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Neurological examination

Performing a neurological examination of a child is a broad and diverse component of physical examination, not only because of all the bodily functions involved, but also because of the need for developmental assessment of the various age groups involved. As is common with physical assessment, some of the techniques you’ll use during a neurological examination will become staples in your practice, and you will use them on a routine basis. Checking pupillary reaction, for example, is a neurologic test that many pediatric nurses perform frequently. Other skills, such as checking deep tendon reflexes (DTRs), are used less routinely or only in some practice settings. Once a child is 5 years old, checking DTRs is often included in a complete neurological assessment, especially in pediatric critical care and emergency units or when a child has a known neurological deficit. In some pediatric practice settings, though, it’s rarely done. Nevertheless, learning the skills you’ll need across all pediatric settings forms an excellent basis for your assessment of children of all ages.

Prior to performing a neurological assessment, familiarize yourself with normal developmental variations in assessment parameters, as well as procedures that assess language development, balance and fine-motor development for age, coordination, and cranial nerve function. There is a variety of neurological assessment scales, adapted for age, for children who have neurological deficits or injury. These include a pediatric Glasgow Coma Scale and an AVPU scale (alert, responds to verbal stimuli, responds to pain, unresponsive). After using these, be sure to document any possible deficits and refer the child to the appropriate specialist for further evaluation.

Mental status

Neurologic assessment typically begins with considering the child’s mental status. Is the child alert and responding appropriately to your greeting? Ask the parents about the child’s mental status and any changes or concerns they have. Level of consciousness is difficult to assess in younger patients, thus the best source of data about level of consciousness is the parents. Be sure to correlate what you observe with the parents’ evaluation. And always consider developmental variables. For example, a 2-year old who “cooperates” with venipuncture is not showing a developmentally appropriate response, which would be to cry and pull away from the needle.

Reporting mental status also includes a statement about older children’s mood, or affect. You will get a sense of this as you interact with them. Does the child have good eye contact with the parent? Ask the parents to describe the child’s usual behavior and attention. Is the child’s affect bright, anxious, depressed, angry, frightened, or hostile? Tests of memory are also included in this phase of the neurological examination.

Infants. Assess the mental status of a newborn by observing her general state and appearance as well as looking for the activities most newborns can perform. Begin by evaluating the infant’s level of consciousness. She should be alert and responding appropriately for her age. If she is asleep, it should be easy to arouse her. Observe her position and the pitch, volume, and character of her cry. Note how the infant responds to environmental stimuli and how she interacts with her parents and others. A newborn should be able to interact and bond with parents or other caregivers, selectively shut out negative stimuli such as background noise, track high-contrast objects, and turn to voices. With older infants, it is easier to get more of a sense of some of the other parameters of mental status, such as mood and affect.

Toddlers/Preschoolers/School-age children. With these age groups, the neurologic examination starts the minute you walk into the room and greet your patient. Begin by evaluating the child’s level of consciousness. He should be alert and responding appropriately for his age. Note his affect, or mood. Is he happy, anxious, depressed, angry, frightened, or hostile? Next, test immediate, recent, and remote memory. Ask the child what his favorite toy is and to remember what that toy is. After about 10 minutes, ask the child to tell you again what his favorite toy is. To test remote memory, ask the child what his birth date is. Remember to tailor these tests and tasks according to the age and generally abilities of the child.

Adolescents. The neurological examination of an adolescent is the same as that of an adult. Nevertheless, it is still important to assess the adolescent’s developmental achievements. As with younger children, begin by evaluating the patient’s level of consciousness. He should be alert and responding appropriately for his age. Note his affect, or mood. Is he happy, anxious, depressed, angry, frightened, or hostile? Next, test immediate, recent, and remote memory. Ask him to repeat three words and to remember those words. After about 10 minutes, ask him again to repeat those three words. To test remote memory, ask the patient about an event that took place a couple of years ago.

Motor function, balance, and coordination

For children who are walking, test motor function and balance together with gait assessment, as you learned to do in the musculoskeletal assessment. As you observe the child walking through the various gaits, look for signs of balance problems. Both toe walking and heel walking are effective tests of both motor function and balance. And, of course, tests of muscle strength and joint range of motion can reveal abnormalities with a neurologic cause, as well as primary musculoskeletal disorders.

Infants. The neurological system is not fully developed at birth; in fact, by the age of 3 months, it has progressed substantially. While most newborn activities are primitive reflexes, as the infant grows and develops through the first year of life, movements become directed and purposeful. Test fine and gross motor coordination using the Denver II test. This test assesses for age-specific developmental milestones. You can also assess motor development by observing the infant’s movement while she is lying on the table. Movement should be smooth and symmetrical.

