Clinical Anatomy (2019)

REVIEW

Neurological Examination of the Infant:

A Comprehensive Review
SONJA SALANDY,1 RABJOT RAI,1 SANTIAGO GUTIERREZ,2
BASEM ISHAK,3 AND R. SHANE TUBBS 1,3*
1
Department of Anatomical Sciences, St. George’s University, St. George’s, Grenada, West Indies
2
Pontificia Universidad Javeriana, Bogotá, Colombia
3
Seattle Science Foundation, Seattle, Washington

Clinicians are required to perform neurological examinations on infants to

ensure they meet developmental milestones. A full neurological examination
includes evaluating motor and sensory function, assessing the status of the cra-
nial nerves, testing primitive reflexes, and atypical responses to further evaluate
any developmental pathologies. The difficulty in maintaining infants’ cooperation
requires resourcefulness on the clinician’s part to understand what is being tested
and in what way to complete the examination. This literature will provide clini-
cians with guidance on the way to conduct a thorough neurological examination
of infants. Clin. Anat. 00:000–000, 2019. © 2019 Wiley Periodicals, Inc.

Key words: neurological examination; pediatric examination; physical exam;

cranial nerves; primitive; reflexes; anatomy

INTRODUCTION the neurological examination, should be taken with a

The methods and techniques used to conduct a neu-
rological examination on adults are difficult to transfer
to neonates and older infants, as their immature neu-
rocognitive development creates a barrier in examin-
ing their neurological function. A thorough neurological
examination of infants should include first a detailed
review of the history of present illnesses, past history
regarding other diseases, medications, allergies, famil-
ial disorders, vaccination status, past obstetric history
of the mother, perinatal, and neonatal history, social
network, and a review of other systems.
Once the history has been taken and a general
inspection made, the neurologic assessment should
include higher cortical functions, developmental his-
tory, cranial nerve status, motor and sensory func-
tion, and primitive reflexes. Each component provides
important details about neurological function. This
article’s purpose is to provide a comprehensive and
systematic approach to conducting, evaluating, and
scoring infant neurological examinations.
HISTORY
Before beginning a neurological examination, the
infant’s history, which is an important component of
special focus on the central and peripheral nervous
systems. The history should include past medical/
surgical history, family history, and review of systems
(Haslam 2013). Another important issue is reviewing
the mother’s history of pregnancy and the infant’s peri-
natal and neonatal stages, including gestational age at
the time of labor, fetal presentation, weight, height,
head circumference at birth, Apgar scores, infections
during pregnancy, parents’ drug use, and whether the
infant required resuscitation, to identify possible chro-
mosomal or genetic or congenital defects associated
with neurological disorders or central nervous system
abnormalities (Haslam 2013).
PHYSICAL INSPECTION
An infant’s physical examination begins as soon as
the patient enters the examination room, and it
*Correspondence to: R. Shane Tubbs, 550 17th Ave, James
Tower, Suite 600, Seattle, WA 98122. E-mail: shanet@
seattlesciencefoundation.org
Received 29 January 2019; Accepted 11 February 2019
Published online 00 Month 2019 in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/ca.23352

© 2019 Wiley Periodicals, Inc.

2 Salandy et al.
provides a considerable amount of information that
will be useful in the further physical examination. It
should focus on general appearance, measurement of
height, weight, and head circumference, cutaneous
observation, mucosae color, including cyanosis, exam
of the midline of the back and neck, gait if present,
and fontanel’s state to look for anomalies or dehydra-
tion. It is important that the patient is seated or
placed as comfortably as possible in the parent’s lap.
This will reduce his/her apprehension of the clinician
and facilitate the examination. Furthermore, it is very
useful to leave invasive procedures, such as retinal,
oral, and ear examination, until the end to reduce the
patient’s disruption of the examination (Yang 2004).
COGNITIVE AND DEVELOPMENTAL
ASSESSMENT
The cognitive assessment is one of the most
important aspects to consider while examining a pedi-
atric patient and that must be taken before proceeding
to a further examination. This includes the assessment
of higher cortical functions, as well as developmental
milestones.
Higher cortical and cerebral functions are assessed
by observing consciousness, alertness, response to
visual, auditory, and tactile stimuli, interaction with
the examiner or parents and language, if present.
At certain ages, neurodevelopmental milestones in
fine and gross motor movements should be achieved
and reported by primary caretakers. Because office
visits have time constraints, certain milestones may
not be elicited in the presence of physicians. Thus, it
is important that the comprehensive history includes
questions about age-related markers (Blasco 1994;
Ghassabian et al. 2016).
