Neuro exam: Adaptations for children

Obtaining the History

Unlike in adults, most children cannot give a full history without the help of a parent (or guardian). This person is an invaluable resource when it comes to accurately relating how events unfolded. That said, you must remember that the parent may harbor their own loving perceptions about or fears for their child. Your role in gathering the history with a child’s parent is to mentally construct a narrative that enables you to independently generate a localization for the problem and a differential diagnosis, which will help to guide your examination and further narrow the location and nature of the problem.

In order to secure the interest and cooperation of both parent and child, an open conversation with the parent at some physical distance from the child is usually the least threatening way to begin.

One common approach is to address the child and parent together, introduce yourself, and explain that you will allow the parent to discuss their concerns first, then the child, before the exam. That said, children have varying attention spans and interest, so especially if they are tired or hungry, putting the exam at the beginning of the visit may make sense rather than attempting to coax an exhausted or cranky child. Reassure the child that the examination will not hurt. Do not promise a painless experience if there is any chance you will be ordering a blood draw after the visit! Simple rewards, such as the promise of stickers, are helpful for younger children.

Older teens deserve the same considerations as adults (to be addressed directly and to see you as their physician), and those over 14 should have the chance to speak with you alone if desired. For older teens, make it a routine part of your history to politely offer to excuse the parent from the room for a few minutes to give the teenager a chance to bring up any potentially embarrassing concerns.

Developmental Considerations

In addition, children come with the added challenge of rapid development. Part of your role is to tease out whether the child’s history and exam is appropriate for her chronological age. For anyone under one year old, the gestational age at birth and perinatal history is very relevant. This will inform which reflexes you expect to find, how you test strength and coordination, and which milestones you expect the patient to have reached.  The OFC (occipito-frontal circumference) is a sensitive, though not specific, measure of growth that can serve as a vital sign. For children of any age, language and speech development (include sign language and other non-English languages) both serve as insights into cognitive development.

Ask parents about developmental milestones by asking open-ended questions, such as “What sounds or words are you hearing? Any signs?” or “How is your child moving around? How does your child play with small toys?” Then you can ask further clarifying questions such as “Does she use two fingers or her whole hand to pick up the toy?” Try not to ask whether a child has yet reached a particular milestone as the initial question; many parents feel a bit defensive at this.

In the beginning, rather than trying to memorize each and every milestone and reflex (key ones are found in table below under Reflexes), it is best to simply gather detailed information about the child’s motor, verbal, and social development, as well as to perform an exam geared towards either infants (up to 12 months) or older children (similar to an adult). Most typically developing children can start to do a standard neurologic exam by ages 6 or 7. In the next few sections, you will find some specific tips and tricks for examining children.

Examining a Child: Introduction

The most important difference between examining a child and examining an adult is the role of observation and play. To many learners, it may seem as though pediatric neurologists watch a child for a while, play with her for a few minutes, have her run around in the hall, tap on her reflexes, watch a cute video on the parents’ phone, and declare the exam complete. Indeed, that is the impression we are hoping to convey to the child, and to cause as little distress as possible. However, critical information can be gleaned from careful observation.

For example, many cranial nerve palsies are readily apparent through playing and speaking with a child. Strength differences and asymmetries may also come out in playful interaction, but only if you are watching for them. It is difficult to do a systematic, confrontation exam of sensation or strength in a specific order in a young child; instead, learn to store away the information gleaned from interaction as it becomes available, and reorganize it in a way that you and others can easily interpret. Reflex testing may precede fundoscopy and cranial nerve testing may need to follow an active gait examination in a child with “the wiggles”, but try to always organize and present your notes in the usual manner.

Some portions of the exam are unique to babies (see section at the end). The best place to practice examining healthy babies is in the newborn nursery and at the many well checks that take place in the first year of life, and at the homes of willing friends. This will enable you to recognize what is abnormal.

If possible, try to involve the parents in the exam. Have them close by, or holding the child. Explain what you will do before you do it. Some portions must be done without the parent. For instance, gently coach them not to answer for the child during direct questioning; you are not wondering what the child actually had for breakfast; you are trying to see whether the child remembers and can tell you! Often, offering options will interest the child and they will participate more readily: “Would you like to check your eyes with a flashlight first, or go run in the hall?”

Mental Status and Language

Comment on the resting state of the child and what type of stimulus it took to get them to the most alert and awake state possible. Infants who have just eaten are likely to appear quite somnolent, and this can affect their entire exam; likewise infants who are hungry can appear quite jittery. Ask when an infant most recently fed; this can be reported as part of mental status. For language, remember a child should speak one word at a time by one year, two-word sentences by two years; three word sentences by three; able to produce long and mostly grammatical, intelligible sentences by four. Vocabulary should increase exponentially. A two-word sentence comprises two distinct words (i.e., “thank-you” counts as one, “no, thank-you,” counts as two). Words in ASL count. Sounds count as long as they are specific to a certain concept (such as “Ro-Ro” for the family dog and all dogs). Bilingual words count as one, i.e., “savon” in French and “soap” in English are the same concept. It is not true that bilingual children develop more slowly, or that younger siblings develop more slowly.

