2ND PRECEPTORIALS: INFANT AND OLDER CHILD

OUTLINE HISTORY TAKING

I. History Taking General Data Name, Age, Gender, Birthdate, Address, Number of Hospitalization and Dates, Religion, Race, Informant, and Reliability of
II. Observation and Mental Informant
Status HPI Main part of medical history
III. Head Examination (Infant) • Signs and symptoms described in chronological order
IV. Cranial Nerves o Stated in number of hours, days, weeks, months before time of consult
V. Motor Examination Symptom Elaboration (clarify chronology of occurrence of symptoms)
VI. Cerebellar Review of Systems Benefit of asking the ROS after the HPI:
VII. Sensory Examination → Helps uncover symptoms related to the present illness that you missed to ask in the HPI
VIII. Developmental Reflexes → Identifies other problems or symptoms not related to the HPI
IX. Deep Tendon Reflexes Past Personal / Medical Pre-natal or Gestational Natal or Birth History Neonatal
X. Superficial and Other History Importance: Assessing • Term, pre-term APGAR score
Reflexes congenital or neonatal illnesses • Manner of delivery Determine “survivability” of the newborn
XI. Developmental Milestones • Mother’s age during → Normal vaginal delivery • Appearance: color
pregnancy → Cesarean section – ask • Pulse: heart rate
• Gravity and parity (OB why • Grimace: reflex irritability
score) → Vacuum? Forceps? • Activity: muscle tone
• Prenatal check-ups • Assisted by OB? Midwife? • Respiratory rate
• Maternal illness during (Ask location as well: home, 0 1 2
pregnancy hospital, taxi) Heart rate Absent <100 >100
• Intake of drugs • Birth weight Respiratory Absent Slow/irregular Good;
• Duration of pregnancy → Nelson: the average rate crying
term newborn weighs Muscle Limp Some flexion Active
approximately 3.4 kg tone of extremities motion
(7.5 lb) Reflex No Grimace, Crying
→ Average weight does irritability response slow
vary by ethnicity and Color Blue/pale Acrocyanosis Pink
socioeconomic status.
PHASES OF EXAMINATIONS 1-MINUTE APGAR 5-MINUTE APGAR
• After newborn period until 2 Years 0-4 Severe depression, requiring 0-7 High risk for subsequent CNS and other organ
of Age immediate resuscitation system dysfunction
• PHASE 1: EVALUATION OF THE 5-7 Some nervous system depressions 8-10 Normal
PATIENT 8-10 Normal
→ Observation Feeding History GOAL: identify any feeding problem that occurs even prior to illness (e.g., inadequate caloric intake) that may lead to
→ Level of alertness, awareness, malnutrition.
affect • Type of feeding: Breastfeeding? Formula Milk?
→ Communication skills • Complimentary food
• PHASE 2: • Sample diet (prior to illness) & food preferences - To determine if the child is getting enough nutrition, he/she needs for
→ Head, muscle tone, superficial normal growth
and deep sensation, gross • Feeding problems
response to sound, visual fields Developmental History, Cognitive and Language History (Doc Villaluz’s Lecture)
• PHASE 3: Past Illnesses • Hospitalizations Immunizations Any adverse reactions to any vaccines?
→ More invasive
• Infectious diseases • Fever
→ May require help from
• Operations, blood transfusions • Seizure
caregiver or assistant
• Allergies, medications • Rashes
• PHASE 4:
Anaphylaxis (severe allergic reaction, angioedema, difficulty
→ Child is placed on the floor and
breathing, hypotension)
encouraged to crawl, walk, and
Family History Seizures, Congenital defects, Metabolic disorders, Neurodevelopmental disorders
run if possible
Personal and Social • Primary care giver
History → occupation & financial status of parents
• Environmental
→ Exposure to pollution, second-hand cigarette smoke
→ Sewage disposal
→ Insects: mosquito, ticks
 OBSERVATION / MENTAL STATUS
TEST/PROCEDURE INFANT OLDER CHILD
Dr. Villaluz:
• Observe play behavior (>6mos)
• Recall personal information (informal) – beyond 3yo
• Recall 3 objects (formal-cognition and immediate
memory) – children 7yo and above

1. Normal waking state

• Sensorium fully intact
• Sleeps at appropriate times, arouses fully, and
appropriately maintains waking state
2. Somnolence or lethargy
LEVELS OF
CONSCIOUSNESS / • Arouses spontaneously at times or after normal stimuli
SENSORIUM but drifts off inappropriately
• Sensorium functions adequately when aroused but
drifts back to sleep when the stimuli is removed
3. Stupor
• Appears asleep but arouses to vigorous verbal stimuli
• May awaken spontaneously for brief periods, but
sensorium clouded
4. Semi-coma
→ ask for sleeping pattern (established sleep-wake pattern) • Moves mainly in response to painful stimuli
5. Coma
• No spontaneous movements or arousal; reflexes may
or may not be present
• Observe the infant when their name is called • Does the patient converse normally? (>3yo)
LANGUAGE
• Observe babbling • Articulation, comprehension, repeat words, name objects
COGNITIVE FUNC. • review developmental milestones, and observe their play activity and behavior Communication skills can be noted and compared with age-
appropriate expectations
ASSESS CAREGIVER-CHILD INTERACTION: Offer clues into what home environment is like
• Attention span
Normal child: plays independently early in the visit but then engages in the interview process
• Orientation to time, place, and person
• Memory – immediate, recent and remote
Abnormal movements: • Fund of information (where is your eyes? Your nose?)
CLINICAL • Epilepsy • Insight, judgment, planning (>7yo)
CORRELATION • Motor tic disorder • Calculation (>2yo → count 1 to 3; 7yo: simple math)
• Behavioral diagnosis (ADHD) • School performance – indirect measure of difficulty in
reading, math, etc.

