International Emergency Nursing (2011) 19, 199–205

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REVIEW

Pediatric neurologic exam

a,*
Sharon Sables-Baus PhD, RN, PCNS-BC (Assistant Professor) ,
Marylou V. Robinson PhD, FNP-C (Assistant Professor) b

a
The College of Nursing, University of Colorado Denver, Children’s Hospital Colorado, Aurora, CO, USA
b
The College of Nursing, University of Colorado Denver, Aurora, CO, USA

KEYWORDS Abstract
Pediatric; Although emergency nurses receive education and training in performing comprehensive and
Neurologic exam;
rapid assessment, pediatric patients may prove to be challenging due to dynamic growth,
Emergency care
development and maturation. If the emergency department (ED) has limited exposure to pedi-
atric patients, performing assessments and prompt interventions may be daunting. Neonates,
infants and young children with illness or trauma have unique and often times subtle signs
and symptoms that can change rapidly. Although the neurological exam for older children
may be similar to that of an adult, there are significant differences based on maturation.
The neurologic exam for neonates and infants provides the nurse with even more opportunity
to be familiar with developmental differences. Therefore, it is important for ED nurses to
become familiar with typical development and early recognition of neurologic insult.
ª 2011 Elsevier Ltd. All rights reserved.

Introduction have a high center of gravity and they tend to be impulsive

leading to falls, poisoning, burns, and auto-pedestrian acci-
Common reasons for parents to seek emergent care for their dents. For school age, there may be bicycle, sports or
child where a neurological evaluation is indicated include playground injuries. Therefore, knowledge of pediatric
trauma or head injury as well as headaches, syncope, fever, developmental stages is imperative.
and seizures (Menkes and Moser, 2006). The mechanism of Identifying neurologic disorders in infants and children is
injury is influenced by the developmental stage of the child. difficult due to the maturational influence of presenting
For example, rapid changes in mobility for an infant may symptoms (Goldstein and Greer, 2009). The CNS continues
lead to falls, and exploration with their mouths may lead to develop after birth and does not reach full maturity until
25 years of age (Kotagal, 1990). Therefore the neurologic
to suffocation and/or choking. Toddlers and preschoolers
examination of children is unique based upon age and devel-
opmental stage. The nurse must provide a rapid and accu-
rate illness and injury triage, localize the disturbance and
Corresponding author. Tel.: +1 720 777 5349 (O); fax: +1 303 724
quickly assess developmental function as well as offer fam-
8559.
ily support (Pellock and Myer, 1984; Strange et al., 2009;
E-mail address: [email protected] (S. Sables-
Baus). Swaiman et al., 2006).

1755-599X/$ - see front matter ª 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ienj.2011.07.008
200 S. Sables-Baus, M.V. Robinson