Developmental history should go into your history, but observed aspects of development (for instance, how fluent/how many words are said per sentence) should go into the appropriate section of the exam (usually mental status or motor).

Mental status questions should be appropriate to the age and stage of development. To test orientation, naming, memory, and attention, try asking about colors, objects in the exam room, cartoon characters, school friends, plush toys, what they had for breakfast, identity of family members and teachers, or the name of their school. Children over 5 may be able to give you their home phone number or address.

Vocal quality can be gleaned through videos in a very shy child. Some dysarthria is normal until about five; healthy toddler dysarthria is different from slurred speech and has a specific quality. Often, /l/, /r/, and /w/ may be conflated.

Cranial Nerves

Acuity can be tested with toys and stickers across the room; often not better than this. Hearing can be tested by whispering instructions and by air conduction with a tuning fork. Extraocular motions can be tested with a toy. Fundi are best done in a slightly sleepy child at the end of the exam, or one who has the energy to participate and focus. Have them look at a parent who can prompt them to keep their eyes pointed at the parent during fundoscopy. Facial strength may be checked by blowing air through a pinwheel or making funny faces. Playing with a flashlight can give you a pupillary exam, a tongue exam, and a palate exam. Asking the child to copy your facial expressions is the quickest way to obtain a cranial nerve exam in a young child.

Motor Exam

Bulk can be tested by look and feel in the child. Comment on whether muscles feel appropriate versus too rubbery or fibrous.

Tone must be tested in a resting muscle. In babies, tone is paramount. Compare central/axial tone to limb/appendicular tone (see section on infants at the end of this chapter). Check the ability to hold the head up in an upright and prone position.

A crying child will activate their muscles, rendering a tone exam useless. Try to check their limbs casually while they are focused on something else, such as watching a cartoon or eating. A velocity-dependent increase in tone is called spasticity. Check for it slowly first, then quickly, in arm extension and leg flexion.

In order to check strength, functional testing is often the easiest – that is, having the child mimic you through a series of motions. For example, a child who can squat, rise from the floor without using her arms, climb onto the exam table, bend over to pick something up without falling, jump, run, hop on one foot, and do it all symmetrically, is unlikely to have significant lower extremity weakness.  In older infants and toddlers who are uncooperative or afraid, pushing gently on arms and legs often prompts them to push you away, giving you a rough idea of their limb strength and symmetry. By pinning the proximal portion of the limb, you can attempt to isolate a muscle group. Use a small toy or ball for them to push at or kick for the same purpose, as many children are afraid to push or kick against an adult.

Sensation

As in adults, you can check light touch, temperature, proprioception and vibration in a child. Light touch can be done with a paintbrush or gauze – have the child close their eyes and guess where the paintbrush is, or say “now” when they feel it. Check temperature by asking them to tell you which of two water cups in colder, or whether the floor or your tuning fork is colder, etc. Look for any cuts or burns that the child did not notice. Do not check pain in an awake child unless you have a specific reason to. Proprioception: many children can perform a Romberg; but help them cover their eyes or they will likely peek. Proprioception in the fingers can be screened for by having the child close their eyes (or have parents cover), and then touch their nose with the selected finger. In addition, a child who can walk down the hall while playing a game on an iPad likely has intact proprioception! Vibration sense is more difficult; often all you can tell is that the child feels it. However, a child that truly has dorsal column dysfunction should have other signs on exam, such as an abnormal gait (sensory ataxia), and difficulty with proprioception.

Reflexes

Similar to testing in adults.  Remember that children have, in general, “jumpier” reflexes than adults. 1-2 beats of clonus can be normal in a child. You can test most reflexes with a finger over the tendon so that it does not hurt. In addition, you can check reflexes in children that are often difficult to obtain in adults, such as pronator (C6) at the wrists and medial hamstrings (L5). The latter is helpful in a child who refuses to turn over for the exam and lies face down on the bed or ground. Triceps (C7) can also be easily tested in a child lying face down, as can Achilles (S1) and the plantar response. Use your thumbnail, not the pointy tip of your hammer, to check the plantar response, as many children have a very strong withdrawal of the foot that will fool you if you use too noxious a stimulus.

If you are not getting any reflex at all, check that you are in the correct place. It takes practice, also, to allow the reflex hammer to swing down with gravity on the tendon rather than applying force. All the force should be in the upswing, and none in the downswing except to guide the hammer to the correct location. This is both the correct method and less painful. Start by using your wrist’s full range of motion (this standardizes your exam because it is always the same length); if very brisk, you can use smaller and smaller arcs to see what the least amount of necessary force may be to elicit the reflex. Primitive reflexes are discussed at the end of this chapter.