HEAD EXAMINATION (INFANT)

TEST/PROCEDURE
Look for: Expected Findings Clinical Correlation
• Asymmetry • Fontanels and cranial sutures • Open fontanels, No mass • Bulging fontanels indicate
• Indentations • Mass • Anterior: close by 9-18 hydrocephalus
• Protuberances • Occipitofrontal circumference should always be measured months (swaiman:12 • Depressed fontanels
months) indicate dehydration
Note: Head Auscultation (Swaiman) is done to check for presence of • Posterior: close by 6-8 • Microcephaly – 2 sd below
• Hair color, distribution, texture, and pattern unusual intracranial bruits weeks the mean
• Occipitofrontal measurement using measuring tape (can be • Macrocephaly - 2 sd above
deferred until later-3rd stage if infant becomes agitated) the mean
→ Measure from most prominent part of glabella above
the eyebrows to the prominent part of the occiput
behind the head
 CRANIAL NERVE 1 (OLFACTORY NERVE)
TEST/PROCEDURE INFANT & OLDER CHILD
Have the child smell pleasant aromas (use stimuli familiar Expected Findings Clinical Correlation
to the child) placed inside an opaque vial Functional by 5 to 7 months of age • Transient anosmia
• Chocolate, Vanilla, Peppermint, Coffee, Soap, → Severe URTI/ Acute Rhinitis
Toothpaste, Lemon oil • Note change in behavior and respiration. → Allergic rhinitis
Do not use strongly aromatic substances • Permanent anosmia
Ammonia inhalants → Head trauma with damage to ethmoid bone
Will stimulate the Trigeminal nerve (CN V) → Shearing of olfactory nerve fibers as they cross the
OLFACTORY PATHWAY: (Swaiman 6th ed, Snell’s clinical neuroanatomy 8th ed) cribriform plate
→ Frontal lobe mass involving the cribriform plate region (rare)
Olfactory receptor cells (first order neuron) → olfactory nerve fibers → pass through the openings of the cribriform plate of → Tumor involving the olfactory bulbs
ethmoid bone → olfactory bulb → inside the bulb: Mitral and tufted cells (second order neuron) → olfactory tract (beneath the → Intranasal drug use
inferior surface of frontal lobe) → reaches the anterior perforated substance → divides into Medial and Lateral olfactory striae → Exposure to toxins
→ Acrylates
Lateral olfactory stria – carries the axons to the olfactory area of cerebral cortex (primary olfactory cortex) → Methacrylates
Medial olfactory stria – carries the fibers that cross the medial plane in the anterior commissure to pass to olfactory bulb of the → Cadmium
opposite side • Congenital anosmia (rare)
→ Kallman Syndrome
NOTE: In contrast to all other sensory pathways, the olfactory afferent pathway has only 2 neurons and reaches the cerebral
cortex without synapsing in one of the thalamic nuclei. • Parosmia: a change in the normal perception of odors, such as
when the smell of something familiar is distorted, or when
Possible questions: something that normally smells pleasant now smells foul.
• Where is the olfactory center? – temporal lobe, BA28
• What structure is responsible for the center’s dual innervation? – anterior commissure
• What type of neuron is olfactory nerve? – Bipolar neuron

CRANIAL NERVE 2 (OPTIC NERVE)

TEST/PROCEDURE INFANT OLDER CHILD
VISUAL ACUITY AND FIELD Expected Findings Clinical Correlation Expected Findings Clinical Correlation
INFANT Adult level of 20/20 reached by Normally causes the child to
• Toys or colorful objects can facilitate assessment of 6 months of age (Dr. Terencio) look from one object to the
extraocular movements in young children other. Failure to take notice of
• Double simultaneous stimulation – simultaneously one object may indicate
bringing 2 objects into both temporal fields – Swaiman homonymous hemianopsia.
VISUAL PATHWAY: (Swaiman 6th ed, Snell’s clinical neuroanatomy 8th ed, YL1-B 2023 Neuro I trans)
CHILD
• 2-4 yo: “E” Snellen Chart game Geniculo-striate system
• > 4 yo: Snellen or Jaeger Charts Four neurons conduct visual impulses to the visual cortex:
• E test: 1. Rods and cones – first order neuron; specialized receptor neurons in retina
→ Discern the direction in which the three “arms” are 2. Bipolar neurons – second order neuron; connect the rods and cones to the ganglion cells
pointing and point a finger accordingly 3. Ganglion cells – forms the Optic Nerve; whose axons pass to the lateral geniculate body
PERIPHERAL VISUA FIELD TESTING 4. Neurons of the lateral geniculate body – whose axons pass to the cerebral cortex
(CONFRONTATION TEST) Pathway:
• Use a small (3-mm) white or red test object, a toy, or in Stimuli → rods and cones → bipolar cells → optic canal → optic nerve → optic chiasm → optic tract → lateral geniculate body → optic
a pinch, the examiner’s fingers can be used radiation → will divide into 2: Superior retinal fibers (Barum’s loop) & Inferior retinal fibers (Meyer’s loop) → occipital lobe (visual cortex BA
• Test object is moved from the temporal to the nasal 17, 18, 19)
fields and then from the superior and inferior portions of
the temporal and nasal fields while the child looks Retino-tectal system (Pupillary light reflex pathway)
directly at the examiner’s nose Afferent: Retina → optic nerve → optic chiasm → optic tract → pretectal nucleus in the superior colliculus (dorsal midbrain)
• Finger counting is used if acuity is grossly distorted → pretectal nucleus project fibers to both ipsilateral and contralateral Edinger Westphal nucleus of CN III via the posterior commissure
Efferent: EWN of CN III → stimulates ciliary ganglion → short ciliary → pupillary constrictor muscle

