COURSE OUTLINE

I. NEUROLOGICAL EXAMINATION IN PEDIATRICS

A. Cerebrum-Mental state
B. Sensorium
C. Speech
D. Cranial nerves
i. CN I (Olfactory Nerve)
ii. CN II (Optic Nerve)
iii. CN III, IV, V (Oculomotor, Trochlear, Abducens Nerves)
iv. CN IX & X (Glossopharyngeal & Vagus Nerve)
v. CN XI (Spinal Accessory Nerve)
vi. CN XII (Hypoglossal Nerve)
E. Motor examination
F. Cerebellar function
G. Sensory system
H. Reflexes

I. NEUROLOGICAL EXAMINATION IN PEDIATRICS GOALS:

  • Primary Inquiry: ● Does the child have a neurologic disorder?

    • Must be based on history taking. Are there signs of:
      ○ Signs of increased intracranial pressure (ICP) - headache, vomiting
      ○ Meningeal irritation - nuchal rigidity
      ○ Neurological deficits - decreased sensorium, seizures
      ○ Abnormal neurologic findings

  • Secondary Inquiry: ● Where is the site of the lesion?

    • Focal - localized in one area

    • Generalized

  • Tertiary Inquiry: ● What is the nature of the lesion?

    • Acute / Subacute / Chronic

    • Static / Remitting

    • Congenital - present at birth?

    • Developmental - only evident during growth?

    • Genetic - is it present in the family?

    • Immunologic

    • Degenerative

    • Vascular

    • Neoplastic

    • Nutritional

A. CEREBRUM-MENTAL STATE

  • Sensorium

    • Observe your patient when entering the examination room or at the emergency room; this is a preliminary check for sensorium.

      • Is your patient ambulatory?

      • Is your patient on a stretcher board?

  • General Behavior

  • Speech

    • Upon interviewing, check if your patient can speak.

  • Mood

    • Effectiveness of response.

B. SENSORIUM

  • Evaluation Criteria:

    • Evaluate the level of consciousness, attention span, orientation to time, place, and person, recent and remote memory.

      • For school-aged children, you can ask the name of their teacher.

    • Observe behavior, degree of awareness and alertness, eye contact, ability to maintain attention/concentration, ability to recall immediate, recent, and remote events, abstract reasoning.

    • Eye contact is critical.

      • For example, if you are conversing with them and they are not looking at you, it indicates an issue.

      • Assess the ability to maintain attention; if they do not listen to your questions, it indicates a problem.

    • Abstract reasoning: When asking a question, if they respond with something unrelated, it shows difficulty in this area.

      • Example: you ask them, "Anong kinain mo?" The response is "this morning" instead of an actual answer.

    • Assess knowledge of general information, reading, spelling, and arithmetic, as well as personality and other emotional factors.

      • In the outpatient department, you can ask them to read; if they cannot read, check if they can recite their ABCs.

      • Age 3 - can already say their name.

      • Age 6 - should already know how to spell.

LEVEL OF CONSCIOUSNESS

  • Categories:

    • Lethargy: Difficulty maintaining the aroused state.

    • Obtundation: Response to stimulation other than pain.

    • Stupor: Responsive only to pain.

    • Coma: Unresponsive to pain.

Table 1. Level of Consciousness

  • Level of consciousness is crucial because, in the first part of your physical examination, you have to describe whether your patient is conscious, lethargic, obtunded, stuporous, or comatose.

PEDIATRIC COMA SCALE

  • Note: Pediatric coma scale differs from the adult coma scale.

C. SPEECH

  • Assessment Criteria:

    • Listen to the produced speech.

      • Check articulation and comprehension.

      • Evaluate receptive and expressive language:

      • DYSPHONIA: Disturbance in or lack of the production of sounds from the larynx.

      • DYSARTHRIA: Disorder in articulating speech sounds.

      • DYSPHASIA: Disturbance in the understanding or expression of words as a symbol for communication.

D. CRANIAL NERVES

CN I (OLFACTORY NERVE)

  • Function: Sense of smell.

  • Testing Instructions:

    • Have the patient close their eyes, then let them smell something familiar like coffee.

CN II (OPTIC NERVE)

  • **Functions:

    • Visual fields (Confrontational Testing).

    • Fundoscopy (using an ophthalmoscope).

    • Pupillary light reflex.

CN III, IV, VI (OCULOMOTOR, TROCHLEAR, ABDUCENS NERVES)

  • Functions:

    • Oculomotor: Innervates almost all the recti muscles.

    • Trochlear: Innervates the superior oblique muscles.

    • Abducens: Innervates the lateral rectus that abducts the eye.

  • Testing Instructions:

    • Test as a group due to interrelated functions to extraocular movement.

    • Check the position of the eyes at primary gaze.

    • Ask the child to track objects and check for any limitations in extraocular movement.

    • Look for nystagmus or subjective complaints of double vision.

    • Check for pupillary size, reactivity to light, and accommodation using a penlight.

  • Abnormalities:

    1. Strabismus: Abnormal ocular alignment due to muscle imbalance.

    2. Ptosis: Drooping of one or both eyes.

    3. Nystagmus: Involuntary rhythmic oscillation of the eyes.

    4. Limitation of eye movements.

CN V (TRIGEMINAL NERVE)

  • Functions: Sensory (touch, temperature) and motor actions.

  • Testing Instructions:

    • Test for light touch and temperature; for instance, apply a cold object (like ice), and the patient should feel that it is cold.

    • Test for pain.

    • Test for facial sensation by using cotton or a finger to touch.

    • Test for corneal reflex by having them look in the opposite direction, then apply cotton to the cornea, leading to blinking.

    • Absence of blinking in the corneal reflex indicates a comatose state.