A child’s motor age can be translated into a motor
quotient that helps establish whether there is any
delay in motor development. The motor quotient is cal-
culated by dividing the current motor age measured
based in the achievements in the milestone chart by
the chronological age of the child in question (Capute
and Shapiro 1985; Blasco 1994). A score above 70 is
considered normal, between 70 and 50 indicates slight
motor impairment and below 50 signifies motor disabil-
ity. The motor quotient should be taken into account in
factors such as prematurity by adjusting chronological
age (Palisano et al. 2008). Furthermore, it is highly
important to look for early signs of autism spectrum
disorders by screening social skills, developmental
milestones, communication with the parents and other
people, parents’ report of anomalies, and regression in
language (Johnson and Myers 2007).
CRANIAL NERVES
Cranial Nerve I: Olfactory Nerve
The olfactory nerve imparts the sense of smell by
transmitting olfactory stimuli to the brain. Although
rarely tested, even in adults, aromatic orders, such as
chocolate or coffee, may elicit a sucking or withdrawal
response, respectively, in neonates. Anosmia, the
absence of the ability to smell, may indicate a tran-
sient condition, such as an upper respiratory infec-
tion, or cranial disorders, such as skull base and
cribriform plate fractures or frontal lobe tumors.
Examiners should be aware to avoid strong irritant
aromas, such as alcohol or ammonia, as they may
stimulate the nerve endings in the nasal mucosa indi-
rectly and therefore stimulate the trigeminal nerve
instead (Greenfield and Long 2016).
Cranial Nerve II: Optic Nerve
Optic nerve examination comprises the assess-
ment of visual acuity, color vision, visual fields, pupils,
and lastly, retinal anatomy through an ophthalmo-
scopic examination of the optic nerve and surrounding
retina.
Visual acuity can be assessed by presenting color-
ful visual stimuli, such as toys or other objects, to
elicit the patient’s following response. In older and
cooperative patients, a standard visual acuity test is
performed using an optometric table. Visual fields
also can be tested while presenting visual stimuli in
the patient’s visual fields, whereas a confrontational
campimetry should be performed in older, more coop-
erative infants.
Pupil assessment is crucial to diagnose the nerve’s
functionality. They should be examined both compar-
atively and one at a time to look for anisocoria. Fur-
thermore, the pupillary reflex must be elicited to
evaluate both the afferent and efferent limbs (cranial
nerves II and III, respectively). The pupillary light
reflex can be elicited as early as 30–32 weeks of
gestation in premature infants; before then, it is diffi-
cult to examine this because the iris is pigmented
poorly, and the eyelids resist opening. Use of medica-
tion, intraocular lesions, infectious or metabolic dis-
eases, and abnormalities of the midbrain and optic
nerves can affect pupil size and the pupillary light
reaction (Haslam 2013).
To perform ophthalmoscopy, a mydriatic can be
instilled before examination to dilate the pupils, but
care must be taken to rule out glaucoma before-
hand. Infants also need someone to soothe and
reassure them during the examination. It is simpler
to obtain neurological findings in older children, as
they usually sit in the parent’s lap, whereas the
other parent plays with the child. Retinal hemor-
rhage can occur in approximately 30% of normal
newborns but disappears within the following sev-
eral weeks (Haslam 2013).
The eye disc is gray-white in neonates and blonde
children and typically is salmon-pink in older children.
Papilledema can result from increased intracranial
pressure associated with changes in the ocular fun-
dus. This includes hyperemia of the optic disc with
dilated veins and constricted arterioles. It can be diffi-
cult to identify the optic disc border in this situation,
because it becomes indistinguishable from the sur-
rounding retina. Vision can be assessed after 28 weeks
of gestation at the earliest (Haslam 2013).