Possible question:
What is marcus gunn pupil? – also known as relative afferent pupillary defect (RAPD); is an
afferent arc defect due to retina or optic nerve defect causing poor direct and consensual pupillary
reflex observed during “swinging light reflex”
 CRANIAL NERVE 3 4, 6 (OCULOMOTOR, TROCHLEAR, ABDUCENS)
TEST/PROCEDURE INFANT OLDER CHILD
PUPILLARY LIGHT REFLEX (Infant & Older child) Expected Findings Clinical Correlation TEST/PROCEDURE Clinical Correlation
• Pupils should be symmetric • Causes of Marcus Gunn EXTRAOCULAR Abnormal: Muscle paresis – separation of
Direct pupillary light reflex with equal response to light. pupil: PALSIES the red and white images when looking in
• Using a penlight, shine a bright light obliquely into each • A bright light causes the → CN2 inflammation/neuritis • Red glass is placed the direction of action of the affected
pupil and observe for pupillary constriction in the same infant to blink or hold the lids → Optic neuropathy in front of an eye muscle
eye. closed. → Glaucoma • Focused, relatively • Farthest peripheral image – perceived
Consensual pupillary light reflex → Retinal detachment intense white light by abnormal eye
• Upon shining a light, observe for the pupillary is aimed at the eyes LR paresis Accompanied by
constriction in the opposite eye. • Kayser-Fleischer ring from various visual volitional turning of
Swinging light reflex → Greenish brown fields while child head to forestall
• Alternately swing the light from one eye to the other and → Pathognomonic of Wilson fixes on the light diplopia
hold it on new eye for 3-5 intervals and watch for equal hepatolenticular SO/SR palsies Tilting of the head
reaction of both pupils. degeneration Normal: Merged, toward the shoulder
solitary, red-white opposite the side of
image is perceived the paretic eye
muscle occurs
OPTICOKINETIC Normal: the child should visually track the
EOM 1º Action 2º CN NYSTAGMUS object in the direction the tape is being
evaluating eye drawn, with a rapid, rhythmic movement
Medial rectus Adduction -- III movements of children (refixation) of the eyes in the reverse
Lateral rectus Abduction -- VI direction to enable fixation on the next
• Drum or tape with figure or stripe
Superior rectus Elevation Intorsion III
stripes or figures is
Inferior rectus Depression Extorsion III slowly rotated or Abnormal: absence of fixation d/t failure of
SO Intorsion Depression IV drawn before the fixation, amaurosis or disturbed saccadic
child’s eyes in eye movements
IO Extorsion Elevation III horizontal and
vertical directions
CLINICAL CORRELATION (OLDER CHILD – SWAIMAN)
• Purposes of EOM → direction of gaze • Brainstem lesions → disrupt the medial longitudinal fasciculus ✓ ptosis
• Heterophorias (phorias) – both globes are directed o May be unilateral or bilateral ✓ EOM paralysis
normally on near or far objects during fixation • Internuclear opthalmoplegia – impairment of conjugate eye CN III ✓ complete paralysis → eye to position
o one or both deviate when one eye is occluded movement downward and outward; poor adduction
while other eye fixes o Weakness of medial r. muscle contraction of the and elevation
o confirms dx: forcing fixation of the uncovered adducting eye which is accompanied by a mononuclear CN VI May be impaired by inc. ICP
eye by alternately covering each eye nystagmus in the abducting eye
o Exophoria – predisposition to divergence • Internal opthalmoplegia – fully dilated pupil that is unreactive to Decreased visual acuity in infants and
Squint
o Esophoria – predisposition to convergence light or accommodation young children
• Heterotropias (tropias) – eye deviations detectable o Extraocular muscle function is normal when each muscle Brainstem nuclei Conjugate eye deviation toward the
during binocular vision is tested separately lesions opposite side
o Esotropias – adduction tropias o Site involved: oculomotor nerve, nucleus, or Destructive cerebral
Eye deviation toward the side of lesion
o Exotropias – abduction tropias parasympathetic ganglion hemispheral lesions
o Most often caused by compromised EOM • External opthalmoplegia – ptosis and paralysis of all extraocular Irritative cerebral
Eyes to turn away from the side of the
innervation muscles hemispheral lesion
lesion
o Pupillary reactivity is normal (seizure focus)
Spontaneous nystagmus → horizontal / vertical / rotary “the patient looks at their stroke but away
Cortical lesion
Jerk nystagmus slow and fast phase from their seizure”
Vertical nystagmus assoc with medication or brainstem dysfunction Dysfunction of tectal
Vertical gaze paresis
Few beats of horizontal nystagmus w/ extreme lateral gaze Normal area of midbrain
Persistent horizontal nystagmus Dysfunction of cerebellum or brainstem vestibular system
components
Pineal tumor or Unable to elevate the eyes for upward
Direction of gaze toward the side of lesion Nystagmus is coarser (amplitude of movements are greater)
hydrocephalus gaze
Seesaw nystagmus Disconjugate (alternating) movement of the eyes
✓ lesions in optic chiasm → move upward and downward in seesaw motion
 FUNDOSCOPY (PHASE 3 IN INFANT EXAMINATION)
TEST/PROCEDURE INFANT OLDER CHILD
• Darken the room. Switch on the ophthalmoscope light Expected Findings Clinical Correlation Expected Findings Clinical Correlation
and turn the lens disc until you see the large beam of • Infant: pale gray colored disc • sharply defined and often
white light. (Shine the light at back of your hand) • Macular light reflex is absent salmon-colored optic disc
• Turn the lens disc to 0 diopter. until approx.. 4 months of age • In presence of deep cup in
• Hold the ophthalmoscope in your right hand and use optic disc - color may appear
your right eye to examine the patient’s right eye (same pale
with opposite side) • Pallor is localized to the
→ Optic discs center of the disc
→ Maculae
→ Appearance of retina