Gait

Most children love this portion of the exam. Go with the child or have the parent do this as well if needed for moral support. Have them walk, run, jump with one and two feet, heel walk, and toe walk. A three-year-old can jump with both feet. Tandem walk is usually difficult before the age of four. Skipping is a complex gait task that requires strength and coordination; many children cannot skip until 5-6 or older, but it is a useful screening tool – intact skip excludes severe gait abnormalities. Pay attention to how the arm is held (older walking infants and young toddlers hold arms up in high guard) and whether arm swing is symmetric. Toddlers have a wide-based gait which disappears around three. Remember: roll at 5 months, sit at 6 months, crawl or creep at 7 months, pull to stand at 9 months (often cruising along furniture), walk at 12 months. There is a lot of normal variation; these are just guidelines.

Coordination

In most children, this can be easily observed while playing with the child and doing the rest of the exam. Look for tremor, dysmetria while reaching out for a toy, truncal unsteadiness or titubation, gait issues, and intrusive movements, especially in limbs, neck, and eyes. Remember that as babies myelinate, they can display all kinds of movements that would be abnormal in an adult, including dysconjugate gaze, jerky or jittery motions, choreiform movements, and truncal/neck unsteadiness. Vertical or rotary (circular) nystagmus are never normal.

Babies Under 12 Months

Certain portions of the exam are specific to babies. Tell the parents what you are about to do and be gentle; one of the greatest fears in life may be that someone will hurt your baby. Watch a more experienced physician before you attempt your first newborn exam.

For general exam: Remember to check the OFC in every baby you examine, and trend it along the growth curve. Check the anterior fontanel for size, tension (how full or soft it feels), and pulsatility. Examine the tone and reflexes while the baby is in either a “quiet awake” or sleepy state (or feeding). Important baby anatomy includes: the soft palate (use your gloved finger and check the suck reflex at the same time), the sacrum (dimples or tufts), genitalia, and skin (looking for melanotic cyanosis, hemangiomas, or other birthmarks). Look at the face and fingers/toes for dysmorphology; compare the child to parents to avoid bias. A child who looks nothing like her biological parents and also has facial features that appear atypical to you may have a genetic syndrome or teratogenic/infectious exposure in utero. Hirsutism varies greatly and is less helpful, but reporting it shows you are paying attention. The more babies you see, the more easily you can do this.

Cranial nerves: Few people check acuity, olfaction, or hearing in a baby. Check extraocular motion using the child’s mother as a target. Move the child relative to the mother or the mother relative to the child, remembering that newborns see only about a foot away. Dysconjugate gaze is normal in the newborn, and usually only disappears after the first several weeks of life. You can overcome the vestibulo-ocular reflex in the normal newborn, so it is not as useful.

For motor exam: Tone in a baby is checked axially (central tone, including neck) and appendicularly (limbs). Check head lag by lifting the supine child gently off the bed by her arms. Never allow a baby’s neck to quickly or forcefully extend; support the head with your forefingers as you hold the child. Check neck control and shoulder “slip through” by suspending the child vertically/axially over a soft surface with your hands underneath the axillae. A child with very low central tone will literally slip through your hands, so be prepared to grab them!

Hold the baby prone over the bed to check neck extension. Remember, a baby with high tone may appear to have head lag when supine, but when you turn them prone, they will extend their neck against gravity and hold their body up and horizontal. A baby with low tone will curl into a C shape facing the floor, because they cannot resist gravity.

Strength in a baby is described as how frequently they move and how easily they resist gravity and gentle pressure from an examiner. Report it in each of the four limbs and head.

Reflexes will be higher on the side to which the head is turned, so check them with head midline. Remember the usual ones as well as rooting, suck, Moro (report as absent, one, two, or three phase), fencer’s (atonic neck), palmar grasp, and plantar grasp. The usual plantar responses are upgoing for the first year. Check startle by clapping near the baby.

Coordination: Differentiating normal movements from seizures in a baby can be subtle. They are usually asymmetric as the nervous system is not mature enough for rapid generalization. Look for forced gaze deviation, hemibody stiffening, or movements that repeat with a baby that looks distressed after them. Seizures in newborns can be subclinical. Seizures can be associated with desaturation and bradycardia, but these can also cause seizures. Threshold for obtaining an EEG in a neonate is lower than in an adult.

Gait: In older infants, have them try to roll, crawl, cruise, or whatever they can do to move under their own power. Motivate them by carrying them away from parents and have them try to return. Children are unlikely to leave a parent and come to you on command for the first year of life.

In general, given that milestones may be difficult to memorize over the course of a single rotation and that infants change so quickly, a detailed description of what you did and saw, categorized in the usual way General/MS/CN/Motor/Sensory/Reflex/Gait/Coordination) should paint a picture in the mind of your listener and will make you very effective as a future child neurologist.