Cranial Nerve III/IV/VI: Oculomotor (III),
Trochlear (IV), and Abducens (VI) Nerves
The eyes’ movement is mediated by the oculomo-
tor, trochlear, and abducens nerves. The oculomotor
nerve innervates most of the extraocular muscles,
including the superior, inferior, and medial rectus,
and the inferior oblique muscles, and the trochlear
and abducens nerves innervate the superior oblique
and lateral rectus muscles, respectively. The oculomo-
tor nerve also controls the levator palpebrae superioris
muscle that lifts the upper eyelid and mediates the
efferent pupillary reflex. Thus, complete loss of oculo-
motor nerve function leads to ptosis and pupillary dila-
tion and results in a down and outward position of the
eye. Dysfunction of the trochlear nerve will present
when the eye is positioned up and outward, whereas
dysfunction of the abducens nerve will present with
the loss of lateral movements in the eye affected
(Haslam 2013; Greenfield and Long 2016). To examine
eye movements, infants are presented with a toy they
attempt to follow. The “doll’s eye” reflex, or oculoce-
phalic reflex, can be used to test neonates (as early as
25 weeks of gestation) to evaluate horizontal eye
movements. During this test, the newborn’s head is
moved gently and quickly to one side, which should
stimulate a temporary movement of both eyes in the
direction opposite that in which the head is turned
(Haslam 2013; Greenfield and Long 2016). It is impor-
tant to evaluate the functional state of the gaze motion
to rule out nystagmus or strabismus.
Cranial Nerve V: Trigeminal Nerve
Trigeminal nerve assessment must include facial
sensitivity, temporomandibular joint proprioception,
masticatory muscle function, and the reflexes related
to it, such as corneal reflex and the masseter reflex.
The trigeminal nerve divides into three facial sensory
branches, the ophthalmic, maxillary, and mandibular.
To examine their function, the clinician may use the
broken end of a tongue depressor to elicit pain or light
strokes to assess touch, which stimulate the appropri-
ate areas. Slight stroking of the face near the nose,
cheeks, or lips may predispose the infant to engage in
the rooting reflex. The corneal reflex is elicited by
touching the lateral corner of the sclera lightly with a
wisp of cotton, which should elicit a blinking response
and allow assessment of the ophthalmic division.
The mandibular division of the trigeminal nerve
innervates the masticatory muscles. To assess their
function, jaw opening is used to evaluate the masse-
ter, temporalis, lateral, and medial pterygoids. These
muscles are tested indirectly by sucking and allowing
the infant to chew on the examiner’s finger (Haslam
2013; Greenfield and Long 2016).
Cranial Nerve VII: Facial Nerve
The facial nerve is responsible for facial move-
ments, mediates taste on the anterior two thirds of
the tongue, and controls sensitive recognition of the
Neurological Examination of the Infant 3
ear lobule, the posterior belly of the digastric muscle,
and motor innervation of the stapes muscle. Lacrima-
tion also is an autonomic function attributable to the
facial nerve. With respect to motor movement, an
upper or lower motor neuron disease can occur,
depending on whether the lesion is above or below
the facial motor nucleus, respectively. An upper motor
neuron lesion results in weakness of the contralateral
lower face, whereas a lower lesion results in weakness
of the ipsilateral upper and lower face (Shargorodsky
et al. 2010; Haslam 2013). To examine facial nerve
palsy, observing the neonate and infant at rest, and
during crying spells, is appropriate. As infants become
older and able to obey requests, they are asked to
smile, raise their brows, puff out their cheeks, and
close their eyes tightly, both passively and against
active resistance. Lastly, testing taste can be accom-
plished using salt or sugar on a cotton swab and stimu-
lating the anterior two thirds of the tongue. Testing
taste is complementary to categorizing facial nerve
lesions as “peripheral,” when taste is impaired
(Greenfield and Long 2016).
Cranial Nerve VIII: Vestibulocochlear
Nerve
The vestibulocochlear nerve is responsible for
hearing and mediating vestibular function. In new-
borns, hearing is evaluated in one of three ways:
(1) a bell is rung next to the infant’s ear, to which
she/he responds by pausing sucking briefly;
(2) habituation to the sound is observed in neurolog-
ically intact infants; and (3) infants older than
3 months will turn their head toward the stimulus.
The examiner also may use the startle reflex to test
hearing function (Haslam 2013; Greenfield and
Long 2016).
Infants who are at risk because of family history of
deafness, prematurity, hyperbilirubinemia, congenital
infections (rubella, herpes, cytomegalovirus), or use
of ototoxic drugs early in life, may be assessed with
auditory brainstem evoked responses or otoacoustic
emissions.
Vestibular function is assessed normally with the
caloric test. However, in infants, induced rotational
nystagmus is performed. The examiner should hold
the infant in his/her outstretched hands and rotate
slowly. In rotation with nystagmus, the infant’s eyes
should deviate in the direction opposite to rotation
(Haslam 2013).
