Examination of the CNS

in Children

Professor Low Poh Sim

Department of Paediatrics
UCMI
 Stop, Look, and Listen
 The infant and child are unable to fully
cooperate for the standard neurological
examination
 Examination must be tailored to the child
and their developmental level and
temperament
 The first part of the examination is to
stop, look, and listen
 Stop and Look
You can determine about child’s mental
status, coordination and motor status
with
Initial hands-off careful observation not forcing
the child to conform to your pattern of
performing the neurological examination
Watching the baby’s spontaneous activity
 Save the Worst for Last
 Most threatening steps to a child are
 undressing the child for a complete
examination
 looking at the fundus with an
ophthalmoscope,
 using the otoscope
 testing the gag reflex
 measuring the head circumference
 Examination of The CNS
 General inspection – dysmorphism / malformations
 Head size, shape
 Measurement of OFC
 Skin – neurocutaneous signs
 Cranial nerves
 Motor system including gait and posture
 Sensory system
 Reflexes
 Developmental status - applies especially to the
preschool child
 Head shape

Dolichocephaly Plagiocephaly Brachycephaly

 Anterior Fontanelle
 Anterior fontanelle
closes at 12-18 mths

 Big
 Small  Hydrocephalus
 Microcephaly  Subdural effusion
 Craniostenosis  Macrocephaly
Normal head size vs Microcephaly
 Cranial Nerves
 Learn your technique for examination
 Special emphasis in children
 Examination for strabismus
 Visual fixation and following (Nystagmus)
 Ability to differentiate UMN facial weakness
vs LMN facial palsy
 Assessment of hearing in children
 Dysfunctional swallowing
 How to examine for
concomitant strabismus
 To ascertain that movements of each eye are
good in all directions
 Cover test
 Ask child to look at an object immediately in front
of him
 Suddenly cover the apparently fixing eye and
watch any movement of the other eye (previously
deviated) in taking up fixation
 The covered eye will now deviate in the same
relative direction as was the other eye
 Cranial Nerves 2,3,4 and 6
Examination In Babies
 Cranial Nerve 2: Testing a baby’s behavior
response to light. Pupillary light reflex is
done in the same manner as in adult exam
 Eye movements (Cranial Nerves 3, 4 and 6)
can be assessed by using the vestibulo-ocular
reflex (doll’s eyes maneuver). When the head
is turned, there is conjugate eye movement in
the opposite direction.
 Examination of the Facial Nerve
Forceful eye closing Testing frontalis
muscle

Symmetry

Depth of
Examination of the Facial Nerve
Purse lips together and Clenching teeth and forcefully pulling
distend cheeks the corners of mouth downward

Symmetry of
UMN weakness vs LMN Facial palsy
LMN lesion: (nucleus or UMN lesion
peripheral nerve)

 Unable to move  Paresis of muscles of

forehead upward the lower face
 Unable to close eye  Muscles of forehead are
forcefully bilaterally innervated
 Unable to elevate and are unaffected
corner of mouth on side
of lesion
Examination of Cranial Nerves
5, 9, 10, 11 and 12 in Babies
 The quality and strength of the cry is a
way of looking at Cranial Nerves 9 and
10 function. Presence of hoarseness
and stridor are important findings
 Sucking and swallowing assesses
Cranial Nerves 5, 7, 9, 10, and 12
because all of these cranial nerves are
involved in this complex act.
 Examination of
Motor Functions
 Size of muscles
 State of muscular tone
 Motor power
 Coordination of motor movements
 Presence/absence of involuntary movements
 Gait
 Contracture of joints
 Size of Muscles
 Wasting / hypertrophy
 Asymmetry
 Distribution of wasting
 Localised to a limb, segment of limb, 1 side
 Generalised
 Proximal
 Distal
Motor Power Assessment
 Grade muscle power (0 – 5)
 In a younger child, to evaluate
 Head control, weight bearing, independent
sitting, standing and walking
 In an older child, evaluate:
 Walking, running, jumping, climbing and hopping
 Patterns of weakness
 Proximal: Suggestive of myopathy
 Distal: Suggestive of peripheral neuropathy
 Muscle Tone