Pediatric neurologic examinations require keen observa-

Table 1 Mnemonic for altered level of consciousness.
tion skills as well as an ability to quickly establish a trusting
relationship with the child and family members (O’Malley A Alcohol, abuse or substances
et al., 2008). This trusting relationship will encourage fam- E Epilepsy, encephalopathy, electrolyte abnormalities,
ily sharing. The relationship begins to develop as the nurse endocrine disorders
obtains an admission history collecting data about the child I Insulin, intussusception
and family and assessing the child’s usual health habits at O Overdose, oxygen deficit
home. A family history is relevant to uncover familial neuro- U Uremia
logical disorders or developmental delays. (Jarvis, 2008b). T Trauma
Obtaining a complete history is especially important if the I Infection
child presents after a motor vehicle accident, serious fall, P Poisoning, psychiatric conditions
high fever or a new onset of seizures to differentiate base- S Shock, stroke, space-occupying lesion (intracranial)
line neurologic status from injury or illness. The history
should include an accurate review of the presenting illness,
developmental history that includes antenatal, perinatal
and postnatal information, as well as developmental Formalized pediatric mental status evaluation is chal-
milestones. lenging due to limited language ability and differences
The process begins with the triage and the ‘‘across the in developmental milestone achievement amongst infants
room assessment’’ followed by a brief but focused general and children. As acuity allows, the mental status assess-
assessment. A great deal of information can be obtained ment can be performed in a cursory and abbreviated man-
from simple observation, such as overall muscle tone, sym- ner in the ED. If stable, children greater than 3 years of
metric movement of all extremities, strength of cry, and age may be expected to be able to cooperate in the
the child’s level of interaction with parents. A primary examination. It is important to perform the assessment
assessment includes airway, breathing, circulation, disabil- in a nonthreatening manner, allowing the child to remain
ity and expose/environment. The secondary assessment on the parent’s lap whenever possible (Hockenberry,
may be required to better differentiate the severity of the 2005). Begin with a series of age appropriate questions
condition. This secondary assessment should include expo- asked of the child designed to test the awareness of
sure of the patient and the use of inspection, palpation and responsiveness to the environment, their ability to
and auscultation. A full set of vital signs to include temper- pay attention and to speak and understand what is said
ature, heart rate, and respiratory rate as well as blood pres- (Crane and Clark, 2008). Tools such as play materials or
sure and pulse oximetry monitoring should be available. puppets may be used to facilitate recall and explanation
Level of alertness and examination of skin, head and spine of experiences. Combing hair motions, drawing and trac-
must be evaluated for evidence of trauma or overt malfor- ing figures on the exam table paper can be used to test
mation (Fenichel, 2009; Goldstein and Greer, 2009). visual–spatial ability and cognitive functioning (Blumen-
thal, 2001).
In the case of trauma, the parents should be encouraged
Pediatric neurological evaluation
to remain close and in physical contact as the medical sit-
uation allows while the child is evaluated (Hockenberry,
The neurologic examination of a pediatric patient consists of 2005). Coma scales are used to evaluate consciousness,
specific evaluation of mental status, motor function, cranial rank the severity of injury and to correlate with outcome.
nerves, reflexes and sensory function. The exam must take The most common scale currently being utilized is The
into account the patient’s age and anticipated developmen- Glasgow Coma Scale (GCS) (Teasdale and Jennett, 1974).
tal norms and be modified accordingly due to the ‘‘age-spe- It is used for children with head trauma to evaluate im-
cific nervous system invoking the need for age-specific paired consciousness by testing eye opening, verbal re-
neurological assessment’’ (Hadders-Algra, 2004). Sequence sponse and motor response (Simpson et al., 1991). The
of a pediatric neurologic exam cannot be expected to occur GCS may not be applicable in the very young child as it does
in a lock-step head to toe order. Some aspects of the exam not reflect changing range of verbal and motor responses of
are best reviewed when a child is calm and not crying. Other infants and toddlers (Reilly et al., 1988). The GCS is bene-
findings indicate a true emergency. Asking the parents if ficial for all ages if the chief purpose is detect life threat-
what you are seeing is typical for the infant or child is impor- ening complication such as intracranial bleeding (Simpson
tant as any ‘‘major changes in behavior are readily apparent et al., 1991). Many versions of the GCS have been devel-
to any clinician, subtle changes often are appreciated best oped for pediatric use by making simple modifications to
by parents and caretakers’’ (Avner, 2006). reflect norms for different ages (Reilly et al., 1988). Table 2
indicates such modifications. A possible score of 3 indicates
Mental status deep coma while the highest score of 15 indicates a fully
awake and aware child. Any combination score of less than
Assessment of the mental status is the first step in the neu- 8 indicates a significant risk of mortality (Teasdale and
rological evaluation. Mental status can progress rapidly Jennett, 1974). The GCS should be used in conjunction with
from a loss unawareness of the environment, to confusion, a detailed evaluation and complete testing of neurological
delirium, lethargy and stupor. The mnemonic AEIOU TIPS functioning. Having family present during this evalua-
(Table 1) is helpful in listing the major categories of illness tion may help with their comprehension of their child’s
or injury to be considered (Avner, 2006). acuity.
Pediatric neurologic exam 201

Table 2 Glasgow Coma Scale.

