Topic: Neurologic Examination of Newborn and Infants

Lecturer: Dr. Tan

Topic Objectives:
a.
b.
c.
d.
e.

Review basic history taking in infants and children

Determine by history and PE if the central nervous
system is involved: 1. Diffuse 2. Localized
Determine what age of development the symptom
may occur
Determine if the disease is: 1. Static 2. Progressive 3.
Familial 4. Sporadic
Search for other signs and symptos that would give
clues to the etiology diagnosis

Neurologic Examination of newborn and infants

Neuro Exam performed in relation to the data
gathered
Should be used as an essential diagnostic tool to
confirm information gathered from the history
examination in children should be done in a playful and
compassionate manner

Example: Cafe au lait

spots

Head shape and Sutures

1. Inspect the head
-

Molding is an expected feature in a

newborn
2. Palpate Sutures and outline the anterior and
posterior fontanelles.

Physical Exam and Neuro exam done in three phases:

1. Observation
2. Inspection
3. Palpation and Manipulation
*note: usual sequence for adult is not done for children.
Reason is children get irritated easily than adults so
proper handling of patient is required*
Age of the child and stage of brain development are
important factors to consider during evaluation
I.

Observation
-First phase of examination
-Major part of the exam is accomplished
thru this
LOOK FOR UNUSUAL PHYSICAL FEATURES:

*note: Posterior fontanelle close 2 to 3 months

Anterior fontanelle close between 10 months
and 20 months
Craniosynostosis premature closure of suture
*Note- Bone growth occurs perpendicular to
the suture. If one suture is closed, compensatory
growth will occur in the remaining open sutures!

Dysmorphisms/physical anomalies
Spinal and back deformities
Skin manifestations
Eyes and facial features

Trans by: Virgilio Vinluan Jr. Neuro Transcom YL 3 2015

1.) Scaphocephaly synostosis of the sagittal suture

MENTAL STATUS EXAMINATION
-

thin elongated head

2.) Brachycephaly synostosis of the coronal sutures

Degree of ALERTNESS, VERBAL AND

NONVERBAL FUNCTION, MEMORY, PICTURE
AND OBJECT IDENTIFICATION,
CALCULATION.
ALL OF WHICH ARE DEPENDENT ON HIS
MENTAL AGE and LEVEL OF
CONSCIOUSNESS

CRANIAL NERVES
-

Accomplished by observing spontaneous

activity of baby

CN II- testing light response

CN III, IV, VI eye movements assessed by
using vestibulo-ocular reflex[Dolls eye
maneuver]
o
Wide Flat Head
3.) Trigonocephaly synostosis of the metopic suture

When the head is turned, there is

conjugate movement in the opposite
direction

CN 5,7,9,10 and 12- sucking and swallowing

CN 7- facial movement observed when crying
for assymetry
CN 8- response to sound
Cranial Nerve VIII Auditory Nerve
Normal newborn - pause briefly during sucking when
bell is presented; after several stimulations, the pauses
stop as habituation occurs No habituation occurs
triangular shaped head
Flattening of the occiput on one side most common
cause of mishapen head [positional in nature]
HEAD CIRCUMFERENCE

for neurologically abnormal infants

Normal Hearing Infants: Turn their head toward a bell,
rattle or crumpled paper By 3 mos. of age, will look

in the direction of the sound source

Also known as Occipito-Frontal-Circumference

because it is measured by puting the measuring tape on
the prominent aspect of the frontal and occipital bones.
Note: Plastic is preferred over paper because paper can
stretch overtime. Usually done at the end of the exam
because babies resent the restriction of the head
movement needed to obtain an accurate measurement

CN 10 quality of cry

Visual testing in older infants

Present an interesting and colorful object to observe
visual tracking in the horizontal and vertical planes.
To test visual fields, have the baby focus on an object
in front of him and then bring a second object from

Trans by: Virgilio Vinluan Jr. Neuro Transcom YL 3 2015

behind him until he sees the object in his peripheral

vision. He should turn toward the new object.