Move limbs passively around the joints

 Hypotonia  Hypertonia
 LMN disease  Spasticity:
 Cerebellar disease  Pyramidal
 Acute UMN lesion  Rigidity:
 Extrapyramidal
 Reflexes
 Superficial  Deep (tendon)
reflexes reflexes
 Plantar reflex  AJ, KJ, BJ, TJ, SJ
 Superficial  Jaw jerk
abdominal  Clonus
 Conjunctival
 Pupillary  Sphincteric reflex
 Palatal  Anal reflex
 Assessment of Gait
 A patient well enough should to made
to walk in a straight line for 4-5 metres,
turn and walk back to the starting point
 Walk on tiptoes forwards
 Walk on heels backwards
 Hop across the room on one foot and
then on the other
 Walking in tandem
 Gait Assessment –
Points to note
 Posture of the body while walking
 Position and movement of the arms
 The relative ease and smoothness of
movement of the legs
 The distance between the feet both in
forward and lateral directions
 The regularity of the movement
 The ability to maintain a straight course
 The ease of turning and of stopping
 Coordination of Motor Movement
Signs of Cerebellar Dysfunction
 Ataxia – titubation,
truncal, gait
 Upper limb  Lower limb
incoordination
incoordination
 Finger-nose test
 Heel sliding
 Building tower with
 Heel tapping
blocks
 Rapidly repeated

/alternating
movements
 Tests for Coordination
of Upper Limbs
Pinching thumb and
little finger together

Finger-nose-finger
testing

One hand
clapping
Tapping one
hand on back
of the other
 Tests for Coordination
of Upper Limbs

Rapid alternating prone-supine-prone position of the hand on the thigh

Test for Coordination in Lower Limbs

Heel

Sliding
Test for Coordination in Lower Limbs

Heel

Tapping
Tandem Walking

 Tandem walking
(in older child >6
years)
 Abnormal
Muscular Movements
 Fasciculation
 Stereotypies
 Involuntary movements
 Dystonia
 Myoclonus
 Chorea and athetosis
 Tremor
 Tics
 Examination of
Sensory Functions
In a child, this is only done when relevant
 For cord lesions
 Touch, pain, temperature
 For posterior column lesions
 Position sense, vibration sense, joint sense
 For cortical sensation
 Stereognosis, two point discrimination,
graphaesthesia, sensory inattention
 Technique in Testing Sensation
 Move from areas of reduced to normal
sensation when testing cutaneous
sensitivity
 Understanding of pattern of cutaneous
distribution of sensory loss in cord lesion
vs peripheral nerve lesion
 Recognition of sensory abnormalities
which suggest non-organic sensory loss
 Recognition of Pattern (1)
 Weakness: proximal < distal
 Wasting (± fasciculations)
 Hypotonia
 Hypo-reflexia
 Normal sensation
LOWER MOTOR NEURON LESION
 Recognition of Pattern (2)
 Weakness
 Wasting
 Spasticity
 Hyper-reflexia
 Sensory level
 Bladder and bowel dysfunction

CORD LESION
 Recognition of Pattern (3)
 Weakness
 Spasticity
 Hyper-reflexia
 Normal sensation
 Babinski’s sign

UPPER MOTOR NEURON LESION

 Recognition of Pattern (4)
 Hypotonia
 Hyper-reflexia
 No weakness
 Developmental delay

CEREBRAL DYSFUNCTION
 Recognition of Pattern(5)
 Hypotonia
 Hyporeflexia
 Fine motor incoordination
 No weakness

CEREBELLAR DYSFUNCTION
 Recognition of Pattern (6)
 Rigidity
 Dystonia
 Variable deep tendon reflexes
 Involuntary movements

EXTRAPYRAMIDAL DYSFUNCTION
 Recognition of Pattern (7)
 Wasting
 Weakness: distal > proximal
 Sensory disturbance (pain, numbness)
 Lack of coordination
 Absent reflexes
 Autonomic dysfunction

PERIPHERAL NEUROPATHY