Cranial Nerve IX: Glossopharyngeal Nerve
The glossopharyngeal nerve transmits taste stimuli
from the posterior third of the tongue and motor
fibers to the stylopharyngeus muscle. The former’s
function is tested via the gag reflex, elicited when the
posterior pharyngeal wall is touched lightly. The glos-
sopharyngeal nerve mediates the afferent sensory
limb, and the vagus nerve mediates the efferent motor
response (Greenfield and Long 2016).
4 Salandy et al.
Cranial Nerve X: Vagus Nerve
The vagus nerve serves various functions: it is
involved in movement of the larynx, including the
vocal cords, palate elevation, and pharyngeal contrac-
tion. A unilateral lesion can result in asymmetry of the
ipsilateral soft palate with resultant weakness and
paralysis of a vocal cord presents with hoarseness.
Bilateral vagus nerve lesions present with regurgita-
tion, pooling of secretions, and a depressed soft pal-
ate. Examining the gag reflex and proper swallowing
assess the function both of the vagus and the glosso-
pharyngeal nerves (Greenfield and Long 2016).
Cranial Nerve XI: Accessory Nerve
The accessory nerve innervates the sternocleido-
mastoid and trapezius muscles, which normally are
tested against resistance. However, testing in infants
is based largely on observation. Neck strength is eval-
uated by observing the infant turn his/her head.
These muscles display atrophy and weakness with
diseases such as motor neuron disease, myasthenia
gravis, and myotonic dystrophy (Haslam 2013; Green-
field and Long 2016). Furthermore, the patient’s voice
should be assessed to rule out vocal cord paralysis.
Cranial Nerve XII: Hypoglossal Nerve
The hypoglossal nerve innervates the tongue and
mediates its movement; hence, abnormalities will
cause the tongue to protrude toward the side of the
deficit, atrophy, exhibit fasciculations or weakness,
whereas bilateral hypoglossal nerve lesions will result
in an inability to protrude the tongue. If generalized
weakness is suspected, the tongue can be observed
at rest for possible fasciculations, which can be an
early indication of neuromuscular disease. Examiners
must be careful not to observe the tongue when it is
protruded, as tremors may be observed, which are
normal movements and not indicative of fascicula-
tions. Examiners may assess hypoglossal strength
and tone with the sucking reflex (Haslam 2013;
Greenfield and Long 2016).
MOTOR EXAMINATION
The challenge in examining infants’ motor function
rests in their limited abilities to cooperate. Until the
infant is 2 or 3 years of age, physicians must
approach the physical examination of infants patiently
and with delicate handling (Blasco 1994). Before
assessing movement, a thorough inspection of pos-
ture and spontaneous movement should be assessed
with the infant lying supine (Dubowitz et al. 2005).
Any abnormal positioning may be indicative of pathol-
ogy, for example, legs crossed at the feet or ankle
may represent increased tone in the hip abductors,
which is often seen in children with corticospinal tract
injuries of the upper motor neuron (Greenfield and
Long 2016). Any observations of tics and tremors
should also be noted. A physical examination of motor
function includes tone, power, mobility, and deep ten-
don reflexes.
Tone
Tone is defined as muscles’ resting resistance eval-
uated against passive motion and also correlates with
gestational age (Haslam 2013; Greenfield and Long
2016). A sleeping or resting infant may appear to
have lower tone; the subjective assessment of tone is
at the physician’s discretion and can be scored between
0 and 4, with 0 indicating hypotonia and 4 rigidity in
flexion or extension, according to the Modified Ash-
worth Scale (Noureddin et al. 2008). There are various
neurodevelopmental scoring systems, such as the Bal-
lard Scoring System, Dubowitz Scale, and so on, that
assess motor tone. At 28 weeks gestation, there is evi-
dence of flexor tone in neck muscles; however, exten-
sor tone is not present until full term. This is important
when evaluating premature infants (Behrman et al.
1976; Palmer et al. 1982; Dubowitz et al. 2005).
There are certain maneuvers that can be used to
evaluate infants’ tone. To examine upper limb tone,
physicians can look for the Scarf sign by extending
the infant’s arm gently toward the opposite shoulder;
as the elbow approaches the midline, the resistance
should increase. If the arm reaches the shoulder with-
out resistance, this is considered a positive Scarf sign
indicative of hypotonia and is given a score of −1
(Greenfield and Long 2016). Scoring depends on which
landmark was reached: a score of 0 if the arm reached
the contralateral axillary line; 1 if it reached the con-
tralateral nipple line; 2 if it reached the xiphoid pro-
cess; 3 if it reached the ipsilateral nipple line; and 4 if
it reached the ipsilateral axillary line (Ballard et al.
1991; Murray and McKinney 2013).