Glasgow Coma Scale Pediatric Infant
Eye-opening response
Score
4 Spontaneously Spontaneous Spontaneous
3 To loud voice To verbal command To verbal command
2 To pain To pain To pain
1 None None None

Motor response
Score
6 Obeys Obeys commands Spontaneous or purposefully
5 Localizes Withdraws from touch Withdraws from touch
4 Withdraws, flexion Withdraws from pain Withdraws from pain
3 Abnormal flexion Flexion to pain Flexion to pain
2 Extension Extension to pain Extension to pain
1 None None None

Verbal response
Score
5 Oriented Uses appropriate words and phrases Babbles, coos appropriately
4 Confused, disoriented Uses inappropriate words Cries, irritable but is consolable
3 Inappropriate words Cries or screams persistently to pain Cries or screams persistently to pain
2 Incomprehensible sounds Grunts or Moans to pain Grunts or Moans to pain
1 None None None
Pediatric scale is the Glasgow Coma Scale modified to pediatrics and infants (Teasdale and Jennett, 1974). Assessment of coma and
impaired consciousness: A practical scale. Lancet, July 13, 1974; 81–4.
Any combined score of less than eight represents a significant risk of mortality.

Motor function 2006). Sustained clonus, involuntary muscle contractions initi-

ated by a reflex, and increased deep tendon reflexes are com-
The motor system evaluation includes examination of passive monly associated signs signifying an upper motor neuron
muscle tone and posture as well as appraisal of active muscle process problem in the cerebral cortex. Clonus is most com-
activity, strength and shape of the muscle (Blumenthal, monly elicited by rapidly flexing the foot upward and watching
2001). Passive muscle tone is defined as the amount of tension for contractions in the ankle. Sustained clonus, 5 beats or more,
present in resting muscles and is assessed by observation or is considered worrisome for problems with the brain’s ability
resistance to passive movement. Active muscle activity and pos- to control bodily functions of the brains stem and spinal cord
ture is assessed by observation of symmetry and quality of such as chewing and walking (Jarvis, 2008a).
movements as well as gait and posture, coordination, balance, Motor function can be assessed formally in the older,
and strength. By 6–9 months of age, children are old enough to cooperative child. Children at age 4 should be able to stand
sit and stand alone with the support of furniture or assistance of on one foot for 10 s and hop on one leg. Gross motor func-
parents. Poor coordination or inaccuracy of movements of the tion can be observed as they stand or sit near the parents
arms and legs may be found in young children and are often re- and respond to being placed on the examination table.
ferred to as ‘‘soft’’ neurological signs. Soft neurological signs Strength is graded on the standard 0–5 scale as in adults,
can be defined as a mild or slight neurologic abnormality that with zero representing no muscle contraction and five rep-
is difficult to interpret or detect. Soft signs are often open to resenting normal strength. Muscle bulk or atrophy should
interpretation or often dependent on family reporting. For be evaluated, as well as posture and gait if appropriate.
example, lack of symmetry in the limbs can be immaturity of Pincer grasp and pick up of toys should be evident between
the nervous system or an indicator of neurologic insult or injury 8–12 months. Strategic placement of toys or child desirable
(Martins et al., 2008). Soft sign along with other clincial con- objects can be used to test reach, coordination, tremors,
cerns must be confirmed with head imaging. and preferential use of one limb. Symmetry of muscle bulk,
Hypertonia is a less common presentation and is associated motion and strength is important. When establishing unilat-
with disturbance of cortical function. Increased muscle tone eral weakness, deliberately placing the object to favor use
can be characterized as either spastic or rigid. Spasticity refers of the suspect extremity is in order. Specific documentation
to a resistance to passive movement that is eventually over- of hand preference can occur with some reliability in pre-
come with a sudden yield under pressure, similar to a clasp- schoolers; dominance of one extremity prior to age 1 is
knife effect. Older children will exhibit problems by walking pathological. Gentle restraint of the dominant hand can ex-
on tiptoes secondary to muscle rigidity which involves increased clude simple preference if the child opts to use the extrem-
tone and constant resistance to passive range of motion (Blosser ity in question (Blosser and Reider-Demer, 2009; Jarvis,
and Reider-Demer, 2009; Kotagal, 1990; Menkes and Moser, 2008b; Menkes and Moser, 2006).
202 S. Sables-Baus, M.V. Robinson

