11/13/24, 7\:07 PM Guide | Paediatric neurological exam

Paediatric neurological exam

Table of contents

Background

Examining the neurological system is di
the complete exam are extensive and usually cannot be performed in a classical fashion. This approach may be carried out on
a cooperative school-aged child – but always be mindful of keeping the examination fun.
Observation is key. Make the most of every opportunity to examine the child. See how they play, taking into account
handedness and motor de
their daily functioning and paint a broad picture of their neurological function.
Some tips include\:
Using items such as a tennis ball, small toys (including a toy car), bells, bubbles and an object that will attract the child's
attention (like a pinwheel).
Be mindful to postpone uncomfortable tasks until the end, such as head circumference, fundoscopy and sensory testing.

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the parents and the child, including your name and role.
Con
Brie
" T o d a y I' d l i k e t o p e r f o r m a n e u r o l o g i c a l
e x a m i n a t i o n , w h i c h w i l l i n v o l v e m e t e s t i n g t h e n e r v e s t h a t s u p p l y d i
"
Gain consent from the parents/carers and/or child before proceeding\: " A r e y o u h a p p y f o r m e t o c a r r y o u t t h e e x a m i n a t i o n ?"

General inspection

With toddlers – the initial phase of observation is best done with the child in the parent’s lap. Through minimising
apprehension, assessment of higher cortical function, muscle tone and tendon re

Higher cortical functions

Observe the child during play\:
Attention span
Gross and
Problem-solving abilities
Observe for age-appropriate milestones (see our guide on developmental milestones).

Cranial nerves

Testing in infants is often by observation for speci
children, it may be possible to formally assess at least some cranial nerves, however, this very much depends on the exact age
of the child, their current state and the environment. We have provided a guide to each of the cranial nerves below, however, it
is unlikely you will be able to carry out a complete neurological assessment in one sitting with most children.
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Olfactory nerve (I)

The olfactory nerve is responsible for the sense of smell.
Assessment
Test the ability to detect a smell with the child's eyes closed (i.e. chocolate).
Olfaction is not assessed in small children or infants.
Olfaction can be impaired after closed head injury and in infants with arhinencephaly-holoprosencephaly.

Optic nerve (II)

The optic nerve is responsible for vision and a
Testing visual acuity
Infant\: observe the infant reach for objects of varying size.
>6 months old\: observe reaching for scraps of paper less than 5mm in size when placed on a dark background.
Older children\: standard recognition of letters, numbers or shapes on a Snellen chart (see our guide to visual assessment).
Visual
Introduce objects into the peripheral
Note if the child becomes aware of the peripheral object (e.g. turning head towards it).
Pupillary re
To best see pupillary re
Direct pupillary re
Shine a light into the pupil and observe constriction of that pupil.
Sluggish reaction or lack of constriction may suggest pathology (optic nerve or brainstem lesion).
Consensual pupillary re
Again shine a light into the pupil, but this time observe the contralateral pupil.
A normal consensual response involves the contralateral pupil constricting.
Lack of a normal consensual response may suggest damage to one or both optic nerves or damage to the Edinger-
Westphal nucleus.
Fundoscopy
Fundoscopy is often di
using equipment designed speci
Assess the fundal re
Look through the ophthalmoscope, shining the light towards the child's eye at a distance of approximately one arm’s length.
Observe for a reddish/orange re
A white fundal re
Assess the fundus\:
1. If you are assessing the child's right eye, you should hold the ophthalmoscope in your right hand and vice versa. Place the
hand not holding the ophthalmoscope onto the child's forehead to prevent accidental collision between yours and the child's
face.
2. Approaching from a 10-15 degree angle slightly temporal to the child, move closer whilst maintaining the fundal re
3. Begin by identifying a blood vessel and then follow the branching of this blood vessel towards the optic disc (the branches
point like arrows towards the optic disc).
4. Once you identify the optic disc assess its characteristics including the contour, colour and cup (“3Cs”)\:
Contour\: the borders of the optic disc should be clear and well de
presence of optic disc swelling (papilloedema) secondary to raised intracranial pressure.
Colour\: a healthy optic disc should look like an orange-pink doughnut with a pale centre. The orange-pink colour represents
well-perfused neuro-retinal tissue. A pale optic disc suggests the presence of optic atrophy which can occur as a result of
optic neuritis, advanced glaucoma and ischaemic vascular events.
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Cup\: the cup is the pale centre of the orange-pink doughnut mentioned previously. The pale colour of the cup is due to the
absence of neuroretinal tissue. The vertical size of the cup can be estimated in relation to the optic disc as a whole, known as
the “cup-to-disc ratio“
. A cup-to-disc ratio of 0.3 (i.e. the cup occupies one-third of the height of the optic disc) is generally
considered normal. An increased cup-to-disc ratio suggests a reduced volume of healthy neuro-retinal tissue, which can
occur in glaucoma.
5. Methodically assess each quadrant of the retina and the associated vascular arcades in a clockwise or anticlockwise fashion
looking for evidence of pathology\:
Superior temporal (ST)
Superior nasal (SN)
Inferior nasal (IN)
Inferior temporal (IT)