Upper limb traction and recoil maneuvers are
other means to assess upper limb tone. Arm traction
involves lifting the arms upward by the wrists and
examining the resistance and angle of flexion at the
elbows as the shoulders come off the surface: a score
of 0 is given if the arms remain straight with no resis-
tance; 1 when there are slight flexion and resistance;
2 when the arms flex to the shoulder and lift off the
surface, but then straighten again; 3 when the arms
are flexed to 100 and maintained, whereas the shoul-
ders are lifted from the surface; and 4 when the arms
are flexed more than 100 and maintained as the
shoulders are lifted from the surface (Dubowitz
et al. 2005).
Arm recoil involves positioning the arms extended
and parallel to the body for 3 sec and releasing quickly
when the infant should flex the arms again. Infants
with hypotonia will have an incomplete or slower flex-
ion response. Arm recoil tests the biceps’ tone; an
asymmetrical or absent response may indicate patho-
logical findings of brachial plexus injury or Erb’s palsy
(Dubowitz et al. 2005). The scoring depends on the
angle of flexion: a score of 0 for 180 ; 1 for 140–180 ;
2 for 110–140 ; 3 for 90–110 , and 4 for <90 (Ballard
et al. 1991; Murray and McKinney 2013).

The lower limbs’ tone is examined by leg recoil,
traction, and popliteal angle. To conduct leg recoil,
the infant’s legs and hips are flexed and held then
extended quickly and released. A normal response is
indicated when the infant reverts to a flexed position.
A score of 0–4 is given, with no flexion scored 0;
incomplete flexion 1; complete, slow flexion 2; com-
plete, fast flexion 3, and difficult extension with a
quick snap to flexion 4 (Dubowitz et al. 2005).
Leg traction is performed while the physician holds
the infant’s ankles and raises the legs upward. A nor-
mal response is flexion at the knees with resistance
as the buttocks lift from the surface. An infant is given
a score of 0 if the legs remain straight and no resis-
tance is felt; 1 if there is slight flexion of the knees,
resistance, and the buttocks remain on the surface;
2 if the legs are flexed only until the buttocks are
lifted; 3 if the legs remain in flexion while the buttocks
are lifted; and 4 if the legs remain flexed as the but-
tocks and back are lifted (Dubowitz et al. 2005).
Lastly, the popliteal angle is measured by flexing
the lower limb, placing the thigh against the abdomen,
and straightening the leg until resistance is encoun-
tered. When resistance is met, the angle at the popli-
teal space is measured and scored 0–5 (Ballard et al.
1991; Murray and McKinney 2013). The scores for the
angle are 180 without resistance, 150, 110, 90, and
less than 90 , respectively (Dubowitz et al. 1999).
Trunk and neck muscle tone are evaluated with
head control and lag and a test of ventral suspension.
When assessing head control, the examiner places
the infant in a supine position and helps the infant
adopt the posture by placing his/her hands around
the infant’s thorax, which allows the head to move
forward and back freely. The degree to which the
infant can bring the head vertical and hold it vertical
is scored 0–4. If the infant begins with the head back-
ward, flexor tone is being evaluated. When beginning
with the head forward, extensor tone is being evalu-
ated. The scores are as follows: 0 if no attempt to lift
head; 1 if a slight attempt; 2 if able to lift, but drops
back; 3 if the head is vertical and wobbles; and 4 if
the patient’s head remains upright.
Axial and neck tone also are assessed by the head
lag, in which the infant is pulled from supine to
upright by the wrists, and the head and flexion of
the arm’s response evoked is examined (Dubowitz
et al. 2005). The scores are the following: 0 when
the head remains dropped back; 1 when a head lift is
attempted, but the head falls back; 2 when the head
is lifted slightly; 3 when the head lift is in line with the
body; and 4 when the head is lifted in front of the
body (Dubowitz et al. 1999).
The ventral suspension test examines the axial
tone, in which the infant is placed over the examiner’s
arm, and the examiner supports the infant with
his/her hand under the infant’s chest. Although the
infant is draped over the examiner’s arm, the head’s
position in relation to the trunk and the amount of
arm flexion are evaluated (Greenfield and Long
2016). A curved back and low head with straight
limbs is scored 0; a curved back, low-lying head, and
mildly flexed limbs 1; a slightly curved back with
Neurological Examination of the Infant 5
flexed limbs 2; a straight back in line with the head
and flexed limbs 3; and a straight back with head
lifted above the body and flexed limbs 4 (Dubowitz
et al. 1999).
