4/28/2019 Neurologic Exam of the Infant and Child

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Learning Objectives THE NEUROLOGICAL EXAMINATION OF INFANT

AND CHILD

The basic principles in evaluation of an infant are similar to those of an older child or adult.

SPECIAL CONSIDERATIONS

• Reliance on parents and others for historical information and observations.

• Exercise flexibility in approach to the examination.

• Simple observation often yields more information than formal testing. Variations in the norm are age dependent.

PHYSICAL EXAMINATION

Clues to neurologic disease may be obtained from a general physical exam (see Table 1 - not a comprehensive list). Features of the
neurologic examination requiring special attention in infancy include:

Spine

Look for midline defects, dimples, tufts of hair, hemangioma. Palpate for body defects.

Head

Size and shape. Serial measurements rather than an isolated reading are important. An increase in head circumference of a
centimeter per month is normally observed during the first six months, and a centimeter every two months for the remaining six
months of the first year. Head circumference is one of the best measures of brain development in the infant and young child (see
head circumference charts for boys and girls). By age three, the majority will have achieved 90% of adult head size.

• Also look for generalized asymmetry, frontal bossing, prominent occiput, localized bulging.

• Microcephaly (below 3%)

• Macrocephaly (above 98%)

• Scaphocephaly - prominent antero-posterior head growth

• Brachycephaly - shortened antero-posterior with an increase in width

• Palpation of sutures - overlap, ridging, or separations

• Anterior fontanel - Mean age for closure is one year (range 7 to 19 months).

• Normally, the fontanel is somewhat depressed and pulsates, and should preferably be assessed in the upright posture and in a
child who is not struggling or crying.

Auscultation

Systolic bruits may be heard in 50% to 70% of normal children below six years of age. Significant if loud, extend through both
systole and diastole or are symmetrical.

Transillumination

Useful procedure in diagnosing intracranial lesions. It reveals an abnormal amount of transmitted light, which can vary considerably
under normal circumstances dependent on:

• Extracranial fluid (infiltrated scalp IV)

• Thickness of the scalp

• Quantity of hair

Normally, there is slightly increased transillumination in the frontotemporal regions. Complete - glowing of the head - suggests
hydranencephaly: severe hydrocephalus. Localized or asymmetrical transillumination suggests porencephalic cyst, Dandy-Walker
anomaly, subdural effusions, atrophy.

Cranial Nerves. See Table 4.

Motor

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Observing spontaneous activity and/or child in play activity can often reveal deficits of movement and coordination. Motor function
varies with age.

Reflexes (Developmental). See Table 2 and Table 3.

DEVELOPMENTAL MILESTONES

These can be divided into gross motor, fine motor, language, and social behavior.

Interpretation:

• Normal

• Delayed in all spheres

• Normal in some, retarded in others

• Loss of previously attained skills

Older Child: Inquire about school performance. See Table 5.

TABLE 1. Systemic Signs in Patients with Chronic Neurological Deficit

Skin Eczema Phenylketonuria

Pellagra rash Hartnup disease
Ash leaf depigmented spots Tuberous sclerosis
"Shagreen patches"

Café-au-lait spots Neurofibromatosis

Hair Blonde Phenylketonuria

Fine and sparse Cretinism, homocystinuria
White and brittle Argininosuccinicaciduria and Menkes kinky hair
syndrome

Abnormal body size Dwarfism Turner's syndrome

Lowe's syndrome
Cystinosis
Hypophosphatasia
Tall stature Homocystinuria
Klinefelter's syndrome

Eyes Cataracts Lowe's syndrome

Buphthalmos Homocystinuria
Sturge-Weber

Glaucoma, Ectopia lentis Homocystinuria

Chorioretinitis Toxoplasmosis
Cytomegalovirus infection
Rubella
Retinal exudates Tuberous sclerosis
Macula degeneration Neural lipidoses

Hearing Nerve deafness Neonatal jaundice (kernicterus)

Abnormal odor Musty Phenylketonuria

Maple syrup Branched-chain ketonuria
Dried celery Methionine malabsorption
Sweaty feet Isovaleric acidemia

Organomegaly Liver and spleen Tyrosinosis

Gaucher's disease
Niemann-Pick disease

TABLE 2. Developmental Reflexes

REFLEX APPEARANCE AGE DISAPPEARANCE AGE

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Adductor spread of knee jerks Birth 7 to 8 months
Moro Birth 5 to 6 months
Palmar grasp Birth 6 months
Plantar grasp Birth 9 to 10 months
Rooting Birth 3 months
Tonic neck response Birth 5 to 6 months
Truncal incurvation Birth 1 to 2 months
Parachute 8 to 9 months Persists
Landau 10 months 24 months

Table 3. Developmental Reflexes

Moro Reflex: Sudden abduction of the arms, extension of the legs, and flexion of the hips when the position of the head is
changed abruptly in relationship to the body. The Moro reflex is present in all normal, full term infants. It is an indicator of the
symmetry and intactness of the nervous system. It diminishes during the first months of life and usually disappears by 4 to 5
months.

Tonic Neck Reflex: With the infant supine, turning the head to one side results in extension of the arm and leg on that side with
flexion of the contralateral area (i.e., fencing posture). It is usually not present in the newborn but appears after 2 to 3 weeks. The
reflex is most prominent during the second month of life and infants may assume it spontaneously. An obligate or persistent tonic
neck reflex is abnormal.