Oculomotor, trochlear and abducens nerves (III, IV, VI)

The oculomotor (CN III), trochlear (CN IV) and abducens (CN VI) nerves transmit motor information to the extraocular
muscles to control eye movement and eyelid function. The oculomotor nerve also carries parasympathetic
for pupillary constriction.
Inspect for ptosis
Look for evidence of eyelid asymmetry suggestive of ptosis.
Causes include sympathetic paralysis from lesions of cranial nerve III, Horner's syndrome, myopathies, myasthenia gravis
and structural eye lesions (e.g. neuro
Assess extraocular eye movements
Test horizontal, vertical and oblique planes of eye movement by drawing an imaginary
light and asking the child to follow it.
"H"
with a brightly coloured soft toy or
Oculomotor, trochlear and abducens nerve palsy
extraocular muscles can result in paralysis of the corresponding muscles.
Damage to any of the three cranial nerves innervating the
Oculomotor nerve palsy (CN III)
The oculomotor nerve supplies all extraocular muscles except the superior oblique (CNIV) and the lateral rectus
(CNVI). Oculomotor palsy (a.k.a.
'third nerve palsy'), therefore, results in the unopposed action of both the lateral rectus
and superior oblique muscles, which pull the eye inferolaterally. As a result, children typically present with a ‘down and
out’ appearance of the a
palpebrae superioris) as well as mydriasis (pupillary dilation) due to the loss of parasympathetic
innervating to the sphincter pupillae muscle.
Trochlear nerve palsy (CN IV)
The only muscle the trochlear nerve innervates is the superior oblique muscle. As a result, trochlear nerve palsy ('fourth
nerve palsy') typically results in vertical diplopia when looking inferiorly, due to loss of the superior oblique's action of
pulling the eye downwards. Children often try to compensate for this by tilting their head forwards and tucking their chin
in, which minimises vertical diplopia. Trochlear nerve palsy also causes torsional diplopia (as the superior oblique muscle
assists with intorsion of the eye as the head tilts). To compensate for this, children with trochlear nerve palsy tilt their head
to the opposite side, in order to fuse the two images together.
Abducens nerve palsy (CN VI)
The abducens nerve (CN VI) innervates the lateral rectus muscle. Abducens nerve palsy ('sixth nerve palsy') results in
unopposed adduction of the eye (by the medial rectus muscle), resulting in a convergent squint. Children typically
present with horizontal diplopia which is worsened when they attempt to look towards the a
Gaze abnormalities associated with paediatric neurological disease\:
Opsoclonus\: chaotic bursts of eye movements, often associated with myoclonus caused by neuroblastoma.
Up gaze paresis\: associated with Parinaud syndrome.
Impaired downwards gaze\: associated with Niemann Pick Type C disease.
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Oculomotor apraxia\: delayed initiation of eye movement and jerky pursuit movements. Associated with Joubert syndrome
and oculomotor apraxia-ataxia syndrome.