CRANIAL NERVE 5 (TRIGEMINAL)

TEST/PROCEDURE INFANT & OLDER CHILD THEORETICALS
SENSORY COMPONENT Expected Findings Clinical Correlation
Note the change in behavior and Damage to sensory fibers –
• Play a game with a soft cotton ball to test sensation on facial response ipsilateral loss of sensation to
the forehead, cheeks, and jaw on each side. head, face, and oral cavity
• Test corneal reflex
→ Ask the child to look up and away.
→ From the other side, touch the cornea lightly with
a fine wisp of cotton.
→ Look for the normal blink reaction of both eyes
MOTOR COMPONENT Symmetric temporalis muscle, • Temporalis muscle atrophy
no difficulty in swallowing manifests as scalloping of
• Palpate the temporal and masseter muscles. Have the the temporal fossa.
child clench the teeth and do the act of chewing and • Unilateral lesions of CN V
note the strength of muscle contraction. result in deviation of the jaw Trigeminal nerve has 4 nuclei:
• Test jaw opening, protrusion, and lateral motion to the paralytic side. • Mesencephalic nucleus – main sensory nucleus
against resistance. • Center/principal nucleus – touch and proprioception
• Motor nucleus – confined in pons, motor component of CN V
• Spinal nucleus – for touch, pain, temperature, pressure,
proprioception
CN V Sensory component pathway:
Sensation from skin of face and mucous membranes → semilunar or trigeminal sensory ganglion
→ large sensory root of CN V → enter to pons continue to ascend without division

CN V Motor component pathway:

Nucleus located in pons → axon exits in anterolateral pons → enters meckel’s cava
→ travel under gasserian ganglion → axons leave the skull through foramen ovale → joins the mandibular division of sensory CN V
→ form the mandibular nerve

Innervates: muscle of mastication the tensor tympani, tensor veli palatini, and the mylohyoid and anterior belly of digastric muscle

CRANIAL NERVE 7 (FACIAL)

TEST/PROCEDURE Expected Findings Clinical Correlation
Observing the child’s facial movements throughout the entire examination • Younger infant: sucking and rooting • Widening of the ipsilateral palpebral
is helpful reflexes should be obtained fissure or inability to bury the limbus when
INFANT • Sometimes, child can be induced to crying → facial nerve weakness
Tongue fasciculations should be evaluated with the tongue in resting protrude tongue if examiner urgers the • Deformity, atrophy, or abnormal
position and by gently elevating the tongue with a depressor and child to imitate tongue movements positioning of the tongue can be observed
examining the undersurface
 The child should be able to do these without • Central (supranuclear) facial nerve
difficulty impairment: paresis of the muscle
MOTOR COMPONENT involving the lower face
• Have the child “make faces” or imitate you as you make faces (include Complete motor dysfunction on one side: ✓ drooping of the angle of the mouth
raise eyebrows, close eyes, smile, frown, show teeth, puff out cheeks) • Unable to move the forehead upward ✓ disappearance of diminution of the
and observe symmetry and facial movements • Unable to close the eye forcefully nasal labial fold
• Unable to elevate the corner of the mouth ✓ widened palpebral fissue
OLDER CHILD
on the side of the affected nerve
SENSORY COMPONENT Older child should be able to identify each • Ageusia - loss of taste; BA 43
• Test for taste on anterior of tongue substance
• Taste for the Anterior 2/3 of the tongue may be tested by placing a (Salty, sweet, acidic, sour, or bitter)
saline or glucose solution on one side of the protruded tongue, if the
child is cooperative
• Patient’s tongue must remain outside of the mouth until the test is done

CRANIAL NERVE 8 (VESTIBULOCOCHLEAR)

TEST/PROCEDURE Expected Findings Clinical Correlation
• Take note of response to sound made by tuning fork, rubbing fingers • Normal Hearing infants: Turn their head
together, ringing a bell, or using a toy noise maker toward a bell, rattle, or crumpled paper
INFANT o Make sure not to confuse response to visual cue (movement • At 3 months, he/she will look in the
need to elicit noise from a toy) with response to the sound. direction of the sound source
• Otoscopy • Turning with eyes and head appears by
approx. 3-4 months of age.
• Check for ability to hear tuning fork, finger rub, watch ticking, whispered
voice in each ear.
o Whisper a word or command behind the child’s back and have Perform auditory testing by 4 years of age
the child repeat it while masking the ear of the other by
occluding and rubbing the external meatus.
• Tuning fork • Weber’s test
o RINNE TEST (Air bone conduction test): Strike the tuning fork o Lateralization on affected side = conductive hearing loss on same side
and hold the base of fork against mastoid bone. o Probable sensorineural loss on the contralateral ear
OLDER CHILD o WEBER TEST (Sound lateralization test): Strike the tuning • Rinne Test
fork and hold it against the vertex and ask if sound lateralizes o Normal: Air conduction [AC]> Bone conduction [BC]
equally or to affected/unaffected ear o CONDUCTIVE DEAFNESS: BC>AC
• Conscious patient • (+) degree of obtundation: modification of response
• Caloric testing and tilt test
develops coarse o Eyes become tonically deviated ipsilaterally with
o For gross assessment of vestibular function
nystagmus toward the accompanying nystagmus occurring
o Patient is in supine position with head flexed at 30 dec
ipsilateral ear; contralaterally
o Ice water (10mL) is injected over 30 seconds into one external
• No deviation occurs • If comatose:
auditory canal at a time
o Tonic deviation ipsilaterally and no nystagmus
(References: Swaiman 6th ed, Menke’s 7th ed, Snell’s clinical neuroanatomy 8th ed, YL1-A Neuro I trans 2023)

This nerve consists of 2 distinct parts, the vestibular nerve, and the cochlear nerve, which are concerned with the transmission of afferent information from the internal ear to the central nervous system.