Cranial nerves and reflexes includes the gestational age, birth weight, and identifica-
tion of dysmorphic features that may suggest congenital
The approach to cranial nerve exam in children should be anomaly or inborn errors of metabolism.
age appropriate, although cranial nerve (CN) assessment
in older children is similar to that of adults. Table 3 illus- Mental status
trates how to assess each of the cranial nerves as well as
presents examples of concerning findings. A key component in a neonatal evaluation of mental status
For older children, CN I through XII are tested similarly to includes a brief period of observation before handling the
adults. Vision (CNII) is tested by looking for the blinking response infant to determine level of alertness, posture and tone.
when a bright light is presented. Looking at facial grimace tests The level of alertness should be defined as one of five cate-
cranial nerves CNV and VII. Ringing a bell or other instrument gories: quiet sleep nonrapid eye movement), active sleep
near the child can test hearing which is CNVIII. Looking for a (rapid eye movement), awake/drowsy (eyes open with gross
gag reflex tests cranial nerve IX and X (Jarvis, 2008a). movement), alert or crying. The optimal time for assess-
The cover-uncover test can be used to determine appro- ment is when the infant is quiet and awake, a status not
priate eye coordination for a younger child. Strabismus is common in the ED. Altered level of alertness is seen in in-
normal during the first months of life. Specific visual acuity fants with cortical dysfunction (Prechtl, 1977).
tests, if indicated, uses the picture chart from age 30–
60 months; use of the Snellen chart starts around age 5–
Motor function
6 years. Corneal reflexes may be checked with a sudden
hand wave around the face. The cotton wisp test of corneal
reflex should be reserved for obtunded children. Pupils Prechtl (1977) initially established the field of early neurolog-
should be equally responsive to light at any age. Eyes should ical development and recognized the significance of observa-
generally be situated and move in tandem. Withdrawal to tion of motor behavior. He discovered that the quality of
tactile input or stimulus of the trigeminal nerve (5th cranial spontaneous general movements (GM’s) accurately reflects
nerve) of the face and mouth can be used to examine CNV in the condition of the nervous system of the neonate and in-
unconscious patients or by stroking and gentle finger flecks fant. GM’s are gross motor movements that involve all parts
in those who are awake. CNVII can be assessed by observing of the body. Prechtl’s work continues to be the keystone of
for facial asymmetry or flattening of the nasolabial fold. infant examination (Hadders-Algra, 2004; Prechtl, 1977) .
In a crying child, there is an opportunity to evaluate that The assessment of motor function for the neonate or in-
there should be symmetry in tonsil size, midline uvular place- fants begins then with the observation of GM’s while in a
ment and spontaneous halts to swallow secretions. Most tod- resting pose with head in a midline position. The typical
dlers and children enjoy the opportunity to stick their resting pose of a neonate varies based on post menstrual
tongues out at the nurse. Atrophy, uncontrolled deviation age (PMA), with a typical infant at 36 weeks gestation dem-
or fasciculation (twitching) of the extruded tongue can indi- onstrating weak flexion of all four extremities and the term
cate an abnormality of CNXII (Blosser and Reider-Demer, infant having strong flexion of all four extremities (Amiel-Ti-
2009; Jarvis, 2008b; Kotagal, 1990; Menkes and Moser, 2006). son and Grneier, 1986; Blosser and Reider-Demer, 2009). In-
fants should exhibit symmetric, smooth and spontaneous
movements in all extremities which represents their active
Sensory function
muscle function (Blosser and Reider-Demer, 2009; Jarvis,
2008b; Menkes and Moser, 2006). The tone of the muscle
Sensory function can also be assessed in older children as it is usually tested by applying resistance to a relaxed limb
is in adults. Cool versus warm differentiation is typically not
although, for a neonate, it is measured by looking at the in-
done in the ED, but can be accomplished in children older
fant’s head control and resting posture or by observing their
than age 3. Though not typically yielding information in an movement against gravity.
emergent setting, the olfactory nerve, CN I, is assessed by
Hypotonia or decreased muscle tone is characterized by
looking at the response of the child to an inhaled substance.
an overall floppy appearance to the infant, including inabil-
They may be able to identify common smells such as bana- ity to maintain head control. Infants can be observed for
nas or strawberries. Taste is also not normally tested in the
spontaneous movements of the head and extremities. An in-
ED, but if it is deemed necessary, decreased taste in the
fant generally should be able to lift their head by about
anterior two thirds of the tongue in an older child can be 1 month of age and hold it up when placed in a sitting posi-
evaluated with foods or toothpaste from a patient care
tion by about 4 months of age. At 4–6 months infants should
pack. Sensory testing requiring self-report is notoriously
control their heads and roll over. Head tilt in any child after
unreliable in children under age 5–6 (Blosser and Reider-De-
age 6 months might indicate compensation for a visual de-
mer, 2009; Jarvis, 2008b; Menkes and Moser, 2006). fect, muscle development issues or a cranial mass. Head
and neck control should be strong and steady by 6 months.
An infant with hypotonia exhibits a floppy quality or ‘‘rag
Infant neurological examination doll’’ feeling when held. These infants may also lag behind
in acquiring certain fine and gross motor developmental
A comprehensive neurologic assessment should be com- milestones. There may also be a history of feeding or
pleted for any neonate or infant who enters an ED. Key dif- swallowing problems. Causes of hypotonia in the newborn
ferences to the evaluation from the general pediatric include hypoglycemia, hypothyroidism, hypoxia, encepha-
evaluation are noted. History taking specific to the neonate lopathy, infectious, metabolic causes or brain hemorrhage.
Pediatric neurologic exam 203

