Paediatric Assessment

Mental State Examination:

• Mental status (the child's level of awareness and

interaction with the environment) 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.
Level of Consciousness:

• The child’s level of consciousness is probably the most

important part of the neurological examination of the
acutely ill child, as alterations in the level of consciousness
will often be the first manifestation of a problem.
• Consciousness is the state of awareness of the individual,
his/her responsiveness to stimulation and his/her ability to
recall past events.
• Clinically, consciousness can be divided into normal
consciousness, sleep states (light and deep), stupor and
coma, based upon the ease with which the patient can be
aroused.
• Periods of impaired consciousness can be short or long.
The level of impairment can range from slight to severe:

• Lethargy is a slight reduction in alertness or clouding of consciousness.

People tend to be less aware of what is happening around them and
to think more slowly.
• Obtundation, refers to a moderate reduction in alertness or clouding
of consciousness.
• Stupor is an excessively long or deep sleeplike state. A person can be
aroused from it only briefly by vigorous stimulation, such as repeated
shaking, loud calling, pinching, or sticking with a pin.
• Coma is a state of complete unresponsiveness. A person cannot be
aroused at all. A person in a deep coma lacks even the most basic
responses, such as avoidance of pain, although reflexes may be
present.
Pediatric GCS:
• Best eye response: (E)
• 4. Eyes opening spontaneously
• 3. Eye opening to speech
• 2. Eye opening to pain
• 1. No eye opening
 •Best verbal response: (V)
• 5. Smiles, orientated to sounds, follows objects, interacts.
• 4. Cries but consolable, inappropriate interactions.
• 3. Inconsistantly inconsolable, moaning.
• 2. Inconsolable, agitated.
• 1. No verbal response.
 •Best motor responses: (M)
• 6. Infant moves spontaneously or purposefully
• 5. Infant withdraws from touch
• 4. Infant withdraws from pain
• 3. Abnormal flexion to pain for an infant (decorticate response)
• 2. Extension to pain (decerebrate response)
• 1. No motor response
Interpretation of GCS
• 0-8 : Severe
• 9-12 : Moderate
• 13-15 : Mild
• Orientation – place, person & time
• Memory- long-term, short-term & immediate
• Intelligence & Mental arithmetic
• Hearing, Speech & Language
• Mood & Affect
• Other higher functions
• - Lateral dominance
• Concept of Body image
• - Right & Left Discrimination
• - Constructional Praxis
• - Drawing
Cranial Nerve Examination:

• CN 1 (Olfactory N):
• Infant- Not tested.
• Standard test odors used for adults are not familiar to most
children.
• Recommended test substances include oil of roses, oil of
cloves, oil of lavender, toothpaste, but chocolate, oranges and
chewing gum may be more useful.
• In young or uncooperative children changes in facial expression
suggest the child can smell.
• CN 2 (Optic N):
• Infant- Shine a bright light in eyes, A quick blink reflex & dorsal head flexion
indicates light perception.
• A complete Ophthalmic examination is recommended.
• Visual acuity – Far and Near vision
• Visual fields - confrontation
• Pupillary reflex
• CN 3, 4 & 6 (Occulomotor, Trochlear & Abducens):
• Infant: Shine an attractive object & move it side to side.
• Pupillary reflex
• Accommodation
• Eye movements in 9 gaze directions
• Conjugateness
• All ages – inspect eyelids for drooping. Inspect pupillary response
to light.
• Eyelids do not droop and pupils are equal in size and briskly
respond to light.
• CN 5 (Trigeminal N):
• Infant- Stimulate the rooting & sucking reflex
• Turns head towards stimuli at side of mouth & sucking has good strength and pattern

• Sensations over the face

• Muscles of Mastication
• Jaw jerk
• Corneal relfex
• CN 7 (Facial N):
• Observe Facial Expressions, should be symmeteical.
• Taste over anterior 2/3rd of tongue.
• Hyperacusis- exaggerated or unpleasant perception of
loud sounds, especially if of a low pitch and is
attributed to paralysis of facial nerve’s motor branch to
the stapedius.
• Epiphora – increased lacrimation and involuntary flow
of tears down the face due to LMN facial paralysis.
• CN 8 (Vestibulo-cochlear N):
• Infant- Produce a loud sound near the head.
• Blinks in response to sound and moves head towards sound.