AUDITORY PATHWAY: (remember: ECOLIMA)

Eight Nerve (CN VIII) → Cochlear Nuclei → Olivary Nucleus (Superior) → Lateral Lemniscus → Inferior Colliculus → Medial Geniculate Body → Auditory Cortex
Memory aid: Lateral geniculate (L-Liwanag) – visual pathway; Medial Geniculate (M-Music) – hearing

VESTIBULAR PATHWAY:

• The cranial nerves that are involved extraocular muscle movements (CN III, IV and VI) are connected to the vestibular nuclei via the medial longitudinal fasciculus. This is important for the
visual information to maintain balance.
• Vestibular nuclei have afferent and efferent connections with the pontine reticular formation, which subserves vestibulo-ocular and vestibulospinal reflexes that are essential for clear vision and
stable posture.
 CRANIAL NERVE 9, 10 (GLOSSOPHARYNGEAL AND VAGUS)
TEST/PROCEDURE
Dr. Villaluz
• Observe while baby is swallowing milk or
INFANT
water
• Note for the quality of cry and voice
• Check for hoarseness or stridor
• Ask the child to swallow and say “ahhh”
o Phonation – role of CN X
OLDER CHILD
• Observe the movement of the uvula and
soft palate
Elicited by touching the posterior pharyngeal
GAG REFLEX
mucosa with a tongue blade
Expected Findings Clinical Correlation
• If the baby can swallow without choking, we • Asymmetry of the resting uvula and palate and failure to elevate
can deduce that the glossopharyngeal and the palate during phonation indicate impaired vagal motor function.
vagus nerves are intact. • When UMN or LMN lesion of the vagus nerve exists, the uvula
• If there is nasal quality or hoarseness in the cry, deviates toward the unaffected side and with movement, the
it might indicate a vagus nerve impairment. palate is drawn away from affected side.
• Unilateral paresis → ipsilateral droop, even when the patient is expelling air through the open mouth or gagging in
response to a tongue blade
• Bilateral involvement → flaccid soft palate bilaterally
Unilateral weakness causes deviation of the uvula AWAY from the weak side

CRANIAL NERVE 11 (SPINAL ACCESSORY NERVE)

TEST/PROCEDURE
• Trapezius muscles are assessed when
the patient is asked to shrug the
OLDER CHILD shoulders against resistance.
• Sternocleidomastoid muscle is tested by
asking the child to rotate their head to
one side against resistance.
Expected Findings Clinical Correlation
• Paralysis and atrophy of the sternomastoid • Common conditions producing weakness and atrophy of the
and trapezius muscles result from lesions of sternomastoid and trapezius muscles:
the accessory nerve → Motor neuron
• Weakness of the sternocleidomastoid muscle → Myoclonic dystrophy
results in an inability to rotate the head to the
contralateral side. • Myasthenia gravis

CRANIAL NERVE 12 (HYPOGLOSSAL NERVE)

TEST/PROCEDURE
• Ask the child to protrude tongue and
move tongue from side to side
• Examine the tongue and assess its
motility, size and shape and the
OLDER CHILD
presence of atrophy or fasciculations
Expected Findings Clinical Correlation
Normal findings - (+) symmetry (-) fasciculation, • Asymmetry or loss of tongue bulk may indicate abnormalities of
atrophy, and not protruded CN XII or its nucleus.
• Tongue fasciculations often occur along the lateral margins and
underside of the tongue.
• Atrophy and fasciculation of the tongue occur when the ipsilateral
hypoglossal nerve is involved.
• The protruded tongue deviates toward the involved side because
contraction of normally innervated tongue muscle causes
protrusion and is unopposed.
• If injury is bilateral, tongue protrusion is not possible, and
dysphagia may be present.

