NEUROLOGIC EXAMINATION OF KIDS

NEUROLOGIC EXAMINATION OF KIDS 

CNS examination of an infant or a young child frequently poses difficulties. This is particularly true in case of sensory examination. Evaluation of cerebral function, cranial nerves and their integrity, cerebellar function, motor system meningeal signs and involuntary movements should be done as and when indicated. In the case of new born, it is important to assess the primitive reflexes. An estimate about the developmental and mental age should be made.

Clubbing

Definition: Loss of natural angle between the nail plate and nailbed with boggy fluctuation of the nailbed.

Grading

Grade 1: Increased boggy fluctuation of the nailbed.

Grade 2: Obliteration of the natural angle between the nailbed and the nail plate

Grade 3: Increase in curvature and thickness of the nail plate from above downward and from side to side. Altered prostaglandin metabolism and proloiferation of the connective   tissue.

Causes

Pulmonary bronchiectasis, empyema, lung abscess, progressive pulmonary tuberculosis,   cystic fibrosis, etc. Cardiovascular infective endocarditis, cyanotic CUD, etc.

Gastrointestinal Malabsorption states, ulcerative colitis, Crohn disease, multiple polyposis.

Hepatic Biliary cirrhosis, chronic active hepatitis

Miscellaneous Congenital, familial, thyrotoxicosis, Hodgkin lymphoma, syringomyelia.

Clinical Elicitation in Doubtful cases

1. Depth at the base of the nail or greater than the depth at the distal interphalangeal joint.
2. Disappearance of the normal “window” when two fingers are approximated.
3. When the nail is rocked on its bed with examiner’s index finger and thumb, it appears to be floating.

Special features of neurologic examination of infants and children

1. A considerable information can be obtained by carefully watching and interacting with the  child during history taking and while he is moving about or playing.
2. The sense of touch or pain should be tested during rest of the examination or during play, “Let’s play… close your eyes and say “yes” when you feel the touch,” should be the examiner approach. Avoiding testing for pain without first preparing the child for it.
3. Muscle tone is well tested by lifting the child by the shoulders. A child with generalized hypotonia simply slips out of the hands. Second useful test is that such a child’s elbows are able to cross midline of the chest easily (scarf sign)
4. The signs of meningeal irritation may be absent in certain situations, say infancy, gross malnutrition, toxemia and septicemia
5. It is usual for the tendon reflexes to be exaggerated (brisk) in young children
6. Primitive plantar reflex may normally persist well up to 1 year. It is prolonged persistence, say beyond 2 years, must be considered abnormal.
7. A positive Macewen sign (cracked pot sign) in fast 3 years of life may well be normal.
8. As a rule, optic disc on fundoscopy appears rather pale even in normal children. Ignoring this fact may lead to overdiagnosis of optic atrophy.

Pediatric testing of cranial nerves

1. First (Olfactory nerve) Ask the child to close eyes. Find out the odors (say peppermint, orange, lemon, coffee or tea) he is familiar with. Then test for them.
2. Second (optic nerve) Test vision and do fundoscopy to watch the optic disc.
3. Third (Oculomotor nerve) As the child to flow a bright object or light in all direction without rotating the head. Watch any limitation. Also watch for size of the pupil.
4. Fourth (Trochlear nerve) Watch for downward movement of the eye in particular which is impaired in its involvement. Even at rest, the eye tends to move upward.
5. Fifth (Trigeminal nerve) Test sensation over forehead, cheek and lower jaw. Also, test for corneal reflex and jaw jerk.
6. Sixth (Abducent nerve) Test for lateral movement of the eye. In its involvement, the child fails to move his laterally (temporally). At rest too, such an eye has atendency to move medially(nasally).
7. Seventh (Facial nerve) Test for asymmetry of the face when child is asked to smile or laugh, show teeth, close the eyes and attempt wrinkling the forehead. Whistling too fails in its paralysis. In case of upper motor neuron lesion (supranuclear paralysis), forehead involvement is not elicited.
8. Eighth (Vestibulocochlear nerve) For auditory component, test or deafness or ringing in years. For vestibular component, test for positional nystagmus.
9. Ninth (Glossopharyngeal nerve) Test for gag reflexon touching child’s posterior pharynx with a tongue depressor.
10. Tenth (Vagus nerve)  Examine throat for position of uvula. The normal midline uvula turns to the healthy side in case of unilateral involvement)
11. Eleventh (Spinal accessory nerve) Ask the child to shrug shoulders  which showing drooping in its involvement. Moreover, he fails to move head away from the affected side.
12. Twelfth (Hypoglossal nerve) Ask the child to show the  tongue which is deviated to the involved side. The speech of the child too becomes thick.