Crossed Adductor Reflex: Contraction of both hip adductors when either knee jerk is elicited. The crossed adductor response
usually disappears by 7 to 8 months, and persistence beyond that time is a sign of pyramidal tract dysfunction.

Ankle Clonus: 8 to 10 beats may be present in the normal newborn, but generally disappears by 2 months of age.

Neck Righting Reflex: With the infant supine, turning the head to one side causes the infant to turn his shoulders and trunk to
the same side. It appears when the tonic neck reflex disappears (i.e., at 4 months), when the baby begins to roll over. All normal
infants have a neck righting reflex by age 8 to 10 months, after which it becomes part of voluntary activity.

Hand grasp: An infant is able to reach and grasp with his whole hand by 4 to 5 months of age. Thumb and finger (pincer) grasp
begins at 6 to 7 months and is present in normal infants by 1 year. Transferring objects from one hand to the other begins at 7 to 8
months. A strong preference to use one hand is abnormal prior to 1 year of age, when the first clear evidence of handedness
appears.

Posture in Horizontal Suspension: A test of head control and motor function. At age 5 months, infants held horizontally (parallel
to the floor) begin to arch their backs and hold their heads above the horizontal plane.

Posture in Vertical Suspension: Flexor during the first half-year of life. Persistent adduction or scissoring of the lower extremities
is always abnormal and a sign of spasticity. In the standing position, a normal positive supporting reaction consists of the child
briefly bearing some weight. A "too good" positive supporting reaction is often the earliest sign of spasticity. In atonic dysplegia,
withdrawal of extremities and lack of a positive supporting reaction may be present.

Parachute Reflex: The infant is suspended horizontally then plunged downwards; the reflex consists of arm extension to "break
the fall." It begins at 6 to 7 months and is well developed by 1 year. The parachute reflex is an excellent test of upper extremity
pyramidal function, and if asymmetrical, may be a sign of hemiparesis.

TABLE 4. Cranial Nerve Examination in Infancy

CRANIAL NERVE FUNCTION TESTED BY

I Olfactory nerve Smell Simple odors (vanilla, tobacco, etc.), change facial
and tract expression suggests recognition

II Optic nerve and Visual acuity and fields Colored ball or block in visual field
retina

III Oculomotor Extraocular movements, pupil Observation of tracking, Vestibular response

IV Trochlear nerve response, lid elevation (gently rotating the child)

VI Abducens
nerve

V Trigeminal Mastication History of chewing

nerve Facial sensation Corneal reflex

VII Facial nerve Facial expression Observation for symmetry

Taste

VIII Acoustic
nerve
Auditory division Hearing Tuning fork, musical toy, rotation

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Vestibular Spatial orientation

division

IX Swallowing, voice History, feeding, quality of cry, gag reflex

Glossopharyngeal
nerve
X Vagus nerve

XI Spinal Elevate shoulder Observation in upright and prone positions

accessory nerve turn head

XII Hypoglossal Tongue movements Symmetry, protrusion, atrophy, fasciculations

nerve
Adapted from The Practice of Pediatric Neurology, Swaiman, K. and Wright, F.

TABLE 5. Child Development from Two Months to Two Years*

2 Months Hands predominantly fisted

Lifts head up for several seconds while prone
Startles to loud noise
Follows with eyes and head over 90° arc
Smiles responsively
Begins to vocalize single vowel sounds
3 Months Hands occasionally fisted
Lifts head up above body plane and holds position
Holds an object briefly when placed in hand
Turns head toward object, fixes and follows fully in all directions with eyes
Smiles and vocalizes when talked to
Watches own hands, stares at faces
Laughs
4 Months Hold head steady while in sitting position
Reaches for an object, grasps it, brings it to mouth
Turns head in direction of sound
Smiles spontaneously
5 to 6 Months Lifts head while supine
Rolls from prone to supine
Lifts head and neck up in prone position
No head lag
Transfers object from hand-to-hand
Babbles
Sits with support
Localizes direction of sound
7 to 8 Months Sits in tripod fashion without support
Stands briefly with support
Bangs object on a table
Reaches out for people
Mouths all objects
Says "da-da," "ba-ba"
9 to 10 Months Sits well without support, pulls self to sit
Stands holding on
Waves "bye-bye"
Drinks from a cup with assistance
11 to 12 Months Walks holding on
Pincer grasp
Two to four words with meaning
Creeps well
Assists in dressing
Understands a few simple commands
13 to 15 Months Walks by self - falls easily
Says several words, uses jargon
Scribbles with a crayon
Points to things wanted
18 Months Climbs stairs holding on, climbs up on a chair
Throws ball
Builds two to four block tower
Feeds self
Takes off clothes
Points to two to three body parts
Many intelligible words
24 Months Runs, walks up and down stairs alone (both feet per step)
Two to three word sentences
Turns single pages of a book
Builds tower of four to six blocks

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Kicks ball
Uses pronouns "you," "me," "I"
*Represents the age at which the average child acquires the skill. Data from Gesell, A., and Amatruda, C.S.: Developmental
Diagnosis, Paul C. Hoeber, New York 1956; Illingworth, R.S.: The Development of the Infant and Young Child, 5th ed., Williams and
Wilkens, Baltimore, 1972.

Neuroscience Clerkship | Department of Neurology | Case School of Medicine

Last Update: 02/25/2007 | Comments and Feedback
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