MOTOR EXAMINATION
TEST/PROCEDURE INFANT OLDER CHILD
Clinical Correlation TEST/PROCEDURE Clinical Correlation
OBSERVATION PHASE 2 SCREEN GROSS MOTOR
• General posture and symmetry of movements • In an examination table FUNCTION
of arms and legs • 3 mos: prone position, able to hold the head and chest off the table • Rapid screening examination Check for Gower’s maneuver
• Note any gross discrepancies in muscle bulk • 4 mos: good head control held in sitting position → Child standing • Rise quickly from squatting
or limb length • 8-9mos: able to sit unsupported and maintain adequate balance → Hop in place on each foot position followed by asking to
• Careful palpation helps distinguish fat and → Tandem-walk forward and stand with feet close together,
muscle PHASE 4 backward eyes closed, and arms and
• 10 mos: independent sitting, crawl, pull to stand position → Toe-walk and heel-walk hands outstretched
• 11 mos: creep → Simultaneous
• 12 mos: walk with support Muscle bulk → gentle palpation & assessment of Romberg’s
• 13-14mos: walk without support observation sign and adventitious
• Myotonia – tapping over the movements
thenar eminence and deltoid Finger-to-nose test
muscle • Cerebellar function
MUSCLE TONE Child is actively resisting the • Hypertonia – greater-than- MUSCLE TONE
• Resistance to passive stretch examiner – reflection of strength normal resistance Evaluated when child is relaxed so • Decreased tone → cerebellar
• Also requires palpation → spontaneous muscle • Hypotonia – less-than-normal that resistance to passive disease and anterior horn cell
• Muscle tone and ROM are best assessed movements against gravity resistance movement can be monitored disease
when child is in relaxed state • UMN involvement – → Extensibility of muscles by • Increased tone → rigidity
→ gently shaking and moving the hands Interacting with the infant using toys decreased movement of an shaking the limbs and assoc. with basal ganglia
and feet in flexion and extension may facilitate evaluation of limb entire extremity determining the ROM is disease
→ pronation & supination of hands and strength, range of motion, and → Limited flexion of the arm assessed • Spasticity → corticospinal
forearm coordination at the elbow tract dysfunction
Hypotonic infant: Hypertonic infant: → Persistent fisting
• Ventral suspension: infant droops over the • Ventral suspension: persistent → Adduction of the thumb
examiner’s arms without raising head or legs hyperextension of the legs and against the palm
• Vertical suspension: tends to slide through the neck • LMN disorder – Erb’s brachius
examiner’s hands • Vertical suspension: Extension plexy injury
and scissoring of the legs with → Internal rotation and
fisting adduction at the shoulder
(“waiter’s tip”)
CORTICOSPINAL TRACT: MUSCLE TESTING
Pyramidal cells → corona radiata → posterior limb of internal capsule → cerebral peduncle → basis pontis → medullary • Arm and shoulder strength – • Normal child will spring back
pyramid → (1); (2) ask the child to lean against a • Weakness of hip extensors –
(1) Anterior funiculus (10%) → anterior corticospinal tract → cervical & upper thoracic segments wall with legs placed a foot or Gower’s maneuver will be
(2) Lateral funiculus (90%) → lateral corticospinal tract → all spinal cord segments two from the wall edge and arms engaged
→ anterior horn cell → peripheral nerve → muscle outstretched with palms against → patient climbs up their
the wall own legs, pushing
UMN Lesion LMN Lesion GRADING MOTOR STRENGTH → Lower extremity – sit on themselves into erect
the floor then rapidly stand position
Weakness + + 0 No muscle movement
Atrophy - + Visible muscle movement, but no movement
1
at the joint GALEAZI’S SIGN (INFANT)
Fasciculations - + • child in supine position
Movement at the joint, but not against the • flex the hips 90 degrees with feet on the examination table
Reflexes   2
gravity • note any asymmetry of femur length
Tone   Movement against the gravity, but not against
3
Babinski + - added resistance Hip disease such as subluxation:
→ shorter leg and may exist separately or as a result of spasticity
Spastic paralysis + - Movement against resistance, but less than
4 → increased excursion → hypotonia or ligamental laxity
Flaccid paralysis - + normal
Clasp-knife spasticity + - 5 Normal strength

CEREBELLAR
INFANT OLDER CHILD
• Difficult to assess in infants • Free walking for broad based gait
Gait dystaxia
• It is easiest when a cooperative child can be observed during sitting, standing, walking, or • Tandem walking
reaching for objects Nystagmus Inspect and have patient follow your finger through fields of gaze
• Observation during playing to see Arm dystaxia and • Finger-to-nose
• Resting or intention tremor, dysmetria, titubation, or truncal sway while sitting and fine motor irregular alternating • Pronation-supination test
coordination movement • Thigh slapping test
• Wrist slapping test
Overshooting
• Arm-pulling test
• Heel-to-knee
Leg dystaxia
• Shin tapping test
• Inspect for rag doll postures and rag doll gait
Hypotonia • Passive movement of extremities
Cerebellar tests (older child) reference: Doc Villaluz’s Lec (1.1 Trans) • Pendular quadriceps reflex
 SENSORY EXAMINATION
TEST PROCEDURE Clinical Correlation
Important to rule out neurocutaneous disorders • Hypopigmented macules – tuberous sclerosis
CUTANEOUS EXAMINATION • Café au lait spots – NF
• Port wine stain – Sturge Weber syndrome
Check for scoliosis, sinus tracts, scars, dimples • Unusual skin lesion or hair growth – (+) underlying mesodermal
SPINE EXAMINATION
Palpated along its entire course defect (diastematomyelia or spina bifida)
INFANT Light Touch Gently stroke the extremities using cotton tip • Signs of recognition: eye deviation and facial response to
(Superficial) → Hands, trunk, feet withdrawal of the limbs
Vibration Causes arrest of motion and wide-eyed look of wonder who cannot
Application of tuning fork
SENSORY (Deep) otherwise describe the feeling
EXAMINATION Proprioception Cannot be directly evaluated at this age
(Deep) • Observations of sitting position, gait, posture
Pain Light application of a pin or gentle pinching
(Superficial) → Hands, trunk, feet
Light Touch Gently stroke the extremities using cotton tip Can also be assessed by a single stimulus or by double
(Superficial) → Hands, trunk, feet simultaneous stimulation of two skin areas
Application of tuning fork
Vibration → Assessed in all four limbs Extinction – failure of the child to perceive both stimuli
SENSORY (Deep) → Knuckles, fingernails, malleoli of ankles,
EXAMINATION and toenails Two-point discrimination: normal findings have been reported for 2
Proprioception Test position sense of fingers and toes using the to 12 years old
(Deep) 4th digits (Dr. Villaluz) → Absence: parietal lobe dysfunction
Pain Light application of a pin or gentle pinching
OLDER CHILD (Superficial) Hands, trunk, feet
• Child closes the eyes Recognition of familiar objects by touch
• Objects are placed in one hand then the other
Stereognosis • Patient should recognize the objects by size, Astereognosis – absence of stereognosis
CORTICAL texture, and form → Lesions of the parietal lobe
SENSORY → Button, coins, safety pin, or key
FUNCTION • Trace the symbols while child’s eye ar eopen Ability to recognize numbers, letters, or symbols traced on skin
• Eyes closed, figures are traced over the palm
Graphesthesia Dysgraphethesia – failure to identify the symbols
or forearm
• Identify the figure/symbols → By 8 yrs of age – able to identify all single digits correctly