Head control is another important milestone in motor development. To assess head control, grasp the infant’s wrists and gently pull her to a sitting position. Initially, the infant’s head will stay in the same plane as her body, will briefly balance when she is in a sitting position, and then it will fall forward. Another way to assess head control is to lift the infant up from a prone position while supporting her chest. A newborn will hold her head at a 45-degree angle to horizontal with her back straight or slightly arched. Her elbows and knees will be slightly flexed. By about 3 to 4 months of age, the infant can lift her head with her back arched. This is called the Landau reflex and is usually present until the infant is 18 months old.

Toddlers/Preschoolers/School-age children. For children in these age groups, test motor function and balance along with gait assessment. Clear an area in the room for the child to take five or six steps, then ask him to walk that distance using his normal gait. Watch for smoothness of the gait. His toes should point forward, and his foot should swing straight forward between steps. Watch also for arm swing. His arms should swing in opposition to the legs. After assessing normal gait, ask the child to walk the same distance, this time walking heel to toe. This also tests balance. Now, ask the child to walk several steps on tiptoe and then on his heels. Both toe walking and heel walking are effective ways to test balance and motor function.

Testing balance is part of both the musculoskeletal and neurological examinations. It can be tested during activities such as walking, hopping, and standing on one foot or by conducting the Romberg test. For the Romberg test, have the child stand in front of you, with his feet together and his hands at his sides. While you extend your arms so that one is on either side of the child, ask the child to close his eyes. Watch for 20 seconds to see how well he can maintain balance in that position. A little bit of swaying is acceptable, but if the child sways more than a couple of inches, stop the test and document that your patient has impaired balance.

After testing balance, test coordination in the upper extremities using rapid alternating movements. Ask your patient to pat his thighs with his hands, alternating between a palm-up and a palm-down. Another test of upper-extremity coordination is the finger-to-nose test. Hold your finger about 18 inches from the child’s face and have him touch his nose and then your finger. Repeat that pattern several times as you move your finger to different locations. Movement should be smooth, and, if the child is able to come within 1 to 2 inches (2 to 5 centimeters) of his nose, this is considered normal.

To test lower-extremity coordination, ask the child to perform the heel-to-toe test. Have the child close his eyes and slide the heel of one foot up and down his opposite shin, from ankle to knee. Repeat on the other side. Movement should be smooth with the heel moving in a straight line.

Adolescents. Test motor function and balance along with gait assessment and coordination as described for toddlers, preschoolers, and school-age children (above).

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Cranial nerves

Assessment of the cranial nerves is an important facet of the neurological examination. Most cranial nerves can be evaluated quite well in children, provided you use developmentally appropriate strategies, such as presenting nerve testing as a series of games.

Click the text below to see descriptions of the different cranial nerve functions

I olfactory

The first cranial nerve, the olfactory nerve, has only sensory function. Testing this nerve, although often omitted, requires having an aromatic, non-noxious scent available.

Infants: No test is performed.
Toddlers through adolescents: Perform a smell test for common scents.

II optic

Cranial nerve II, the optic nerve, is a sensory nerve that is best tested by checking visual acuity.

Infants: Shine a light in the eyes to elicit a blink reflex.
Toddlers through adolescents: Test for visual acuity.

III oculomotor, IV trochlear, VI abducens

The third cranial nerve, the oculomotor nerve, is responsible for pupillary constriction and dilation and for elevation of the upper lid. Along with cranial nerves IV, the trochlear nerve, and VI, the abducens nerve, it also controls eye movements.

Infants: Shine a light in the eyes and move it from side to side to elicit a tracking response.
Toddlers through adolescents: Test for the six cardinal fields of gaze.

V trigeminal

Cranial nerve V, the trigeminal nerve, has three branches, which innervate the forehead, cheeks, and chin, and provide both sensory and motor functions.

Infants: Test for the rooting and sucking reflex.
Toddlers through adolescents: Check for sensory perception on the forehead, cheeks, and jaw. Also test the teeth for strength and alignment.

VII facial

The seventh cranial nerve, the facial nerve, has several motor branches that innervate a number of facial muscles and a sensory branch, not usually tested, that detects taste on the anterior tongue.

 

All ages: Check for facial features and expressions.

VIII acoustic

Cranial nerve VIII, the acoustic nerve, has sensory function only and is tested by checking hearing.

Infants: Test for a blink response to sound.
Toddlers through adolescents: Check hearing for soft sounds and a startle response to loud noises.

IX glossopharyngeal, X vagus
Cranial nerves IX, the glossopharyngeal nerve, and X, the vagus nerve, have both motor and sensory branches. However, the sensory branch is not often tested, largely because it would involve checking taste on the posterior tongue, which is cumbersome in practice. However, intact sensation is also essential for an intact gag reflex, which is not always necessary to test, but is checked more frequently than taste is.