Trigeminal nerve (V)

The trigeminal nerve (CN V) transmits both sensory information about facial sensation and motor information to the muscles of
mastication.
The trigeminal nerve has three sub-divisions, each of which has its own broad set of functions (not all are covered below)\:
Ophthalmic (V )\: carries sensory information from the scalp and forehead, nose, upper eyelid as well as the conjunctiva and
1
cornea of the eye.
Maxillary (V )\: carries sensory information from the lower eyelid, cheek, nares, upper lip, upper teeth and gums.
2
Mandibular (V )\: carries sensory information from the chin, jaw, lower lip, mouth, lower teeth and gums. It also carries motor
3
information to the muscles of mastication (masseter, temporal muscle and the medial/lateral pterygoids) as well as the
tensor tympani, tensor veli palatini, mylohyoid and digastric muscles.
Assess sensory function
Assess response to light touch over the three sub-divisions of the trigeminal nerve using a piece of cotton wool.
In a baby, the presence of the rooting re
Assess motor function
Ask the child to open their mouth against resistance.
Jaw jerk re

Facial nerve (VII)

The facial nerve provides motor innervation to the muscles of facial expression and is also involved in taste sensation.
Inspection
Inspect the child's face for asymmetry.
Compare the nasolabial folds to identify subtle asymmetry.
Assess motor function
It is di
Instead, observe their facial expressions for any asymmetry (e.g. when smiling, crying etc).
In older children, you may be able to ask them to copy your facial expressions (e.g. blowing out your cheeks, showing teeth,
screwing up eyes, wrinkling forehead).

Vestibulocochlear nerve (VIII)

The vestibulocochlear nerve is responsible for balance and hearing.
Assessment
Infants\: make a soft sound close to the ear (i.e. rustling of paper). The child should show an ‘alerting response’
.
>5-6 months\: the child should be able to localise the sound to a speci
School-age children\: softly whisper a number approximately 30 cm from the ear. Rinne and Weber’s can also be used.
Vestibular function\: poor head control, truncal unsteadiness, gait ataxia, nausea, vomiting and horizontal nystagmus may
indicate vestibular system dysfunction.
See our guide to hearing assessment for more details.

Glossopharyngeal and vagus nerve (IX, X)

The glossopharyngeal (IX) and vagus (X) nerves have various functions including\:
IX\: sensation from the soft palate and taste.
X\: palatal movement, vocal cord control and cough.
Assessment
Observe the child swallowing\:
Observe the child drinking or eating.
Dysfunctional swallowing may present with salivary drooling, pooling of saliva and coughing during feeding.
Observe the movement of the soft palate\:
Observe the uvula and ask the child to say “ A h h” (if possible).
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Unilateral CNX lesions result in deviation of the uvula to the side contralateral to the lesion.
Listen to the child's voice\:
Hoarseness may be due to unilateral dysfunction of the recurrent laryngeal nerve (X).
Bilateral dysfunction results in a bovine cough.
Gag re
Assesses both the a
You should have an awareness of this test, however, it is not performed in routine clinical practice.

Accessory nerve (XI)

The accessory nerve provides motor innervation to the trapezius and sternocleidomastoid muscles, which assist with head-
turning and shoulder shrugging.
Assessment
Test elevation of the shoulders\:
If the child is old enough, ask them to scrunch their shoulders up towards their ears (demonstrate for them).
Test turning the neck against resistance\:
If the child is old enough, ask them to look over their shoulder whilst you observe the sternocleidomastoid muscle.
Small child\: when supine, gently push the head laterally while supporting the shoulder.

Hypoglossal nerve (XII)

The hypoglossal nerve is responsible for the movement of the tongue.
Assessment
Inspect the tongue when inside the mouth for fasciculations.
Ask the child to stick out their tongue\: a unilateral CNXII lesion results in deviation of the tongue to the a
Check whether the tongue can be equally protruded on both sides.