When assessing tone, it is imperative to observe
muscle tone individually and by comparison to that of
other muscles to understand its distribution. When
assessing tone, extensor and flexor tone should be
compared. Greater extensor tone may indicate hyp-
oxic injuries, such as meningitis, ischemic lesions, or
increased intraventricular pressure (Dubowitz et al.
2005). The upper and lower limbs also should be
compared: atypical lower limb tone can be attributed
to interventricular hemorrhages, hypoxic–ischemic
encephalopathy, and basal ganglia lesions. When
there is poor resistance during leg traction, but a
tight popliteal angle, this can be suggestive of germinal
matrix or interventricular hemorrhages (Dubowitz
et al. 2005).
Power
Power involves testing isolated muscle groups’
strength (Greenfield and Long 2016). When assessing
muscle power, the muscle’s strength and bulk should
be observed and is rated on a scale of 0–5, as follows:
0 for no contraction; 1 for slight evidence of contrac-
tion; 2 for active movement, but not against gravity;
3 for active movement against gravity; 4 for active
movement against gravity and resistance; and 5 for
normal power against strong external resistance
(Haslam 2013; Greenfield and Long 2016). Evidence
of a muscle group’s weakness may be associated with
atrophy or fasciculation secondary to denervation
(Haslam 2013).
In infants, testing power is less reliable because of
their inability to participate fully in the examination.
However, various methods are used to overcome this.
To assess shoulder girdle strength, the infant is held
from the axilla and slipping through demonstrates
weakness. Other examinations to assess the upper
extremities include observing the preference for one
hand over another before the age of 1 (shows weak-
ness on the side not preferred) or testing the infant’s
strength while grasping the examiner’s finger.
Evaluating power in an infant’s lower extremities
largely is observational, as there are limited testing
techniques. One maneuver used to assess lower
extremities’ power is to hold infants at the axilla, place
their lower extremities on a surface, and determine
whether the child is able to support his/her own
weight; if not, it indicates decreased power. Observa-
tion is an excellent tool with which to assess infants’
power, for example, to evaluate hip girdle strength,
observe the way an older child climbs stairs, and
stands up from a sitting position, or sits up from a lying
position.
The presence of a Gower’s sign, in which the child
stands by climbing up the legs using his/her hands
and arms, demonstrates proximal muscle weakness.
By the age of 3 years, children are able to follow such
commands as squeezing the examiner’s finger, flexing
6 Salandy et al.
and extending limbs, and abducting and adducting
muscles against resistance (Haslam 2013; Greenfield
and Long 2016).
Mobility
Assessing infants’ mobility is achieved by observ-
ing the infant lying supine and evaluating the amount
and quality of spontaneous movement. The move-
ment’s quality is poor if a child exhibits only stretches,
but normal when an infant displays variable, alternat-
ing movements of arms and legs. Continuous exagger-
ated, synchronized or jerky movements are considered
abnormal (Dubowitz et al. 2005)
Deep Tendon Reflexes
Stretch receptors in joints and muscles facilitate
deep tendon reflexes (DTR); thus, an intact, function-
ing unit is necessary to elicit a response (Greenfield
and Long 2016). DTR are scored from 0 to 4, in which
0 indicates absent; 1 present, but hypoactive; 2 nor-
mal; 3 brisker reflex; and 4, hyperactive with possible
clonus (Murray and McKinney 2013). DTR reflexes
may be tested at any age, although eliciting DTR in
infants can be difficult because of their spontaneous
movements and small size, which make them smaller
targets to tap with the hammer. Upper extremity
reflexes tested commonly include the biceps (C5/C6)
anterior to the elbow; the brachioradialis (C5/C6) at
the radial aspect of the wrist; and the triceps (C6/C7)
posterior to the elbow (difficult to achieve in neo-
nates). In the lower extremity, DTR includes the ankle
reflex (L5/S1/S2) elicited by tapping the Achilles ten-
don following the foot’s dorsiflexion; the adductor
reflex (L2–4) at the medial epicondyle of the distal
femur elicited by tapping the adductor tendon, and
the patellar reflex (L2/L3/L4), in which the reflex
elicits a jerk when the patellar ligament is tapped
(Greenfield and Long 2016). This can be followed by
the crossed adductor response, in which the reflex
causes the contralateral leg to contract. This response
disappears by 6–7 months. The plantar extensor
reflex, also known as the Babinski reflex (L4-S2), is
elicited by stroking the foot’s sole from heel to the
base of the toes with a blunt object, which causes the
big toe to move upward and the others to fan out.