 

Infants: Perform a swallow test.
Toddlers through adolescents: Test for a gag reflex.

XI spinal accessory
The eleventh cranial nerve, the spinal accessory nerve, is predominantly motor and innervates the sternocleidomastoid and trapezius muscles.

 

Infants: No test is performed.
Toddlers through adolescents: Test for strength in the neck and shoulders.

XII hypoglossal
The twelfth cranial nerve, the hypoglossal nerve, innervates the tongue and primarily consists of motor neurons.

 

Infants: Check for sucking and swallowing.
Toddlers through adolescents: Test speech for accuracy and articulation.

 

Depending on the age of the child, you might not be able to test all 12 nerves.

Infants. For an infant, you’ll test cranial nerves II, III, IV, V, VI, VII, VIII, IX, X, and XII. You’ll test eye movement and pupil response, the rooting and sucking reflexes, facial expressions, hearing, the swallowing and gag reflexes, movement of the tongue, and articulation. To test eye movement, for example, have the infant track a light or a toy.

Toddlers/Preschoolers/School-age children. From age 3 onward, you should be able to test all the cranial nerves. Have the child close his eyes, occlude one naris, and identify a scent, such as mint. Test the other naris with another scent. After age 3, use a Snellen chart to test vision. Play a game with a cotton ball to test sensation. Have the child “make faces” so you can observe symmetry and facial movements. To test hearing, whisper a few words behind the child’s back and have the child repeat them. Have the child shrug his shoulders against resistance while you tell him you want to see how strong he is. Have the child stick out his tongue all the way, clench his teeth, and swallow some food. All these actions test the various cranial nerves.

Adolescents. Cranial nerve tests for this age group are performed as they would be for adults. For a complete description of methods of testing of all the cranial nerves of an adult, see the neurological accepted practice section of the skills module on physical examination (adult).

Sensory function

There are many tests of sensory function, but most are used rarely, if at all. Sensory testing is commonly limited to checking for light touch and sometimes sharp/dull discrimination, and comparing responses for both sides.

Infants. Sensory function is not routinely tested for infants. However, you can observe their response to pain when they receive an immunization. When exposed to pain, an infant usually responds by crying and withdrawing all limbs. By 7 to 9 months of age, an infant can usually localize the pain stimulus and show more specific signs of withdrawal.

Toddlers/Preschoolers/School-age children. Sensory testing is often difficult to perform on toddlers and preschoolers and is usually limited to checking for light touch. Use a cotton ball or your finger. Ask the child to close his eyes and point to the area where you touch or tickle. Start proximally near the shoulders and move distally. Try to use random locations and random time intervals.

Adolescents. Sensory testing is usually limited to checking for light touch and sometimes for sharp and dull discrimination. Test for light touch using a cotton ball or your finger. Ask your patient to close his eyes and tell you when he feels the cotton ball or your finger lightly touching his extremities. Start proximally near his shoulders and move distally. To test sharp and dull discrimination, break a tongue blade in half. Ask your patient to close his eyes again and, with the sharp end and the dull end of the tongue blade, touch the extremities just as you did with the cotton ball. Try to use random locations and random time intervals, and vary the touch between sharp and dull. With both light touch and sharp and dull discrimination, the patient’s responses should be equal bilaterally.

Reflexes

The last part of the neurologic examination is checking infants’ primitive reflexes, and for older children, deep tendon reflexes, or DTRs. Learning to elicit DTRs takes some practice. Remember to hold the reflex hammer lightly between your thumb and index finger and to use your wrist to tap the tendon briskly with a quick, bouncy motion. Some tendons are easier to strike with the pointed end of the hammer, others with the flat end; with practice you will develop a technique of your own. Remember that the child must be relaxed for you to be able to elicit the reflexes. Distracting the patient with a task or a question that requires some thought is often helpful.

DTRs are graded from 0 to 4+, where 0 denotes no response and 4+ is a hyperactive, exaggerated response. The normal response to DTR testing is 2+. With some practice, you will be able to grade reflexes appropriately. If you see and feel no response, consider whether the reflex is truly absent or you just can’t elicit it. Usually, this is not a critical determination. If unsure, simply document that you are “unable to elicit” the reflex.

Infants. Deep tendon reflexes are not assessed before a child is about 5 years old. But the primitive reflexes are tested, most often the rooting, palmar grasp, tonic neck, Moro, and Babinski reflexes.

Test the rooting reflex by gently stroking the infant’s cheek near her mouth. A normal response is for the infant to turn her head toward that side and open her mouth. This reflex is present at birth and usually disappears around 3 to 4 months of age.