• Up to the age of 3 or 4, testing of hearing is difficult.

• To confirm the diagnosis, audiology examination is recommended.
• The best test objects are those producing slightly unusual sounds, preferably not too loud,
such as rattles, small hand bells, crinkling paper or even rustling of the examiner’s finger
against thumb.
• The criterion of hearing is a change of expression or more frequently turning of the head or
eyes toward the source of the sound.
• Startle reaction to sound is another criterion of hearing.
• Speak towards ear and ask to repeat, child should repeat correctly.
• For older and cooperative children, Rhinne and weber tests are performed.
• Caloric test and Barany’s chair test are performed to rule out the integrity of vestibular
component.
• Vestibular functions can also be assessed by Post-rotatory Nystagmus
• CN 9, 10 (Glossopharyngeal N and Vagus N):
• Infant- Observe swallowing during feeding, should have good swallowing pattern
• Taste over posterior 1/3rd of tongue.
• Paletal examination
• Ability to articulate and swallow
• Gag reflex, gags with stimulation should present

• CN 11 (Spinal Accessory N):

• Upper trapezius and SCM muscles should be evaluated for bulk and power.
• Ask child to raise shoulder & turn head side to side against resistance.
• CN 12 (Hypoglossal N):
• Infant- Observe feeding
• Sucking & swallowing are coordinated.
• Tongue movements should be evaluated.
• Tongue in midline with no tremors
• Mass of the tongue should be evaluated.
• Words clearly articulated.
Observation:
• Observation of spontaneous movements during free play:
• In supine
• In prone
• During mobility
• Informal gait observation:
• Preferred mode of ambulation,
• Gait abnormalities if any,
• Use of walking aids,
• Use of orthotics,
• Base of support,
• Climbing up & down stairs,
• Ability to navigate or step over obstacles
• Running, hopping, jumping, etc.,
General Physical Examination:
• Measurements:
• Child’s height/length, weight and head circumference.
 
• General appearance:
• Configuration of the face (dysmorhic features, if any), mobility
of expressions and quality of mood, built for his/her
chronological age.
Anthropometry
• Weight measured in gms (normal range ;2500-3500gm).

• Length is measured using an infantometer in cms (normal avg. length ; 50 cm).

• Head circumference is measured by placing a soft non-stretchable tape

around the head just above the eyebrows & finding the largest circumference
over the occiput (normal in term babies ; 33-37 cm).

• Chest circumference at the level of nipples ,is about 3cm < HC .If it is > ,it may
be an indicator of IUGR.
• Depending on weight newborns are termed as:
a) Low birth weight - < 2500g.
b) Very low birth weight - < 1500g .
c) Extremely low birth weight - < 1000g.
Regional Examination:
• Head & Neck:
• Facial dysmorphism
• Telorism
• Size and shape of the cranium,
• Serial measurements of head circumference to rule out micro and
macrocephaly
• Positional asymmetry
• Palpation of fontanalles and sutures
• ‘Cracked pot ‘ sign/note- used to diagnose hydrocephalus (accumulation of
excess CSF) & brain abscesses. Tapping the skull near the junction of the
frontal, temporal & parietal bones will produce cracked pot sound.
• Engorged scalp veins,
• Teeth, Tongue, Lips, Palate, Position of the head upon neck, Infantile Torticollis,
Swellings, Nodules in occipital region, Position of pinnae.
• Thorax and Arms:
• Child should be undressed to the waist and the front and back of the
chest inspected.
• Symmetry of the thoracic cage, rate, rhythm and character of
respiratory movements.
• Auscultation is done if indicated.
• Position of spine and scapulae are examined.
• Shape of hands and fingers are noted.
• In Down’s syndrome there will be broad palm and abnormalities of
palmar creases and prints.
• Long, slender fingers may indicate arachnodactyly (Marfan’s
syndrome).
• Short, stubby fingers indicate pseudo-hypoparathyroidism or
achondroplasia.
• Spine & Pelvis:
• Spinal ROM,
• Check for kyphosis, scoliosis, kyphoscoliosis, lordosis and pelvis
asymmetry,
• Back of the child should be examined for swellings, dimples or tufts of
hair in the mid-line.
• Lower limbs:
• CDH and CTEV,
• Coxa varum & valgum, Genu varum & valgum
• Limb length (apparent, true and segmental length)
• Contractures around hip/knee/ankle
Sensory Examination:

• Complete sensory examination is rarely indicated unless the history or

other physical findings particularly suggest a sensory deficit.
• Sensory mapping is performed to rule out the superficial sensory
modalities incase of spinal pathologies. (The expected response from
neonates/infants/children with speech & language problems may be
some facial expressions or movement of the part tested).
• For grown-up children, all the sensory modalities (Superficial, Deep &
Cortical) are tested by using the same methods of examination as for
adults.
Motor Examination:
• ROM
• Muscle Power
• Muscle Tone
• Reflexes – DTR, Superficial and Developmental reflexes &
reactions (Primitive reflexes, Transitional & Equilibrium
reactions)
• Abnormal / Involuntary movements
• Associated movements
Grading Description (MuscleTone)

Modified Ashworth scale

• 0 -No increase in muscle tone
• 1 -Slight increase in muscle tone, manifested by a catch and release or by
minimal resistance at the end of the ROM
• 1+- Slight increase in muscle tone, manifested by a catch, followed by
minimal resistance throughout the remainder (less than half) of the ROM
• 2 -More marked increase in muscle tone through most of the ROM, but
affected part(s) can be easily moved
• 3 -Considerable increase in muscle tone, passive movement difficult
• 4 -Affected part(s) are rigid in flexion or extension
Tardieu scale

• V1 – Velocity to stretch as slow as possible

• V2 – Velocity to stretch with the speed of limb segment falling with
gravity
• V3 – Velocity to stretch as fast as possible (> natural drop)
• R1 – Angle of catch seen at velocity V2 or V3
• R2 – Full range of motion (ROM) achieved when muscle is at rest and
tested at V1 velocity
 Analysis of Range of Motion &
Joint Contractures
• Hip joint
• Thomas’ hip flexion test- measuring hip
flexion contracture
• The test is performed with the patient in supine
position and the uninvolved limb is adequately
flexed to eliminate exaggerated lumbar
lordosis.
• The angle formed between the horizontal axis
of the thigh and horizontal line parallel to the
floor measures the hip flexion contracture.
Adductor Contracture
• With the patient in supine position, passive abduction of the hip is
performed with the knee in extension and with the knee in 90° flexion
(Phelp’s Test)
• If abduction improves on knee flexion, the primary pathology lies in
the medial hamstring muscles and gracilis.
• If both the measurements are the same, the prime pathology is in the
adductor muscles.
Knee Joint
• commonly presenting deformity in knee is that of flexion contracture,
which is more pronounced in a nonambulatory child.
• The first step in assessment is to differentiate true joint contracture
from contracture due to muscle spasticity or tightness.
Knee joint
• Joint contracture- With the hip
in extension and ankle in gravity-
assisted plantar flexion, the
residual knee flexion measures
true joint contracture
• Muscle (hamstrings) contracture – Also called popliteal angle test
• it is performed with the hip joint in 90° of flexion in supine position, the residual
knee flexion shows the amount of muscle tightness or contracture.
• Duncan-Ely’s/Prone Rectus test- pelvic rise on knee flexion indicating
spasticity of the rectus femoris
Ankle and foot
• Silfverskiold test- gastro-soleus spasticity/contracture
• It is done by passive dorsiflexion of ankle with knee in extension and
then with knee joint in 90° flexion (Silverskiold test)
• A difference of 20°–30° shows a spastic gastrocnemius component.
 Selective Motor Control
• The typical scale for muscle group selectivity is given as follows:

• Grade 0 – No ability/only patterned movement observed

• Grade 1 – Partial ability/partially isolated movements
• Grade 2 – Complete ability/completely isolated movements.
Coordination:
• Nose-finger-nose test
• Finger-to-nose test
• Tracing a square or triangle in space
• Rebound test
• Rapid alternating movements
• Heel-to-shin test
• If objective examination is limited or impossible, the examiner should attempt to
appraise coordination separately, by his own observation or by questioning parents:
• Fine coordination is appraised in terms of ability to lie shoelaces, to cut up food or eat with spoon or
fork, to do puzzles, or to use pencil or crayon on paper
• The working of puzzles and use of pencil and paper which also involve visual-motor coordination
• 
Balance / Equilibrium:

• Equilibrium reactions are directly assessed by pertubating the child over a

therapy ball/balance board/scooter board/swing
• Indirectly, coordination of large muscles is considered in terms of whether the
patient can walk and run normally, go up and down stairs, ride a tricycle or
bicycle, can stand in one leg, can kick a stationary/moving ball, can move in
backward space etc.,
• For grown-up children Pediatric Balance Scale can be used to assess the
Balance
• Document the abnormal as well as aversive reactions, if any.
Abnormal/Involuntary Movements:

• Fasciculation: A very quick involuntary contraction of one or more

motor units of a muscle, usually insufficient to produce movement of
a joint but visible as a brief transient furrow in the skin overlying the
muscle and presumed to be involuntary discharge of one or more
motor units.
• Location of lesion: AHCs or Bulbar motor neurons.
• Fibrillation: Spontaneous contraction of an individual muscle fiber.
• Causes: Myopathies or neuropathies.
• Myoclonus: Quick, non-rhythmic contraction of single muscles or
small muscle groups, sometimes resulting in a sudden jerky movement
of a limb.
• Enhanced by attempted voluntary activity, emotional stress and often by a
wide variety of sensory stimuli.
• Location of lesion: Dentate nucleus or olivary nucleus or red nucleus or
tegmental tract or brainstem reticular formation.
• Static tremor: Tremor at rest when the patient is lying or seated
comfortably, not attempting any activity.
• Fine Rapid tremor (9 – 10 per sec) indicates familial or hyperthyroidism
• Coarse slower tremor ( 3-5 per sec) indicates basalganglionic problem.
• Intentional tremor: Tremor not present at rest but brought out by
attempted voluntary activity.
• Chorea: Rapid involuntary jerks or fragments of movement occurring
unexpectedly and irregularly. Any muscle or muscle group of the
extremities, trunk, head or face may be involved.
• Athetosis: Relatively slow worm-like spasmodic repetitious movements
affecting chiefly the peripheral musculature of the limbs and face.
• Certain characteristic postures are repeatedly assumed, such as hyperextension
of joints (particularly the fingers) and a positive Babinski-like posture of the feet
and toes.
• Facial expressions are often exaggerated. The muscles are usually hypotonic at
rest, although tone is exaggerated during unwanted movement.
• Majority of cases also manifest choreiform movements.
• Dystonia: Involuntary fluctuations of tone and muscular spasms
involving chiefly the muscles of the neck and the trunk and the proximal
musculature of the limbs.
• Strange posture and spasmodic rotations (torsions) are characteristic.
• Location of lesion: Widespread involvement of basalganglia and intralaminar
nuclei of thalamus.
• Ballismus: Large-scale violent tossing or flinging movements which begin
suddenly in the proximal muscle groups of a limb and spread to involve all