    • Assess muscles of mastication by having the child chew and swallow food while palpating the masseter and observing any jaw deviation.

  • Abnormalities:

    • Sensory loss over the ipsilateral face.

    • Absent or weak corneal reflex.

    • Weakness of the muscle of mastication.

    • Jaw deviation.

CN VII (FACIAL NERVE)

  • Function: Innervates the muscles of facial expression.

  • Testing Instructions:

    • Assess muscles of expression by asking the child to smile, frown, show their teeth, and close their eyes, checking for facial symmetry.

    • Test sense of taste by applying solutions of sugar or salt to the protruded tongue using a cotton tip applicator, testing one side then the other.

  • Abnormalities:

    • Central Facial Palsy: Asymmetry of labial folds but preserved function of the upper half of the face.

    • Peripheral Facial Palsy: Complete paralysis of one side of the face and loss of taste on the anterior 2/3 of the tongue.

CN VIII (VESTIBULOCOCLEAR NERVE)

  • Functions: Responsible for hearing and vestibular functions.

  • Testing Instructions:

    • In infants and younger children, test by observing their response to a bell.

    • WEBER TEST: Place a tuning fork on the vertex of the patient’s head or over the forehead; normally, sound should be appreciated in the middle or equally on both sides.

    • RINNE TEST: Evaluates hearing in one ear, comparing air conduction to bone conduction.

  • Abnormalities:

    • Conductive Hearing Loss: Impairment occurring when sound waves cannot efficiently travel through the outer ear, tympanic membrane, or middle ear.

    • Sensorineural Hearing Loss: Issues in the inner ear or auditory nerve.

    • Vestibular Dysfunction: Problem of the auditory system.

CN IX & X (GLOSSOPHARYNGEAL & VAGUS NERVE)

  • Functions:

    • Observe sucking and swallowing.

    • Observe for symmetry in movement of the uvula and soft palate.

    • Test for Gag reflex.

  • Abnormalities:

    • Loss of taste in the posterior third of the tongue (CN IX).

    • Hoarseness (CN X).

    • Loss or decreased gag reflex (both).

    • Deviation of the uvula to the normal side (both).

CN XI (SPINAL ACCESSORY NERVE)

  • Functions: Innervates the sternocleidomastoid and trapezius muscle.

  • Testing Instructions:

    • Assess by having the patient turn their head and shrug shoulders against resistance.

    • Palpate for bulk, tone, and contraction of the muscle during head turning and shoulder elevation, checking for symmetry.

  • Abnormalities:

    • Asymmetry in shoulder movement.

    • Asymmetry in the bulk and strength of sternocleidomastoid and trapezius muscles.

CN XII (HYPOGLOSSAL NERVE)

  • Testing Instructions:

    • Check for atrophy, fasciculations of the tongue muscle.

    • Check the position of the tongue at rest and during protrusion.

  • Abnormalities:

    • Atrophy (unilateral/bilateral).

    • Fasciculations of the tongue.

    • Deviation of the tongue towards the weak side.

E. MOTOR EXAMINATION

  • Observational Criteria:

    • Observe gait and posture of patients while walking.

    • Check for atrophy/hypertrophy.

    • Identify involuntary movements (fasciculations, tics, dystonia, chorea, athetosis).

  • Muscle Strength Assessment (0-5 grading):

    • 0: No muscle contraction

    • 1: Trace of contraction

    • 2: Active movement with gravity eliminated

    • 3: Active movement against gravity

    • 4: Active movement against gravity and resistance

    • 5: Normal strength

Table 3. Muscle Strength Grading

F. CEREBELLAR FUNCTION

  • Coordination Tests:

    • Check for speech and observe for gait.

    • Ask the child to reach for and manipulate toys; observe for tremors, clumsiness, and incoordination.

    • In clinics, children can play with toys as you assess any abnormal movements, clumsiness, and dropping of toys.

    • Perform finger-to-nose and heel-to-shin tests.

    • Check the ability to perform rapid alternating movements (e.g., rapid pronation and supination of the hands).

  • Abnormalities:

    • Ataxia, atonia.

    • Dysmetria, dyssynergia (incoordination, clumsiness).

    • Dysrhythmia (inability to repeat in rhythmic taps).

    • Dysdiadochokinesia (difficulty with rapid alternating movements).

    • Dysarthria (scanning speech).

G. SENSORY SYSTEM

  • Testing Criteria:

    • Test for touch, pain, and temperature sensation using hot or cold objects.

      • Ask patients to close their eyes and determine whether the object placed on their skin is hot or cold; normally, they should identify this correctly.

    • Test for position sense: with eyes closed, ask the patient to identify changes in position (upward and downward); an opposite response indicates an abnormality.

    • Test for vibration sense: placing a vibrating tuning fork on the joints.

    • Romberg Sign Testing:

      • With eyes closed, have the child stand with feet together and both arms extended to the sides.

      • Observe for balance or swaying.

  • Abnormalities:

    • Sensory loss.

    • Astereognosis: Inability to recognize objects through touch.

H. REFLEXES

  • Tests for Deep Tendon Reflexes:

    • Biceps jerk

    • Brachioradialis/supinator jerk

    • Triceps jerk

    • Knee jerk

    • Ankle jerk

GRADING OF REFLEXES

SCORE

REFLEXES

0

Absent

+1

Hypoactive or only with reinforcement

+2

Readily elicited with normal response

+3

Brisk with or without evidence of spread to neighboring roots

+4

Associated with few beats of sustained clonus

+5

Sustained clonus

Table 4. Grading of Reflexes

Reference(s):

  • Pablico, I. (2025). Neurological Examination in Pediatrics. [PPT] PEDIA I LC 10: NEUROLOGICAL EXAMINATION IN PEDIATRICS Dr. PABLICO, I. BATCH TANNAWAG 2E