■ Triceps and brachioradialis reflexes are not tested
as they are difficult to elicit before 6 months of age
■ DTR are variable in newborns and infants because
CST pathways are not fully developed
■ Their exaggerated presence or absence has little
diagnostic significance, unless this response is
different from results of previous testing or extreme
responses are observed
■ Grading of DTR
○ Areflexia 0 prone with one hand and flex the baby’s head
○ Hyporeflexia 1 down. Normal response is that the baby’s head will
○ Normal 2 lift up and the spine will straighten. Seen from birth
○ hyperreflexia 3 until 6 months
○ Clonus present 4
● *not performed:
○ Jaw − Tapping the chin with the mouth slightly open
leads to slight jaw closure.
○ Brachioradialis (supinator) − Tapping above the
wrist on the radial aspect of the forearm leads to
flexion at the elbow.
○ In the newborn, it may be difficult to elicit the
triceps reflex because of strong flexion of the
elbows in the normal neonatal resting posture.
○ Superficial Reflexes
■ Abdominal reflexes in four quadrants of the abdomen
are elicited by gentle stroking in an axial to peripheral
direction, resulting in contraction of the abdominal wall.
The absence of response may be consistent with an
ipsilateral pyramidal tract lesion.
■ Cremasteric reflex in males can be demonstrated by
stroking the inner thigh area in an anterior to posterior
direction, which results in ipsilateral scrotal retraction and
testicular rise due to contraction of the scrotal dartos
muscle. The lack of response or an asymmetrical
response may be consistent with a corticospinal tract
abnormality.
■ Anal wink reflex is elicited by gentle stroking of the
perianal region, which results in contraction of the
perianal muscle. The absence of an anal reflex suggest
loss of innervation of the external sphincter muscle
caused by spinal cord abnormalities such as:
● Spina bifida
● Tumor
● Injury
■ Babinski reflex
Using an applicator stick or tongue blade, slowly stroke
the lateral side of the patient’s sole from the heel to the
great toe.
in the newborn infant, an extensor plantar response
(Babinski) may be physiologic and may persist for
several months.
○ Primitive Reflexes (palmar to galant reflex - bates &
menkes)
■ Palmar grasp - Touch the palmar surface of the
neonate and the positive response for this is the
fingers of the neonate will curl around your finger.
Present at birth to 4-5 months.
■ Plantar grasp - Touch at the base of the toes, and
the neonate will respond by curling his/her toes
around your finger. Present at birth to 9-12 months
■ Rooting reflex - Stroke the perioral skin at the
corners of the mouth then the neonate is expected
to respond by opening his/her mouth, turning on to
the stimulated side and begin to suck. Present at
birth until 3-4 months
■ Moro reflex (aka Startle reflex) - Make sure to
support neonate’s head and back, including the
legs. Abruptly lower the entire body for about 2
meters. The positive response for this: the arms
will abduct, extend, the hands will open, and the
legs will flex.
■ Tonic neck response - Put the neonate in a supine
position, then turn the head into one side holding
the jaw over the shoulder. The positive response
for this test is that the arm and leg on the side
where the head is turned will extend, while the
opposite arem and leg will flex. Appears at birth
and persists until 2 months.
■ Galant reflex (Truncal incurvature) - Support the
infant prone with one hand. Stroke one side of the
back 1cm from the midline and from the shoulder
to the buttocks. Notice that the positive response
for this is the spinal curves towards the stimulated
side. Appears at birth and persists until 2 months.
■ Landau reflex - done by suspending the baby
■ Parachute reflex - done by suspending the baby
prone and slowly lowering the head toward a
surface. Normal response is the baby will
spontaneously extend the upper extremities in a
protective manner. This begins from 8 months and
does not disappear.
■ Positive Support Reflex - done by holding the baby
around the trunk and lowering the baby until the
feet touches a flat surface. Normal response is
when the hips, knees and ankles extend, the baby
will stand up partially bearing weight and sags after
20-30 secs. Seen from birth or 2 months until 6
months.
■ Placing and Stepping reflex - Hold the baby upright
as in the positive support reflex. Bring the dorsi of
the feet against the under edge of the table top.
Normal response is that upon contact, the hip and
knee of that foot will flex and the other foot will step
forward and alternate stepping occurs.
● Cerebellar Function
○ Hypotonia is characterized by reduced resistance to
passive range of motion in joints. It can be tested from
the earlier examinations and can be tested further by
manipulation of the limbs (examine all 4 limbs. (+)
hypotonia = freely moving joint; check symmetry and
trunk tone). The baby should also be suspended in the
supine, lateral and prone position on the examiner’s
hand.
○ Observe the posture of the child in bed. (+) floppy child
= frog like position (hips abducted, knees flexed).
Palpation: feel the muscle (+) hypotonic muscle = soft
and flabby.
○ Horizontal/Ventral suspension: (+) hypotonia when
baby assumes the rag doll posture or “U” posture in a
horizontal suspension
○ Vertical suspension/Rag doll gait: (+) hypotonia when
infant “slips through” at the shoulders when the
examiner grasps the baby under the arms in an upright
position
○ (+) hypotonia if there is significant head lag with traction
when pulled up from the supine to the sitting position
○ Pendular quadriceps reflex same with the knee
(patellar) reflex. Place your hand under the knee and
the leg at about 90 degree angle at the knee. Strike the
patellar tendon with the reflex hammer using a pendular
action rather than a chopping action.
○ Nystagmus - Inspect the baby’s eye and let the baby
follow your finger/toy through field of gaze