PATHWAYS

• Anterior Spinothalamic Tract – light touch

• Lateral Spinothalamic Tract – Pain

PATHWAY:

1st order neuron – dorsal root ganglion

2nd order neuron – dorsal horn laminae

Cross immediately in the anterior commissure to the opposite anterior and lateral white column
and ascend as spinal lemniscus

3rd order neuron – VPL of thalamus

4th order neuron – post central gyrus (primary somatosensory cortex)
 DEVELOPMENTAL REFLEXES (INFANT)
TEST PROCEDURE EXPECTED FINDINGS DISAPPERANCE

• Initially in supine, then raise the infant. Suddenly Initial extension and abduction of Asymmetry at any age
MORO REFLEX/ STARTLE but carefully allow the head to fall approx. 30 the arms with extension of the is always abnormal.
REFLEX degrees while cradling the head in the examiner’s fingers, followed by adduction of
arms the arms at the shoulder. Disappear: 5-6 months

• Head turned to one side while infant is lying in the

ASYMMETRIC TONIC NECK supine position, there is extension of arm and leg Normal infant should not maintain • Peaks at 2 months old
REFLEX on the side toward which the face is turned while the position beyond few seconds • Absent by 6 months of age
contralateral extremities flex (fencer’s posture)

Subsides by 3 to 6 months of age

and is replaced by voluntary
grasping,
• Place the examiner’s finger in the palm of the leads to an involuntary flexion which is necessary to allow
PALMAR GRASP REFLEX
infant’s hand response transfer of objects from hand to
hand.

Disappear: 6 months

• First elicited between 5 and 10 months

• With one hand supporting the abdomen in the
LANDAU REFLEX flexion of the legs and trunk Disappear: 24 months
prone position, the examiner flexes the infant’s
head with his or her other hand.

The infant flexes the legs at the

• Hold the infant upright in a manner that causes
hips and knees so that contact Disappear: 4-5 months
PLACING REFLEX the dorsal surface of the infant’s feet to touch the
with the underside of the surface (menke’s)
underside of a tabletop.
ceases.

• First elicited between 5 and 10 months

Arms extend and abduct slightly,
• While holding the infant in horizontal suspension,
PARACHUTE RESPONSE fingers spread as if attempting to
suddenly thrust the infant in head first direction
break the fall
towards the floor

1 month: the infant’s head shows 3 to 5 months: the infant is able

• infant in the supine position, examiner grasps both to participate actively with arm
transient neck flexion followed by
TRACTION RESPONSE hands and pulls the infant flexion at the elbow, and by
extension as the infant is pulled
• gently and slowly upward, to a sitting position. holding the head and trunk in a
forward. straight line, no head lag
Swaiman:
• Infants grasping skills are best demonstrated in
response to small objects
• 4–5-month-old infant can grasp an object with
the entire hand
• At 7 months, the thumb and neighboring two
fingers are used
• 9-11 months: pincer grasp should be present
• Persistence of obligate reflex beyond 6
months of age: may indicate corticospinal
dysfunction
• Observation of child’s ability to raise the arms
while reaching for an object – helps assess
proximal muscle strength

Additional from swaiman under development

reflexes:
VESTIBULAR FUNCTION
• Infant in a supine position with the feet closest
to the examiner
• Examiner rotates the infant laterally in each
direction
• The eyes of the infant deviate in the direction of
rotation, accompanied by intermittent
nystagmus to the opposite side
• This maneuver allows extraocular movements
to be assessed

DEEP TENDON REFLEXES (From Newborn Precepts Trans)

• DTRs that are excessively brisk may indicate UMN disease GRADING OF MOTOR STRETCH REFLEX
especially when associated with clonus 0 Absent
• Asymmetry of response is particularly worrisome – associated + Present but diminished
with pathologic condition ++ Normoactive
• Absent DTRs are seen in anterior horn cell disease or +++ Exaggerated
peripheral neuropathy. ++++ Clonus
• Head position had no effect on the reflexes. Clonus – repetitive rhythmic contractions evoked by a stretch
receptor.
Any presence of clonus in one part of the reflexes indicate
spasticity and increased tone
 TEST PROCEDURE EXPECTED FINDINGS Clinical Correlation
• Place a finger horizontally over the chin with the
Slight jerk of the lower jaw exaggerated jerk → a sign of
JAW JERK REFLEX mouth open, and then strike this finger with a
upwards upper motor neuron lesion
tendon hammer.

• Elbow flexed
• Place THUMB over biceps tendon in the
antecubital fossa.
BICEPS REFLEX Flexion of the forearm C5 – C6
• Strike thumb with the POINTED END of the reflex
hammer
• Do the same on the other side

• Flex the patient’s forearm and hold the arm across

the patient’s chest OR allow the patient’s arm to
hang loosely while you support it by placing your
TRICEPS REFLEX hand under the biceps. Extension of elbow C7 – C8
• Using the POINTED END, strike the triceps
tendon located just above the olecranon process.
• Do the same on the other side.