or the major part of the limb. Lesion is in the subthalamic nucleus.
• Tics: An arrhythmic, but usually repeated and stereotyped movement of
restricted muscle groups which resembles voluntary movement much
more than does myoclonus.
• In children there is a predilection for the musculature of face, neck and upper
extremities (Shoulders).
• A yelp or other noise may be uttered.
• For e.g., throat clearing, sniffing, pulling on facial parts.
• Tics do not distort or interfere with voluntary movement cease during sleep.
• Tend to increase in severity while the patient is being watched or while he is
tensed or concentrating.
• Psychogenic Movement Disorders in Children.
Associated Movements:
• Absence of normal associated movements:
• Normal associated movements may be lost or suppressed.
• The most important normal associated movement is arm swinging during walking.
• Other associated normal movements include, vivacity of facial expression while
talking, attentive listening, contraction of frontalis muscle of the forehead on
looking upward, turning of eyes, head and body together in response to sound on
side, contraction of the platysma muscle as the patient opens mouth to the full
range or opposes his chin to the chest, extension of the wrist as the fingers are
fisted, and the general body movements accompanying coughing, sneezing and
yawning.
• All these normal associated movements may be suppressed with disease of either
the pyramidal or extrapyramidal systems.
• Signs with pyramidal implications:
• Associated flexion normally takes place at the patient’s elbow when
the examiner passively flexes wrist and fingers. Absence of this
associated movement is referred to as Leri sign.
• Passive flexion of the fingers produces movement of thumb in the
direction of adduction and opposition. Absence of this is referred to
as Meyer sign.
• Inability to achieve muscular fixation of the pelvis on the paretic
side:
• The patient with hemiparesis can raise either lower extremity separately (the
paretic one less effectively of course) when lying in supine but he cannot raise
both legs simultaneously, and if he elevates the paretic one first, it falls back
as soon as he attempts to raise the normal.
• Mirror movement:
• Voluntary movements on side of the body, particularly with the hands and
fingers are mimicked in mirror image on the opposite side.
• A considerable tendency to mirror movement is normal in preschool children.
• However, very strong tendency to mirror movement which cannot be
suppressed by attention and effort is abnormal.
• Emergence of abnormal associated movements:
• Various maneuvers produce associated pronation and flexion of the wrist; for example,
active flexion of the elbow.
• If the patient is lying supine and attempts to rise to the sitting position, holding his
arms in front of the chest, there may be involuntary associated flexion of the hip in
association with flexion of neck and trunk.
• In supine posture, voluntary flexion of the hip and knee of a paretic extremity is
followed by involuntary associated dorsiflexion and inversion of the foot.
• If the patient is standing erect and attempts to bend as forward as possible by flexing
the waist and hips, there will be associated flexion of the hip and knee on the
hemiparetic side.
• Homolateral limb synkinesis
• Raimiste’s phenomenon
Posture:

• Posture and attitude of limbs should be assessed in Supine lying,

Prone lying, Quadriped, Sitting and Standing. Asymmetries and
abnormal spinal alignments should be documented.
Gait analysis
• Observational gait analysis
• Video graphic gait analysis
• Instrumented 3D gait analysis
Gait:

• Gait of Cerebellar ataxia:

• The patient walks on a wide base, staggering and lurching
irregularly to either side or swaying forwards or backwards.
Truncal tremor may be present. Tandem walking is difficult. If
he/she is asked to take a few steps alternately forwards or
backwards he/she may slowly drift towards the right.
• Gait of Sensory ataxia:
• Resembles that of cerebellar in some ways. While walking heel
is brought down on the floor first, followed by a slapping
contact of the toes.
• Gait of Spastic hemiparesis:
• There is tendency to an equinus posture of the foot, often with
contracture of the Achilles tendon, which makes the lower extremity
functionally longer on the paretic side. The patient may compensate for
this by circumducting the leg in an arc away from the hip, elevating the
pelvic brim on the affected side and dragging the foot a little, scraping the
toes against the floor.
• Gait of Spastic paraparesis:
• In addition to the equinus position of the ankle, adductor spasm about
the hips becomes a major problem. The patient walks with a stiff, shuffling
type of gait, scraping his toes but also adducting the lower extremities so
as bump the knees against one another or to cross one foot in front of the
other in a ‘scissors gait’.
• Gaits of dystonia and athetosis:
• Writhing contortions of the trunk and neck, a tendency to
throw the head backwards or from side to side, grimacing of
the face and often writhing movements of the extremities are
characteristic of athetoid cerebral palsies or progressive disease
of the basal ganglia in which dystonia is a significant
component.
• During the phase of progression in walking, there is often a
characteristic posturing of the lower extremity, which is
brought forward with moderate flexion of the hip and knee,
slight external rotation of the hip and with the foot in an
equinovarus posture. There may be dorsiflexion of the toes or a
babinski-like posture.
• Gait of Footdrop:
• Results from weakness of tibialis anterior muscle.
• The patient may drag the foot, scarping the toe on the floor or may
attempt to compensate for footdrop by exaggerated lifting of the lower
extremity (steppage gait), throwing the foot out and slapping the toe
down before the heel strikes the floor.
• Astasia abasia:
• Loss of the ability to stand and walk without any other abnormality (due to psychic
disturbances).
Gait patterns in cerebral palsy
• Winters et al. described four gait patterns in spastic hemiplegics based on
sagittal kinematics
• Type 1 hemiplegia gait – Drop foot type
• Type 2 hemiplegia gait – True equinus with or without recurvatum knee
• Type 3 hemiplegia gait – Stiff knee gait
• Type 4 hemiplegia gait – In sagittal plane, the ankle is in equinus, knee in
flexion, hip in flexion and anterior pelvic tilt is present. In coronal plane,
there is hip adduction and internal rotation.
Type 2 hemiplegia gait
Gait patterns in spastic diplegia
• In spastic diplegia, there is more proximal involvement and therefore
apparent equinus and crouch gait are seen commonly.
• There are four common patterns of gait in spastic diplegia
• Type 1 – True equinus
• Type 2 – Jump gait
• Type 3 – Apparent equinus
• Type 4 – Crouch gait
Type 2 – Jump gait
Type 4 – Crouch gait
Functional evaluation:

• WeeFIM
• PEDI (Pediatric Evaluation of Disability Inventory)
Investigations:
• Results/Findings of Blood and Urine investigation,
• X-rays, CT scan, MRI scan,
• Sputum examination,
• ECG,
• Doppler studies,
• Fundoscopy,
• EMG, NCV, EEG,
• BAEP, BERA (brainstem evoked response audiometry (BERA)
• Electroretinography,
• CSF examination,
• Chromosomal studies,
• Pharmacological tests,
• Muscle biopsy,
• Psychometric tests are documented in the relevant cases/conditions.
Problem List:
• Delay in the development (Motor- Gross & Fine, Cognition, Language, Personal-Social)
• Unintegrated reflexes and their interference in functions / abilities
• Poor transitional and equilibrium reactions
• Sensory Integrative Dysfunctions
• Abnormal Tonicity
• Reduced / Increased ROM
• Reduced Muscle Power
• Soft tissue tightness/contractures (Secondary to non-progressive CNS dysfunction)
• Deformities (Congenital skeletal deformities, Acquired deformities secondary to non-
progressive CNS dysfunction)
• Hearing deficit
• Visual deficit
• Locomotor problems
• Hand functions impairment
• Poor memory and intellectual skills
• Poor Oromotor functions
• Poor Communication & Language Skills
• Recurrent respiratory infections
• Poor academic performance
• Poor / Abnormal Social behavior
• Poor Coordination
• Poor Balance
• Aversive reactions
• Impaired / Decreased Level of functioning in ADL skills