To test the palmar grasp reflex, place your index finger in the infant’s hand from the infant’s ulnar side. She should grasp your finger tightly with all fingers. This reflex is present at birth, is strongest between 1 and 2 months of age, and disappears at 3 to 4 months of age.

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The next reflex to test is the tonic neck reflex. With the infant in a supine position, turn her head to one side with her chin over her shoulder. A normal response is for the arm and leg on the side her head is turned to extend and the opposite arm and leg to flex. If her head is turned to the other side, the position of her arms and legs should reverse. This reflex is not present at birth but appears by 2 to 3 months of age, decreases at 3 to 4 months of age, and disappears by about 4 to 6 months of age.

The Moro, or startle, reflex is the next reflex to test. Gently jar the crib, make a loud noise, or support the infant’s head and back in a semi-sitting position and then quickly lower the infant to about 30 degrees. A normal response is for the infant to abduct and extend her arms and legs symmetrically, fan her fingers, and curl her index finger and thumb into a “C” position. Then the arms and legs usually come back in close to the body. This reflex is present at birth and disappears between 1 and 4 months of age.

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Test the Babinski, or plantar reflex, on the plantar aspect or sole of the foot by tracing an upside-down J with the handle of the reflex hammer, starting at the child’s heel and moving up the lateral aspect and then across the ball of the foot. The normal response to Babinski testing is no response at all or only slight curling of the toes, and this is the typical finding with most infants. A positive Babinski response is fanning of the toes and dorsiflexion of the great toe, elicited in some normal infants up until the age of 2 years. In older children and adults, a positive Babinski response is commonly associated with upper motor neuron disease.

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Toddlers/Preschoolers/School-age children. Because most children younger than 5 years of age can be uncooperative and cannot relax for this examination, deep tendon reflexes are usually not tested. If you do test them, test on both sides and look for the same responses bilaterally. There are several superficial reflexes you can test. However, the Babinski or plantar reflex is usually the only one tested. To test this reflex, trace an upside-down J with the handle of the reflex hammer on the bottom of the child’s foot. The normal response is slight curling of the toes.

Adolescents. Test deep tendon reflexes on both sides and look for the same responses bilaterally:

Start with the biceps tendon, palpable in the antecubital fossa. With the patient’s arm supported and relaxed, place your nondominant thumb firmly over the biceps tendon and briskly strike your own thumbnail with the pointed end of the hammer. The biceps muscle should contract immediately, causing the forearm to flex. With this reflex, you may feel the response more than you see it.

Next, test the brachioradialis tendon. With your patient’s forearm resting in his lap with the palm up, strike the tendon a couple of inches above the wrist just medial to the radius. The forearm should flex and the hand should supinate.

The triceps reflex is the next reflex to test. With your nondominant hand supporting the patient’s arm, instruct the patient to relax his arm. With the reflex hammer, strike the triceps tendon just proximal to the point of the elbow. A normal response is contraction of the triceps muscle and extension of the elbow.

Next, test the patellar reflex. With the patient sitting, palpate the tendon just below the patella. With the flat end of the reflex hammer, strike the tendon. The quadriceps muscle should contract, causing the lower leg to extend.

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The Achilles tendon is the final deep tendon reflex to test. While supporting the patient’s foot in dorsiflexion with your nondominant hand, strike the Achilles tendon just above the patient’s heel with the flat end of the hammer. The foot should plantar flex.

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There are several superficial reflexes you can test. However, the Babinski or plantar reflex is usually the only one tested. To test this reflex, trace an upside-down J with the handle of the reflex hammer on the bottom of the patient’s foot. The normal response is slight curling of the toes.

References

Ball, J. W., & Bindler, R. C. (2003). Pediatric nursing: Caring for children (3rd ed.). Upper Saddle River, NJ: Pearson Education. Chapter 4.

Bickley, L. S., & Szilagyi, P. G. (2007). Bates’ guide to physical examination (9th ed.). Philadelphia: Lippincott Williams & Wilkins. pp. 692, 730-737.

Dillon, P. M. (2003). Nursing health assessment: A critical thinking, case studies approach. Philadelphia: F. A. Davis Company. pp. 766-771.

Hockenberry, M. J., Wilson, D., & Winkelstein, M. L. (2005). Wong’s essentials of pediatric nursing (7th ed.). St. Louis, MO: Elsevier Mosby. pp. 168-169.

Jarvis, C. (2004). Physical examination and health assessment (4th ed.). St. Louis, MO: Saunders. Unit 3.

Nettina, S. M. (2006). Lippincott manual of nursing practice (8th ed.). Philadelphia: Lippincott Williams & Wilkins. pp. 1345-1348.

Weber, J., & Kelley, J. (2003). Health assessment in nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. p. 593.