• Place your thumb in the brachioradialis tendon

above the wrist in the radial aspect of patient’s
BRACHIORADIALIS REFLEX forearm Flexion of forearm C5 – C6
• Strike the examiner’s thumbnail rather than the
patient’s radius

QUADRICEPS (KNEE JERK) • Gently bend the patient’s knee and tap the patellar
Extension of the knee L2 – L4
REFLEX tendon just below the patella

TRICEPS SURAE (ANKLE • Gently dorsiflex the foot and tap the Achilles
Plantar flexion of ankle L5 – S1 – S3
JERK) REFLEX tendon
 SUPERFICIAL & OTHER REFLEXES (From Newborn Precepts Trans & Swaiman)
TEST PROCEDURE EXPECTED FINDINGS Clinical Correlation

• Abdominal reflexes are tested with the patient

lying down.
Contraction of abdominal Upper quadrants: T8 – T9
ABDOMINAL REFLEXES • The anterior abdominal wall is lightly stroked from
muscles Lower quadrants: T11 – T12
lateral to medial in four quadrants (bilaterally)
around the umbilicus

No response or a muted
response occurs in normal
• Flicking the patient’s nail (2 or 3 finger)
nd rd
Flexion of the distal phalanx of children
HOFFMAN REFLEX
downward with the examiner’s nail the thumb
(+) brisk or asymmetric response
→ corticospinal tract involvement

Afferent: S1
Efferent: L5 – S1 – S2
• The examiner strokes the sole of the patient's foot
BABINSKI REFLEX (TOE Extensor toe response is
on the lateral edge from heel going to big toe
FLEXION REFLEX) NORMAL in infants until 12-24
(using, e.g., the handle of a reflex hammer) Normal: plantar flexion of toes
months of age
Abnormal: extensor toe response
Presence of this reflex beyond 1-
2 years old occurs after
interruption of the UMNs to the
lumbosacral cord
CHADDOCK • Firmly stroking the lateral aspect of the foot
• Downward pressure on the medial aspect of the
OPPENHEIM
tibia

Afferent: L1
• Stroke the inner aspects of the thigh in a caudal- Efferent: L2
Symmetric contraction of scrotum
CREMASTERIC REFLEX rostral direction and observe the contraction of
or testicular rise Absence or asymmetric response
scrotum may indicate corticospinal tract
involvement
 DEVELOPMENTAL MILESTONES
Dr. Villaluz’s Lecture Dr. Adajar’s Lecture
AGE DEVELOPMENTAL MILESTONES AGE EARLY COGNITIVE EARLY LANGUAGE MILESTONE
1 month • Spontaneous motor activity, generalized MILESTONE
• Lifts head on prone, poor supine head control From • Interest in faces • Phonologic discrimination
• Begins to regard surroundings Birth • Begins to make eye contact
• Follow objects to midline Few • Social smile should develop • Responsive vocalization, turn-taking,
2 months • Motor activity, generalized months before 6 weeks of age cooing (vowels)
• Smiles and coos socially • Laughing out loud is a reliable
• Follows objects past midline milestone that should occur
3 months • Visually tracks objects well; looks around around 4 months of age
• Begins to have hand regard 6-8 • Grabbing for objects, exploring • Babbling consonants/ vowels, syllables,
• Good head control on prone months surroundings dada, baba
• No head lag on pull-to-sit 10-12 • Pointing to indicate wanted • 2-3 words with meaning
• Turns head to source of sound months objects • Imitation of animals
• Improved head control on sitting position • Comprehension of words
• Sustained smiling and cooing 18 – 22 • Should follow simple • Vocabulary spurt
4 months • Begins to reach toys/objects symmetrically months commands • Jargonizing develops interspersed with
• Regards toys/objects and pulls them to mouth • Indicate body parts intelligent words
• Removes diaper on face • Ask for objects by pointing • Receptive language and understanding
• Good head control on sitting • Imitate actions are more developed than speech
• Midline regard (plays with hands) • Onlooker, behavior, nonsocial • By 2 years: word combinations/ many
• Laughs activity, and solitary single words
6 months • Reaches for objects with either • Increasing interest in legs independent play • Expansion of comprehension
hand • Laughs and plays with the Around • Limited social participation • 2-word utterances; mostly intelligible to
• Transfers to other hand (may be examiner 2 yr • Parallel play family; comprehend many sentences
earlier) • Practically all primitive reflexes By 3 yr • Beginning social play (the child • Speaks in grammatical sentences (with
• Rolls over (may be earlier) disappear talks about play, borrows/lends some errors)
• May sit briefly when placed toys, controls who may plain in • mostly intelligible to strangers (still
8 months • Sits alone • Crude pincer grasp (prehension) the group) makes phonologic errors)
• Begins to creep • Complains when left alone
• Regards self in mirror • Response to name
• Babbles with infantile rhythms and
polysyllable sounds
10 months • Crawls • Says “mama, “dada” meaningfully
• Pulls to stand • Holds bottle
• Begins to cruise around furniture • Feeds self with cracker
and/or crib
• Better prehension
12 months • Walks alone or with hand held by examiner/guide
• Stands alone
• Says 2 words other than “mama” and “dada”
• Begins to feed self with fingers
• Releases objects (toys) on request
• Well-developed parachute response
15 months • Independent walking (may be earlier)
• Creeps up on steps
• Produces 4 to 6 words vocabulary
• Drinks from cup
• Begins to feed with spoon
• Stalks 2 blocks
• Vocalized and points to something he or she wants