Upper and lower limb examination

This portion of the examination requires an assessment of muscle tone, strength, re
lower limbs.
Upper motor neuron (UMN) lesions
Lesions result in loss of muscle strength and dexterity distal to the injury, hypertonia and hyperre
Due to the corticospinal tract crossing at the pyramidal decussation, UMN lesions will present with contralateral de
lesions above the pyramids and ipsilateral defects for lesions of the spinal cord.
Spinal cord lesions will also present with LMN
nerve at that level.
Lower motor neuron (LMN) lesions
Lesions result in muscle fasciculations and atrophy, loss of strength, decreased tone and absent deep tendon re

Inspection

Begin by inspecting the limbs for symmetry, muscle bulk and posture.
Look for any evidence of abnormalities\:
Asymmetry at rest in infants\: may suggest hemiparesis.
Opisthotonus\: persistent arching of the neck and trunk due to bilateral cerebral cortical dysfunction.
Abducted hips or ‘frog-legged’ posture\: hypotonia
Making a
corticospinal tract involvement.
Tremor\: rhythmic,
Myoclonus\: quick, non-stereotyped jerks around a segment of the body.
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Athetosis\: slow, sinuous movement of the distal extremity with pronation of the distal extremity.
Chorea\: rapid, quasi-purposive, non-stereotyped movements of a segment of the body that is generally proximal.
Tics\: highly stereotyped and repetitive movements.
Muscle atrophy\: may be segmental or generalised and can be associated with neuropathy, myopathy or disuse atrophy.
Pseudohypertrophy\: bulky appearance of a muscle with associated weakness (e.g. Duchenne muscular dystrophy).
Fasciculations\: ripple-like movements of the muscles that accompany the degeneration of anterior horn cells.
Stereotyped hand wringing movements and bruxism\: may be seen in Rett syndrome.

Gait

Observe the child walking (if able)\: pay attention to their posture, arm swing, stride length, speed, symmetry, balance and any
abnormal movements.
Gait abnormalities
Ataxic gait\: broad-based, unsteady and associated with either cerebellar pathology or sensory ataxia (e.g. vestibular or
proprioceptive dysfunction). In the context of proprioceptive sensory ataxia, children typically watch their feet intently to
compensate for the proprioceptive loss. If a cerebellar lesion is present the child may veer to the side of the lesion.
High-stepping gait\: can be unilateral or bilateral and is typically caused by foot drop (weakness of ankle dorsi
child also won’t be able to walk on their heel(s).
Waddling gait\: shoulders sway from side to side, legs lifted o
commonly caused by proximal lower limb weakness (e.g. myopathy).
Hemiparetic gait\: one leg held sti
commonly associated with individuals who have had a stroke.
Spastic paraparesis\: similar to hemiparetic gait but bilateral, with both legs sti
inverted and “scissor”
. This type of gait is typically associated with hereditary spastic paraplegia.

Tone

Muscle tone is assessed by passively taking the limb through a range of motion – including the shoulder, elbow and wrist
bilaterally in the upper limb and the hip, knee and ankle bilaterally in the lower limb.
Spasticity
Spasticity is “velocity-dependent”
, meaning the faster you move the limb, the worse it is. There is typically increased tone in the
initial part of the movement which then suddenly reduces past a certain point (known as “clasp knife spasticity”). Spasticity is
also typically accompanied by weakness.
Spasticity is associated with pyramidal tract lesions (e.g. cerebral palsy).
Rigidity
Rigidity is “velocity independent” meaning it feels the same if you move the limb rapidly or slowly.
Rigidity is associated with extrapyramidal tract lesions.
Clonus
Clonus is a series of involuntary rhythmic muscular contractions and relaxations that is associated with upper motor neuron
lesions of the descending motor pathways (e.g. cerebral palsy).
1. Position the child's leg so that the knee and ankle are slightly
they can relax.
2. Rapidly dorsi
3. Keep the foot in this position and observe for clonus. Clonus is felt as rhythmic beats of dorsi
more than 5 beats of clonus are present, this would be classed as an abnormal

Further upper and lower limb assessment

The assessment of muscle power in young children is less formal and involves comparing the strength of their natural
movements between sides.
The assessment of reNIPE guide for details on how primitive
re
The formal assessment of sensation is often not possible in young children and gross assessment is used instead.
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See our upper and lower limb neurological examination guides for more details on the formal assessment of power, re
and sensation.

