Paediatric Neurological Examination

 
Hi. I’m JI Butuyan and I will be performing pediatric
neurologic exam in a 2yr old with seizure.
A complete and thorough evaluation of a child's
nervous system is important if there is any reason to
think there may be an underlying problem, or during a
complete physical exam.
Damage to the nervous system can cause delays in a
child's normal development and functioning and early
identification may help find the cause and decrease
long-term complications
The following is an overview of some of the areas that may be tested and evaluated during a
neurological exam:
 1st we asses the mental status. Mental status. Mental status may be assessed by watching
the infant interact with the parent, or by asking the older child to follow directions or answer
questions appropriately. The older child will also be observed for clear speech and making
sense while talking. This is usually done just by observing the child during normal
interactions.
 Motor function and balance. This may be tested by having the older child push and pull
against the healthcare provider's hands with his or her arms and legs. The child may be
asked to squeeze fingers or hop, skip, or jump. Balance may be checked by assessing how
the child stands and walks or having the older child stand with his or her eyes closed while
being gently pushed to one side or the other. The child's joints may also be checked simply
by passive and active movement.
 Sensory exam. This may be done by using different instruments: dull needles, tuning forks,
alcohol swabs, or other objects. Touch the child's legs, arms, or other parts of the body with
these items and have him or her identify the sensation (for example, hot or cold, sharp or
dull).

Meningeal Irritation Signs

 Test for these important signs whenever you suspect meningeal inflammation from
meningitis or subarachnoid hemorrhage
o Brudzinski Sign. As you flex the neck, watch the hips and knees in reaction to your
maneuver. Normally they should remain relaxed and motionless
o Kernig Sign. Flex the patient’s leg at both the hip and the knee, and then slowly
extend the leg and straighten the knee. Discomfort behind the knee during full
extension is normal but should not produce pain 

Deep Tendon and Superficial Reflexes 

o Reflex testing is useful in young children because it provides information on the
normal development and maturation of the neuromuscular system 
Deep Tendon Reflexes 
 o Biceps Reflex: With examiners thumb pressed against biceps tendon in antecubital
space, support arm with palm prone; tap thumb briskly; tendon should respond by
tightening. The normal response is Flexion of forearm
o  Triceps reflex: hold arm in flexed position with forearm dangling downward, tap
directly behind elbow on triceps tendon. The normal response is contraction of
triceps and elbow should extend slightly.
o Brachioradialis reflex: Support child’s forearm with his palm resting down, tap briskly
on radius approximately 2 inches above wrist. The normal response is flexion of
elbow and pronation of forearm 
o Patellar reflex: Palpate patellar tendon just below patella and tap briskly with leg
dangling; The normal response is contraction of quadriceps and extension of knee
o Achilles tendon reflex: support foot with ankle slightly flexed and leg relaxed, tap
above heel; vary degree of flexion of foot to assist in eliciting reflex. Observe plantar
flexion
Superficial reflex
o Plantar reflex: stroke sole of foot from heel to ball of foot curving medially with flat
object. The normal response is movement of toes
o Abdominal reflex: stoke briskly above and below umbilicus. The normal response is
contraction of abdominal muscles and umbilicus deviates toward the stimulus 
o Cremasteric reflex: in male, lightly scratch upper inner thigh. The testicles will elevate
slightly on stimulated side
o Anal reflex: gently stroke anal area to test sphincter tone. The normal response is
quick contraction of sphincter.
 
 Evaluation of the cranial nerves. There are 12 main nerves of the brain, called the cranial
nerves. During a complete neurological exam, most of these nerves are evaluated to help
determine the functioning of the brain:
o Cranial nerve I, olfactory. Pass strong-smelling substance (e.g., cloves, peppermint,
anise oil) under nose (not often tested in newborns) Observe for startle response,
grimace, sniffing
o Cranial nerve II, optic . Allen vision cards, tumbling E, or Snellen chart for visual
acuity testing 
o Cranial nerve III/ oculomotor; Cranial nerve IV/ trochlear; Cranial nerve VI/abducens.
Use ophthalmoscope or light source to test direct and consensual pupillary response
to light. With examiner’s hand under chin, have child follow toy, light source, or index
finger through six cardinal fields of gaze to test eye movement 
o Cranial nerve V, trigeminal. Observe child chewing and swallowing to test normal jaw
strength. Touch facial area with cotton swab and observe child move away from
stimulus 
o Cranial nerve VII, facial. Ask child to smile, frown, and puff cheeks, observe for
symmetrical facial expressions 
o Cranial nerve VIII, acoustic. Perform audiometric testing to evaluate range of
hearing. Test vestibular balance with eyes closed 
o Cranial nerve IX, glossopharyngeal, Cranial nerve X, vagus. Observe tongue
strength and movement and elicit gag reflex with tongue blade. Child is able to
swallow without difficulty. Voice quality and sound is normal and intact 
o Cranial nerve XI, accessory Cranial nerve XII, hypoglossal. Have the child stick
tongue out and push tongue against tongue blade. Shrug shoulders to assess
trapezius muscle strength. Turn head from side to side against resistance to test
sternocleidomastoid muscle strength