NEONATAL CNS EXAMINATION

SCHEME OF EXAMINATION
• Mental status and higher mental function
Mental status- Appearance, behaviour,
communication, delusion, hallucination
Higher mental function- Consciousness,
orientation, memory, attention span, abstract
thinking, calculation
• Cranial nerve examination
• Motor system examination- Gait/Posture, Bulk
, tone, Power, DTR, Superficial reflexes
• Sensory system examination-
Pain/Temperature- Lateral spinothalamic tract
Touch/Vibration/Joint position- Posterior
spinothalamictract
Tactile localization, Two point discrimination-
Cortical sensation
• Cerebellar system
• Meningeal signs- Neck rigidity, Kernig sign,
Brudzinski sign
• Skull and spine- Macewen sign,
Transillumination
 PHYSICAL SIGNS
• Which may point to neurologic disease-
Pallor- ICH
Icterus- Hepatic encephalopathy
Rash- Meningococcemia
Petechiae- Dengue
Head and scalp haematoma- Head trauma
 NEUROCUTANEOUS STIGMATA
• Ash leaf macule- Tuberous sclerosis
• Port wine stain- Sturge weber syndrome
• Café au lait macules- NF
• Multiple pigmented nevus- Neurocutaneous
melanosis
 CHECKLIST FOR HIGHER MENTAL
FUNCTION
• MENTAL STATUS- ABCDE-
Appearance
Behaviour
Communication ( speech/language)
Delusion/Hallucination
Emotion/Mood
 HIGHER MENTAL FUNCTION
• COMA-PIFAC
 Consciousness
 Orientation
 Memory
 Attention span
 Perception
 Insight
 Abstract thought
 Calculation
 DISORDERS OF CONSCIOUSNESS
• Coma
• Brain death
• Vegetative state
• Minimally conscious state
• Locked in state
• Akinetic mutism
 FOUR SCORE
• Full outline Unresponsiveness scores
• 4 components-
Eye response
Motor response
Brainstem reflexes
Respiratory pattern
Condition Self awareness Sleep wake Brainstem Respiration
cycle function
Coma - - Variably Variably
preserved depressed
Brain death - - - Absent
Vegetative - Preserved Variably Normal
state preserved
Minimal + ( Minimal) Preserved Preserved Normal
conscious state
Locked in state + Normal Preserved Variably
depressed
Akinetic Limited Normal Preserved Variably
mutism depressed
 EYE RESPONSE
• E4- Eyelids open, tracking, blinking oon
command
• E3- Eyelids open but not tracking
• E2-yelids closed but open to loud voice
• E1-Eyelids closed, but open to pain
• E0- Eyelids remain closed to pain
 MOTOR RESPONSE
• M4- Thumbs up
• M3- Localizes pain
• M2-Flexion response to pain
• M1- Extension response to pain
• M0- No response to pain/ Generalized
myoclonus
 BRAINSTEM REFLEXES
• B4- Pupil and corneal reflexes present
• B3- one pupil wide and fixed
• B2- Pupil or corneal reflexes absent
• B1- Both pupil and corneal reflexes absent
• B0- Absent pupil, corneal and cough reflex
 RESPIRATORY PATTERN
• R4- Not intubated, regular brearthing
• R3- Not intubated, Cheyne Stikes breathing (
Hyperventilation- Apnea- Hyperventilation)
• R2- Not intubated, irregular breathing
• R1- Breathes above ventilaory rate
• R0-Apnea
 GCS FOR CHILDREN
• Eye response- 1-4, Motor response- 1-6
• Verbal response-
 Alert, babbles, coos, words/sentences to usual
ability-5
 Less than usual ability/Spontaneous irritable cry-
4
 Cries inappropriately-3
 Occasionally whimpers/moans-2
 No vocal response-1
 VERBAL RESPONSE FOR INTUBATED
PATIENTS
• Spontaneous normal facial/oromotor activity-
5
• Responds to touch-4
• Vigorous grimace to pain-3
• Mild grimace to pain-2
• No response to pain-1
 SPINAL CORD LEVELS
• Cervical spinal cord- Cervical vertebrae
• Thoracic spinal cord- T1-T8
• Lumbar spinal cord- T9-T11
• Sacral spinal cord- T12-L2
 ROOTING REFLEX

• A rooting reflex can be elicited by stroking the

cheek with a finger.
• The newborn responds by turning the head
towards the side being stroked and by
opening the mouth, as if ready to eat.
• Although it may sometimes seem difficult to
elicit in the first few days, it becomes stronger
over the first week or two.
 SUCKING REFLEX

• As soon as the baby feels his thumb at his

lips, he begins sucking.
• Sucking is a self-soothing manuever for infants
• An examiner can take advantage of this reflex
(and its ability to soothe a fussy baby) by
allowing the infant to suck on a finger or
pacifier during the examination.
•
 SUCKING REFLEX

• The examiner should note the quality and

strength of the suck.
• Preterm infants are more likely to have a suck
reflex that seems uncoordinated or weak.
• Other infants do more biting initially (making
breastfeeding challenging!).
• Rubbing the infant's palate with the pad of the
examiner's finger or firmly stroking in an anterior-
posterior direction under the side of the chin may
help stimulate a sucking reflex in an infant who is
slow to start.
 MORO REFLEX
• The Moro reflex (also known as the "startle reflex") is
easily elicited in a newborn by pulling up gently on the
arms and then suddenly letting go.
• The infant will extend the fingers and arms out and
around and then frequently cry.
• The reflex is produced by the suddenness of the
stimulus, not the distance of the fall.
• An asymmetric or absent Moro is of concern.
• Brachial plexus or upper extremity injury or underlying
CNS pathology should be considered in those cases.
 GRASP REFLEX OF THE FOOT

• The grasp reflex is also strongly present in the

feet of a newborn.
• Stroking up the middle of the foot will elicit
the reflex -- the toes curl under and seem to
grasp onto the thumb of the examiner.
• This is not the same as a negative Babinski
reflex.
• The grasp reflex is present until 2 - 3 months
of age.
 GALANT REFLEX

• The galant reflex is elicited by suspending the

infant in a prone position -- the feet should
not be touching the bed. The side of the back
is then stroked in a cephalocaudal direction.
• The infant will respond by moving the hips
towards the side that was stimulated.
GALANT REFLEX
 JITTERY MOVEMENTS

• Jitteriness most commonly occurs in an

otherwise well-appearing infant on the first day
of life.
• The most common cause is hypoglycemia.
• In some cases, the glucose level will be normal
and the jitteriness will be a transient, idiopathic
finding.
• Other medical causes of jitteriness include
hypocalcemia and drug withdrawl.
POWER
 GRADING OF REFLEXES
• 0- Absent
• 1- Present but diminished
• 2- Normal
• 3- Increased
• 4- Hyperactive/Clonus
 HEAD EXAMINATION
• Shape
• Size
• Transillumination sign
• Macewen sign /Crackpot sign