Too little or too much resistance reflects

hypotonia or hypertonia.

II.Arm recoil
tests tone and action of the biceps.
The arms are held in flexion against the chest
for a few seconds, then are quickly extended
and released. The arms should spring back to
the flexed position.
hypotonic infant - slow incomplete recoil
Asymmetry to this response with lack of recoil
would be seen with Erbs or brachial plexus
palsy.
Saccadic eye movements are tested by using
interesting toys and sounds and watching the eyes jump
from object to object.

Motor exam
Components include:
1.) Testing of strength (power)
2.) Muscle bulk
3.) Tone
4.) Posture
5.) Locomotion and mobility
6.) Deep tendon reflexes (DTRs)
7.) Presence of primitive reflexes

III.Lower extremity tone

Assessment begins with passive range of
motion.
This is done by flexing the hips, then
abducting and adducting the hips. Next, flex
and extend the hips, the knees and ankles.

IV.Heel to ear
Holding the babys foot in one hand, draw the
leg towards the ear to see how much resistance
there is to the maneuver.
The foot should go to about the level of the
chest or shoulder, but not all the way to the
ear. If the foot can be drawn to the ear then
there is hypotonia.

V. Neck tone
Tone: resting posture in newborn
flexion of the extremities with the extremities
closely adducted to the trunk
After the first few days of life, the extremities
are still predominantly in the flexed position but
they are not as tightly adducted as they are in
the first 48 hours of life.

Assessed by passively rotating the head towards

the shoulder.
The chin should be able to rotate to the
shoulder but not beyond the shoulder. If the
chin goes beyond the shoulder then there is
hypotonia of the neck muscles, which is
associated with poor head control.

VI.Head lag

Assessment begins with passive range of

motion.

Baby is pulled by the arms from supine to the

sitting position. The head and the arms are
observed during the maneuver.

This is done by rotating each extremity at the

shoulder, elbow and wrist and feeling the
resistance and the range of movement.

The arms should remain partially flexed at the

elbow and the head may lag behind the trunk,
but should not be fully flexed backwards.

I.Upper extremity tone

Trans by: Virgilio Vinluan Jr. Neuro Transcom YL 3 2015

 When the baby is in the sitting position, the

head should be able to come to the upright
position for at least a few seconds before
dropping forward or backward.

VII.Ventral suspension
a good way to assess a babys neck and trunk
tone
Baby is placed in prone position, suspended in
the air by hand placed under the chest.

A normal newborn can have hyperreflexia and

still be normal, if the tone is normal, but absent
reflexes associated with low tone and weakness
is consistent with a lower motor neuron
disorder.
Preserved or exaggerated reflexes associated
with low tone is the hallmark of what is called
central or cerebral hypotonia and the cause is
an upper motor neuron lesion.

DTRs absent or decreased in:

Head -> same plane as the back

1.Myopathy - disorders of the muscle

2.Neuropathy - nerves
3.Disorders in the myoneural junction
4.Abnormalities of the cerebellum

Back should show some resistance to gravity

and not be simply draped over the hand on the
chest.

DTRs increased in upper motor neuron lesions

Extremities should maintain some flexion tone

and not dangle in extension.

NOTE: Asymmetry of the DTRs suggests a

lateralizing lesion.

VIII.Vertical suspension
Examiner holds baby in upright position with
feet off the ground by placing the hands under
the arms and around the chest. The baby
should be suspended in this position without
slipping through the hands of the examiner.
If there is shoulder girdle weakness, the arms
will extend upwards and the examiner will have
to reposition their grasp of the baby to avoid
the baby slipping through their hands.