This response is normal until 3 months of age. An
increased DTR could suggest an upper motor neuron
disease, whereas absent and decreased DTR could
suggest lower motor neuron disease (Haslam 2013).
SENSORY EXAMINATION
Infants’ unreliable responses during sensory exam-
ination limit the type of testing feasible. Infants may
disregard a stimulus because of habituation, which
occurs sooner in the neonate period, whereas older
children ages 3–4 are easier to test. Physicians use a
cotton applicator to assess touch and a broken tongue
depressor to evaluate pain. Different dermatomes are
stroked, and the response is observed. Typically, the
infant will look at the area that is being stimulated
and grimace or otherwise change demeanor (Yang
2004; Haslam 2013).
Another way to study sensory response is through
tactile reflexes. The afferent neurons are sensory
receptors coupled with motor efferent neurons. These
tactile reflexes include the rooting, Galant, abdomi-
nal, and grasp reflexes, the plantar response, and
extension of the fingers following a dorsal stroke
(Haslam 2013). These reflexes will be discussed fur-
ther in the following section.
PRIMITIVE REFLEXES
Rooting and Sucking Reflexes
Following birth, obtaining nourishment depends on
the infant’s ability to suck. This behavior involves an
infant’s lips’ response following contact with the nip-
ple, and the act of sucking. These reflexes, hypothe-
sized to be related to suckling behavior, include the
rooting and sucking reflexes.
When the infant’s cheek or mouth is touched, the
rooting reflex causes the infant to turn his/her head
toward the stimulus. Subsequently, following the root-
ing reflex, the sucking reflex is triggered when the nip-
ple is in the infant’s mouth. When the examiner places
his/her finger in the commissure of the infant’s mouth,
it also can elicit the sucking reflex (Gentry and Aldrich
1948; Woolridge 1986). The sucking reflex can test
the trigeminal and hypoglossal nerves indirectly by
assessing the strength and control of the muscles of
mastication, lingual tone, and strength, respectively
(Greenfield and Long 2016). The rooting and sucking
reflexes should be present at birth. However, they may
be absent in premature infants secondary to depression
of the central nervous system via maternal anesthesia,
anoxia, or congenital defects. The reflexes are present
until 3–4 months and retained until 7–8 months in
sleeping infants (Paine 1969).
Moro Reflex
The Moro reflex can be elicited as early as 25 weeks
of gestation in preterm infants and in most infants by
30 weeks (Futagi et al. 2012). Moro discovered the
reflex in 1928 by striking the surface on either side of
the infant and eliciting a motor response in which the
infant’s four limbs abduct and extend, then subse-
quently abduct and flex. Infants also will extend their
spine and outstretch initially and then close their fingers
(Mitchell 1960; Paine 1969; Campbell and DeJong
2005). There are many ways to elicit this response,
including loud noise, inducing the sensation of falling via
abrupt loss of support of the head and trunk, and
extending the infant’s arms followed by sudden release
(Mitchell 1960; Greenfield and Long 2016). The most
reliable technique to test the Moro reflex is to lift the
newborn’s head and shoulders with respect to the body,
and allow the head to drop. It is imperative to determine
whether the response is symmetrical, as a dispropor-
tionate Moro reflex may indicate brachial plexus injury,

fracture of the clavicle or humerus, injury to the shoul-
der joint, and rarely, neonatal hemiplegia (Paine 1969;
Dubowitz et al. 1980). The reflex is normally present up
to 3 or 4 months of age and disappears by 6 months of
age. However, the Moro reflex is inhibited in infants with
spastic cerebral palsy during the first 3–5 months,
appears between 5 and 7 months, and is retained up to
11 months (Paine 1969; Zafeiriou 2004).
Stepping and Placing Reflexes
The stepping reflex is present during the first
6 weeks of life. To elicit it, the infant is held upright and
slightly forward, with knees bent marginally, and feet
touching a surface. In response, the infant will raise
his/her leg and then the other, as if taking steps
(Murray and McKinney 2013; Greenfield and Long
2016). This reflex of upright locomotion that resembles
walking disappears by 2 months and is not present until
the end of the first year of life (Thelen et al. 1982).
The placing reflex is similar to the stepping reflex.
The infant is held upright, but when the dorsum of the
foot touches the edge of the examining table, it
causes the infant to lift his/her leg and place it on top
of the table. The response diminishes by the end of
the first year. However, it persists in infants with
motor deficits (Campbell and DeJong 2005).