Table 3 Testing cranial nerve function of a child.

Cranial nerve Name Type and when to test How to test Abnormal
Cranial nerve I Olfactory Test those with head With child’s eyes closed
trauma and abnormal occlude one nostril and
mental status present an aromatic
substance that is non noxious
Cranial nerve II Optic nerve Papilledema with Using the ophthalmoscope to
increased intracranial examine the ocular fundus to
pressure; optic atrophy determine the color, size and
shape of the optic disc
Cranial nerve III, Oculomotor, Motor function, sensory Check pupils for size, Increasing intracranial
IV, VI trochlear, and function and corneal regularity and equality and pressure causes a
abducens nerves reflex consensual light reaction and sudden, unilateral,
accommodation. Nysstagmus dilated and nonreactive
is a back and forth oscillation pupil. Nystagmus occurs
of the eyes with disease of the
vestibular system,
cerebellum or brain
stem
Cranial nerve V Trigeminal Nerve Muscles of mastication, Palpate the temporal and
sensory function and masseter muscles as the
corneal reflex person clenches the teeth.
Lightly touch a cotton wisp to
forehead, cheeks and chin.
Place wisp of cotton on the
cornea coming in from the
side
Cranial nerve VII Facial nerve Motor and sensory Note mobility and facial Muscle weakness is
function symmetry as person responds shown by flattening of
to request to: smile, frown, the nasolabial fold,
close eyes tightly, lift drooping of one side fo
eyebrows, show teeth the face, lower eyelid
sagging. These may
indicate central nervous
system lesions and
peripheral nervous
system lesions
Cranial nerve VIII Acoustic Ability to hear normal
(vestibulocochlear) conversation, by whispered
nerve voice, and by Weber and
Rinne tuning fork
Cranial Nerve Glossopharyngeal and Motor and Sensory Depress tongue with tongue Absence or asymmetry
IX and X Vagus Nerves function blade and note pharyngeal of soft palate, uvula
movement as the person says deviates to side or
‘‘ahhh’; the uvula and soft asymmetry of tonsillar
palate should rise in the pillar movements
midline and tonsillar pillars indicate an abnormal
should move medially finding
Cranial nerve XI Spinal accessory nerve Check for symmetry of Atrophy or muscle
sternomastoid and trapezius weakness or paralysis
muscles by asking the person indicate abnormal
to turn head and shrug findings
shoulders against resistance
Cranial nerve XII Hypoglossal nerve Inspect tongue. No wasting or Atrophy or fasciculations
tremors should be present. or tongue deviates to
Note the forward thrust in the side with lesions of
midline as the person hypoglossal nerve
protrudes the tongue
This information was published in Jarvis (2008c).
204 S. Sables-Baus, M.V. Robinson