Plantar reflex
The normal response to stroking the lateral
aspect of the plantar surface of the foot is
extension of the great toe and fanning of the
other toes.
If the stimulus is brought across the ball of the
foot then a grasp reflex will be elicited and the
toes will plantar flex.
Lateral Aspect EXTENSION/FANNING
Ball of foor GRASP REFLEX

REFLEXES
In infants, absence or presence of primitive and
adaptive reflexes are determined to evaluate
the maturation age of the nervous system.
On the other hand, the segmental reflexes of
the muscle stretch reflexes and the superficial
reflexes are elicited to determine the site of the
nervous system, i.e. location of lesion.

Deep tendon reflexes

They can be technically difficult to do.
Absence of deep tendon reflexes is a much
more important finding than hyperreflexia in
the newborn.

The up going toes or Babinski sign is normal in

the infant and may be present for the first year
of life because of the incomplete myelination of
the corticospinal tracts.

Primitive reflexes suck, root

The baby should have a strong coordinated suck
reflex with good stripping action of the tongue.
There should be resistance to pulling out the
pacifier.
A root reflex is obtained by gently stroking the
cheek towards the lips. The baby should open
the mouth towards the stimulus and turn the
head to latch on to the object.

Trans by: Virgilio Vinluan Jr. Neuro Transcom YL 3 2015

Most important reflexes:

1.Moro Reflex - place the infant in a semi-upright
position. Allow the head to fall backward momentarily
with immediate support by the examiners hand
Response:Abduction and extension of the arms;
flexion of thumb followed by flexion and
adduction of the upper extremities
Asymmetric response may signify:
a. fractured clavicle
b. brachial plexus injury
c. hemiparesis
Absence of Moro Reflex in a term NB- suggesting
significant CNS dysfunction
2.Grasp Reflex place a finger or object on the
open palm of each hand
Placement of the examiners finger in the palm
of the hand or on the sole of the foot will cause
flexion and grasping of the fingers or toes.
One should avoid touching the dorsum of the
hand while eliciting the grasp reflex because
stimulating the back of the hand causes a hand
opening reflex to occur. With the two
competing reflexes, the grasp response will be
incomplete or inconsistent.

The stepping or walking reflex is obtained by holding

the baby upright over the mat with the sole of the foot
touching the mat. This initiates a reciprocal flexion and
extension of the legs and it looks like the baby is
walking.

POSTURAL REFLEX
Postural
Relflex
General Static
Reaction
Tonic Neck

Neck Righting

Age Reflex
Appears

Age Reflex
Disappers

Never
complete &
obligatory
4 to 8
months

Never
complete &
obligatory
Covered up
by voluntary
action
4 to 5
months
9 to 12
months
4 to 5
months

Grasp
28 weeks
Reflex(Palmar)
Grasp
Newborn
Reflex(Plantar)
Moro Reflex
28 to 32
weeks

Response: Normal infants grasp the object

3. Tonic neck reflex turn the head to one side while
supine
Response: extension of the arm on the ipsilateral side/
flexion of the contralateral extremities
NOTE: An obligatory tonic neck response by which the
infant remains locked in the fencers position, is
abnormal and implies a CNS disorder.

GOWERS SIGN child uses hands to climb up to

assume upright position

4.Parachute reflex suspend the child by the trunk and

produce a sudden forward flexion as if the child were to
fall

Sensory Examination

Response: child spontaneously extends the upper

extremities
Note: Appears before the onset of walking

Difficult to perform in an infant or

uncooperative child
Disorders involving the sensory system are less
common in the pediatric population than
among adults
Success of the sensory examination depends on
the ingenuity and patience of the examiner.

5.Stepping

Trans by: Virgilio Vinluan Jr. Neuro Transcom YL 3 2015

SUMMARY:
NEUROLOGIC EXAMINATION SHOULD ALWAYS
BE A PART of the developmental and routine
evaluation of a child.
The success in obtaining a good result is
dependent on the cooperation of the child.
A significant part is made thru observation.

Reference: Lecture of Marilyn Tan and Additional

Notes/Pictures

Trans by: Virgilio Vinluan Jr. Neuro Transcom YL 3 2015