Palmar Grasp
The palmar grasp is elicited by the examiner placing
his/her finger into the infant’s palm and applying pressure
near the base of the fingers. The infant’s reflex response is
flexing his/her fingers to form a fist around the examiner’s
finger (Futagi et al. 2012). This response involves two
phases: catching and holding. Muscular contraction upon
deep pressure on the palmer surface is the “catching”
phase. The subsequent “holding” phase applies traction to
the flexor tendons or adductor muscles. Resting with
his/her palm on the dorsum of the infant’s hand will dimin-
ish the grasp reflex (Schott and Rossor 2003). Injury to
the arms’ nerves will result in a weak or absent reflex
(Murray and McKinney 2013). This reflex is present at
28 weeks gestation and strongest at 37 weeks, when the
infant is able to lift him/herself from a supine position
(Yang 2004). The response disappears at 6 months of age
(Zafeiriou 2004).
Plantar Grasp
Similar to the palmer grasp, the plantar grasp is
elicited by applying pressure to the region below the
toes, which causes the toes to curl over the exam-
iner’s fingers (Murray and McKinney 2013). This
response disappears at 15 months of age.
Babinski
The Babinski response is elicited by applying lateral
pressure on the plantar surface of the foot from the
heel to the toes and curving inward toward the base of
the big toe. A normal response is no movement or the
Neurological Examination of the Infant 7
toes’ downward flexion, whereas a positive Babinski
sign is upward movement and fanning of the big toe.
Because of the newborn brain’s immaturity, they will
have a positive Babinski sign. Unlike in adults, where a
positive sign indicates an upper motor neuron disease,
in infants, a positive Babinski can be present until one
to 2 years of age in the absence of any neurological
pathology (Paine 1969; Greenfield and Long 2016).
Landau
The Landau response initiates within the first
3 months of life and is present throughout infancy
(12–24 months). To stimulate the response, the infant
is placed either lying face down or in horizontal sus-
pension (ventral portion of the body parallel to the
ground), which causes the infant to extend his/her legs
and look up (Campbell and DeJong 2005).
Glabella
The glabella sign, also referred to as the blinking
reflex or nasopalpebral reflex, causes a reflex blinking
bilaterally when the glabella is tapped lightly. The
reflex consists of two responses, the myotatic monosyn-
aptic and multisynaptic nociceptive reflexes. Normally,
the latter reflex habituates with continued stimulation. A
positive glabella sign is indicative of the absence of
habituation (Schott and Rossor 2003).
Asymmetric Tonic Neck Reflex and Neck
Righting Reflex
The asymmetric tonic neck reflex involves the pos-
ture the infant adopts when lying supine; the infant will
extend the arm and leg to the side the head is turned
and flex the opposite arm and leg. This reflex is
referred to as the asymmetric tonic neck reflex or
“fencing reflex” (Murray and McKinney 2013). Turning
the infant’s head toward the preferred side for 15 sec
can elicit this response, which diminishes by the fourth
to sixth month of age. Recurrence of this response
later in life may indicate decerebration or decortication
(Zafeiriou 2004; Campbell and DeJong 2005).
The asymmetric tonic neck reflex’s disappearance
is replaced by the neck righting reflex, in which rota-
tion of the head toward one side is followed by rota-
tion of the shoulder, trunk, and pelvis, which helps the
infant roll over. The reflex can be elicited both by pas-
sive and active head rotation (Paine 1969).
Parachute Response
The parachute response occurs from the eighth to
ninth month and is preserved throughout life. Posi-
tioning the infant prone in the air and bringing him/
her down to the surface headfirst triggers a response
in which the arms extend and abduct, and fingers
spread in an effort to break the fall. The response
should be compared bilaterally, as a disproportionate
reaction may indicate upper extremity weakness
or spasticity, whereas the absence of a parachute
8 Salandy et al.
response can be indicative of a serious neurological
disease (Campbell and DeJong 2005).
CONCLUSION
A thorough neurological examination should assess
infants’ general, cognitive, developmental motor, sen-
sory, cranial nerve, and primitive reflexes. A clinician
should conduct a thorough evaluation to obtain a
comprehensive picture of the patient’s current neuro-
logic status to prevent misdiagnosis. Neurological
examination in infants poses a challenge for the
examination because of patients’ variability in lan-
guage and communication skills and interaction with
the examiner. Thus, examiners must be creative and
sufficiently careful to guide the consult and determine
important information to make accurate diagnoses
and provide helpful further therapy if needed.
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