Cerebellar examination

Cerebellar function should be assessed as part of a complete neurological examination.
If the child is unable to follow instructions - noting how a child reaches for and manipulates toys can be used as a crude
assessment of coordination.
See our cerebellar examination guide for more information (adapting it as appropriate to the age of the child).

Neurological examination of the infant

See our guide to the newborn infant physical examination (NIPE), which covers basic neurological assessment of the infant,
including primitive re

Cognitive assessment

Young children

Cognitive assessment in young children typically focuses on whether they are currently meeting the various milestones that
would be expected of a child that age (e.g. communication abilities).
Parents should be asked about how the child is progressing in relation to their milestones. A history of loss or plateauing of
developmental milestones is a red
See our developmental milestones guide for more details.

Children aged >7 years

The mini-mental state examination (MMSE) may be used, with modi
(e.g. MMSPE for preschool-aged children).

To complete the examination...

Explain to the child and parents that the examination is now
Ensure the child is re-dressed after the examination.
Thank the child and parents for their time.
Explain your
Ask if the parents and child (if appropriate) have any questions.
Dispose of PPE appropriately and wash your hands.
Summarise your

Further assessments and investigations

Suggest further assessments and investigations to the examiner\:
Skin assessment\: both the skin and the nervous system develop from ectoderm during embryogenesis, so dermatological

spots in tuberous sclerosis).
Assessment of the back\: scoliosis or a patch of hair which may indicate an undetected vertebral anomaly (e.g. spina bi
Cardiovascular examination\: important if considering causes of loss of consciousness or a thromboembolic source of stroke.
Abdominal examination\: important if considering metabolic diseases (e.g. hepatomegaly in glycogen storage disorders).
Vital signs
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Measure and plot height and weight on a growth chart.
Lumbar puncture (e.g. meningitis, encephalitis)
Neuroimaging (e.g. CT/MRI)
EEG\: if investigating possible seizures.
Nerve conduction studies (e.g. visual and somatosensory evoked potentials).

Reviewer

Dr Sunil Bhopal
Senior Paediatric Registrar

References

Text references

Acedillo, R (2011). Pediatric Neurological Exam Checklist. L e a r n p e d i a t r i c s .c o m N a r r a t i o n . The University of British Columbia.
[LINK](Accessed 20 Mar 2019)
Bishop & Statham (2011). Neurology Examination. L e a r n p e d i a t r i c s .c o m N a r r a t i o n . The University of British Columbia. [LINK]
(Accessed 20 Mar 2019)
Hills, W. Pediatric and Infant Neurologic Examination. OHSU. [LINK] (Accessed 20 Mar 2019)
Kotagal (2019). Detailed neurologic assessment of infants and children. Nordli Jr. (ed). U p T o D a t e . Waltham MA. [LINK]
(Accessed 20 Mar 2019).
Lissauer, T., Clayden, G., & Craft, A. (2012). I l l u s t r a t e d t e x t b o o k o f p a e d i a t r i c s . Edinburgh\: Mosby.
Miin Lee (2014). Neurological Examination Guide. M R C P C H C l i n i c a l R e v i s i o n . Trainees Committee, London School of
Paediatrics. [LINK](Accessed 20 Mar 2019)
Snowdon, D (2006). Neurological examination.
Tasker, R. C., McClure, R. J. & Acerini, C. L. (2013). O x f o r d h a n d b o o k o f p a e d i a t r i c s . Oxford\: Oxford University Press.

Image references

1. Photo by Caleb Woods on Unsplash
2. Photo by Christian Bowen on Unsplash
Source\: geekymedics.com
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