and Grneier, 1986; Blosser and Reider-Demer, 2009; Prec-

Table 4 Testing cranial nerve function of an infant.
htl, 1977) Hypotonia is very concerning finding when it is
Cranial nerve Response associated with weakened and absent tendon reflexes and
II–IV, VI Optical blink reflex – shine light in neurologic injury if often present.
open eyes, note rapid closure. Size Neonatal or congenital hypertonia, on the other hand,
shape and equality of pupils. Regards means the muscle tone is abnormally rigid and its finding
face or close object. Eyes follow is usually a result of severe brain damage (Prechtl, 1977).
movement A hypertonic infant clenches their jaws and fists and extends
V Rooting reflex, sucking reflex their legs when lifted. In most typical term infants, small
VII Facial movements (e.g. wrinkling amplitude, choreo-athetoid movements of the hands and
forehead and nasolabial folds) feet may be seen. These movements may look as if the in-
symmetric when crying or smiling fant is playing a piano or dancing. Fragmentary myoclonus
VIII Loud noise yields Moro reflex – infant movements, or sudden muscular contractions, facial
blinks in response to a loud hand twitches and irregular respiratory rate are often seen during
clasp 30 cm from head (avoid making active sleep (Prechtl, 1977). Although these movements
air current). Eyes follow direction of may be considered normal, concern begins when the move-
sound ments are sustained. This is best assessed when the child is
IX, X Swallowing, gag reflex. Coordinated undressed so that the nurse can observe symmetrical muscle
sucking and swallowing development, and look for any twitching or abnormal move-
XII Pinch nose, infant’s mouth will open ments, or gestures.
and tongue rise in midline
This table was published in Jarvis (2008d).
Cranial nerves and reflexes

Table 4 shows cranial nerves and how to evaluate them in an

infant. In newborns, blinking in response to a bright light
Neonatal myasthenia gravis, botulism, infant spinal muscu- (CN II and VII) is noted by 28 weeks gestational age. Full
lar atrophy, or early spinal cord injuries should also be con- term infants at age 2–3 months should fix and follow an
sidered. Failure to meet developmental milestones in the examiners face. Infants 6–12 months can be expected to
setting of hypotonia may indicate a skeletal muscle disor- track a large, bright object testing all extraocular muscle
der, down syndrome or Prader–Willi syndrome (Amiel-Tison movements and vision (CN II, III, IV, VI). Newborn infants

Table 5 Primitive reflexes.

Reflex Age Age How to elicit Response Notes
appears disappears
Rooting Birth 3–4 month Head midline, stroke Infant opens mouth and Absence signifies severe
perioral area turns head to stimulated CNS disease/depression
side
Sucking Birth 3–4 month Place nipple or finger 3– Suck should be strong Absence signifies CNS
4 cm into mouth depression
Asymmetric tonic Birth 4–6 month Baby supine, rotate head Arm and leg extend on Persistence beyond 4–
neck (ATNR) to one side and hold 15 s facial side, arm and leg on 6 month signifies CNS
other side lesion (cerebral palsy)
Palmar grasp Birth 3–6 month Place finger into infant’s Flexes al fingers around
palm and press examiner’s finger
Trunk incurvation Birth 2 month Suspend baby prone and Baby flexes toward Asymmetry is significant;
(Galant) stoke 2–3 cm from spine stimulus should not persist after
with fingernail 6 month
Stepping Birth 6–8 weeks Infant is held as though Infant steps raising one Tests brainstem, spinal
weight bearing with feed foot at a time column; absence signifies
on surface paralysis or depression
Moro Birth 4 month Present loud noise or Arms spread and fingers Asymmetry signifies
allow infant’s head to extend and the flex paralysis or fractured
drop slightly clavicle; absence
signifies brain stem
problem
Plantar grasp Birth 8–10 month Place finger firmly against Toes should curl down Tests S1–S2 spinal nerves
base of toes
This table was published in Burns et al. (2009).
Pediatric neurologic exam 205

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