A neurological examination in pediatrics is a structured assessment of a child’s nervous system function, tailored to their developmental stage. It evaluates brain, spinal cord, and peripheral nerve integrity through observation and interaction, often using play-based techniques to engage the child.
Preliminary Assessment
- Assess the child’s previous neurological, general health, nutritional, and developmental history.
- Assess the understanding of child’s family regarding his/her current health status.
Preparation for neurological examination
- Explain the procedure and the purpose of neurologic examination to the child and the family.
- Review results of child’s last neurologic assessment to provide baseline data.
- Review child’s medical diagnosis, developmental, and health history to determine whether any neurologic changes may be consistent with current health problems or medical history.
Procedure
- Perform hand hygiene
- Observe the child at rest, noting behavior and modes; response to surrounding and movements
- Assess level of consciousness, noting stimulus needed elicit arousal, quality of response to stimuli and length of response time.
- Measure the HC.
- Inspect the child’s cranial shape for symmetry and palpate fontanels to assess whether they are open, note the sunken or bulging.
- Inspects the child’s skin noting neurocutaneous findings such as sacral dimples, spine curvature and hemangiomas.
Reflex Assessment
- Biceps: Flex the child’s forearm, place your thumb over child’s antecubital space, and tap with reflex hammer.
Response: slight flexion at the arm when the tendon is tapped
- Triceps: Abduct the child’s arm and support forearm with your hand or hold child’s wrist over his/her chest to flex arm at elbow. Tap directly above elbow.
Response: partial extension - Brachioradialis tendon: Place the child’s arm and hand in relaxed position with arm flexed and palm down. Tap the radius of about 1 in. above the wrist.
Response: Flexion of forearm and upward turn of the palm. - Patellar: With the child sitting on edge of table or bed with legs dangling, use reflex hammer to tap front outer aspect of child’s knee, midline, and just below patella.
Response: slight extension - Achilles tendon: Assist the child in a seated position on the edge of a table or bed. The child’s legs should dangle freely over the edge. Support the child’s foot at 90° angle and use a reflex hammer to tap the back of the child’s heel. If the child is in a supine position, flex one leg at knee and hip supporting the lower position of that leg on the opposite shin. Lightly support foot in your hand in dorsiflexion and tap Achilles’ tendon. Response: Plantar flexion
- Babinski: Strike the outer sole of the child’s foot from heel to toe with the handle of reflex hammer and note movement of toes.
Response: In children older than 2 years of age, the toes should flex downward. The upward movement of the big toe with other toes fanning outward is called Babinski sign. - Kernig’s sign: With child lying supine, lift child’s leg with flexion at knee and hip.
Note any pain or resistance. - Brudzinski’s sign: An involuntary flexion of the hip and knees when neck is passively flexed (positive in meningitis).
- Anal reflex: Gently stroke the perianal skin, the child will contract the anal sphincter.
- Abdominal reflex: With child lying supine, stroke abdominal skin in all four quadrants by moving handle of reflex hammer from the side toward the midline.
The umbilicus should move toward the stroking in children >6 months. - Cremasteric reflex: Gently stroke inner aspect of a male child’s thigh; the testis of the side of the stroked thigh should retract into inguinal canal.
Assessment of Level of Consciousness
The level of consciousness of the child will be assessed by using Glasgow Coma Scale.
Muscle Strength
- Assess the grip strength, individual muscle strength and assessment findings are generally graded from 0 to 5.
0- No movement
1- Trace muscle contraction
2- Active movement
3- Active movement against gravity
4- Active movement against gravity + resistance
5- Normal power of movement
- Ask the child to squeeze your fingers.
- Ask the child to make muscles by bending arms at elbows with palms facing body and resist your attempt to straighten arm to assess biceps strength.
- Triceps: Ask the child to extend arms and resist your attempt to flex or bend arm.
- Quadriceps: While child is seated with legs dangling over edge of bed or table, ask the child to extend each leg straight and resist your attempt to bend leg.
- Gastrocnemius muscle: Ask the child to press the sole of foot against your hand.
- Tibial-radialis strength: Ask the child to bend toes up toward his/her face while you place your hand on top of foot.
- To detect spasticity: Passively move the child’s extremities, noting tone ease of movement (it should be smooth and flexible).
- Lift smaller children under armpits and note child’s ability to lock shoulders and prevent slip through.
- Ask the child to sit on stool or chair and rise to standing position, keeping arms crossed in front of chest.
- Ask the child to draw a picture and build a tower of blocks (to assess motor dexterity).
- Ask the child to pick up a small object, such as a piece of cereal observing finger and hand movements bilaterally.
- With arm lifted away from body, ask the child to quickly press thumb and index finger together and apart repeatedly and then have the child use thumb to alternatively touch each finger of same hand. Observe movements of one hand and then other.
Cerebella Assessment (Balance and Coordination)
- Ask the child to walk, run, hop, skip, and walk heel to toe.
- Technique to elicit actions includes rolling a
ball along the floor and asking a young chila
to go get it or having a child to run and try to catch his or her parent. - Ask the child to use index finger to touch his/her nose alternatively touching your index finger in various locations near child’s body, noting tremor or post pointing
- To assess the Romberg’s sign, ask the child to stand with feet together, arms at sides, and eyes closed, like a soldier (should not fall over).
Cranial Nerve Assessment
I cranial nerve
Ask the child to identify some common odorous material (e.g., orange, chocolates) with his/her eyes closed.
Il cranial nerve:
- Acuity of vision: >3 years- the vision can be screened by use of Snellen’s charts. In infants-checking blinking response to bright light, turning of head toward diffuse light, or following red moving ball or ring.
The visual acuity in term newborn baby is around 6/45 and it gradually matures to an adult level of 6/6 by the age of 6-7 years. - Field of vision: >3 years-an object suspended from a thread is gradually brought from the periphery toward the eye and child is asked to indicate when the object is visualized.
- Color vision: >3 years— by showing different color objects.
III, IV, and VI cranial nerves
Look for squint, movements of eyeballs, diplopia, and nystagmus. The child is asked to look at the examiner’s fingers that are moved slowly horizontally in either direction and vertically up and down.
Infant: doll’s eye movement phenomenon is used to test the ocular movements.
V cranial nerve
- Infant: Note strength of infant’s suck of pacifier, examiner’s thumb, or bottle.
- Children: Assess the strength of bite and ability to discern light touch on face.
VII cranial nerve
Note symmetry of facial expressions.
- Infant: Monitor during spontaneous cries or smile.
- Older child: Ask the child to whistle or blow. Ask him to blow out his cheeks with air under pressure and test the tension on both sides by taping each cheek with finger.
Assess taste by asking to discern certain common tastes (salt, sugar).
VIII cranial nerve
- Enquire any hearing defect, tinnitus, vertigo, and dizziness. Ask for response of the child to noise of jet plane, banging of door, music, calling of his name, etc. Use Weber’s or Rinne’s test.
- Infants: Assess for startle response, blinking of eyes, sudden change or cessation of activity, turning of head toward the sound stimuli of a bell, whistle, squeaky toy, etc.
IX and X cranial nerve
Ask the child to identify different tastes on the back of the tongue and tell the child to swallow. A tongue blade may be used to elicit the gag reflex.
XI cranial nerve
Ask the child to turn his/her head from side to side against mild resistance, or to shrug the shoulders.
XII cranial nerve
Ask the child to stick out his/her tongue and instruct him/her to speak
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
- Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840.
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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