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    Examination of The CNS in Children: Professor Low Poh Sim Department of Paediatrics Ucmi

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    Vanessa Hermione
    This document provides guidance on examining the central nervous system in children. It emphasizes tailoring the examination to the child's developmental level and temperament. Key aspects of the examination include initial observation without touching; testing motor function, coordination, reflexes and gait; examining cranial nerves; and assessing sensory function when relevant. The document outlines techniques for different components and provides examples of patterns that may indicate different neurological conditions.

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    Examination of The CNS in Children: Professor Low Poh Sim Department of Paediatrics Ucmi

    Uploaded by

    Vanessa Hermione
    23 views40 pages
    This document provides guidance on examining the central nervous system in children. It emphasizes tailoring the examination to the child's developmental level and temperament. Key aspects of the examination include initial observation without touching; testing motor function, coordination, reflexes and gait; examining cranial nerves; and assessing sensory function when relevant. The document outlines techniques for different components and provides examples of patterns that may indicate different neurological conditions.

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    Fundamental_Lecture-_CNS_Examination_2015

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    This document provides guidance on examining the central nervous system in children. It emphasizes tailoring the examination to the child's developmental level and temperament. Key aspects of the examination include initial observation without touching; testing motor function, coordination, reflexes and gait; examining cranial nerves; and assessing sensory function when relevant. The document outlines techniques for different components and provides examples of patterns that may indicate different neurological conditions.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    23 views40 pages

    Examination of The CNS in Children: Professor Low Poh Sim Department of Paediatrics Ucmi

    Uploaded by

    Vanessa Hermione
    This document provides guidance on examining the central nervous system in children. It emphasizes tailoring the examination to the child's developmental level and temperament. Key aspects of the examination include initial observation without touching; testing motor function, coordination, reflexes and gait; examining cranial nerves; and assessing sensory function when relevant. The document outlines techniques for different components and provides examples of patterns that may indicate different neurological conditions.

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    Examination of the CNS

    in Children

    Professor Low Poh Sim


    Department of Paediatrics
    UCMI
    Stop, Look, and Listen
     The infant and child are unable to fully
    cooperate for the standard neurological
    examination
     Examination must be tailored to the child
    and their developmental level and
    temperament
     The first part of the examination is to
    stop, look, and listen
    Stop and Look
    You can determine about child’s mental
    status, coordination and motor status
    with
    Initial hands-off careful observation not forcing
    the child to conform to your pattern of
    performing the neurological examination
    Watching the baby’s spontaneous activity
    Save the Worst for Last
     Most threatening steps to a child are
     undressing the child for a complete
    examination
     looking at the fundus with an
    ophthalmoscope,
     using the otoscope
     testing the gag reflex
     measuring the head circumference
    Examination of The CNS
     General inspection – dysmorphism / malformations
     Head size, shape
     Measurement of OFC
     Skin – neurocutaneous signs
     Cranial nerves
     Motor system including gait and posture
     Sensory system
     Reflexes
     Developmental status - applies especially to the
    preschool child
    Head shape

    Dolichocephaly Plagiocephaly Brachycephaly


    Anterior Fontanelle
     Anterior fontanelle
    closes at 12-18 mths

     Big
     Small  Hydrocephalus
     Microcephaly  Subdural effusion
     Craniostenosis  Macrocephaly
    Normal head size vs Microcephaly
    Cranial Nerves
     Learn your technique for examination
     Special emphasis in children
     Examination for strabismus
     Visual fixation and following (Nystagmus)
     Ability to differentiate UMN facial weakness
    vs LMN facial palsy
     Assessment of hearing in children
     Dysfunctional swallowing
    How to examine for
    concomitant strabismus
     To ascertain that movements of each eye are
    good in all directions
     Cover test
     Ask child to look at an object immediately in front
    of him
     Suddenly cover the apparently fixing eye and
    watch any movement of the other eye (previously
    deviated) in taking up fixation
     The covered eye will now deviate in the same
    relative direction as was the other eye
    Cranial Nerves 2,3,4 and 6
    Examination In Babies
     Cranial Nerve 2: Testing a baby’s behavior
    response to light. Pupillary light reflex is
    done in the same manner as in adult exam
     Eye movements (Cranial Nerves 3, 4 and 6)
    can be assessed by using the vestibulo-ocular
    reflex (doll’s eyes maneuver). When the head
    is turned, there is conjugate eye movement in
    the opposite direction.
    Examination of the Facial Nerve
    Forceful eye closing Testing frontalis
    muscle

    Symmetry

    Depth of
    Examination of the Facial Nerve
    Purse lips together and Clenching teeth and forcefully pulling
    distend cheeks the corners of mouth downward

    Symmetry of
    UMN weakness vs LMN Facial palsy
    LMN lesion: (nucleus or UMN lesion
    peripheral nerve)

     Unable to move  Paresis of muscles of


    forehead upward the lower face
     Unable to close eye  Muscles of forehead are
    forcefully bilaterally innervated
     Unable to elevate and are unaffected
    corner of mouth on side
    of lesion
    Examination of Cranial Nerves
    5, 9, 10, 11 and 12 in Babies
     The quality and strength of the cry is a
    way of looking at Cranial Nerves 9 and
    10 function. Presence of hoarseness
    and stridor are important findings
     Sucking and swallowing assesses
    Cranial Nerves 5, 7, 9, 10, and 12
    because all of these cranial nerves are
    involved in this complex act.
    Examination of
    Motor Functions
     Size of muscles
     State of muscular tone
     Motor power
     Coordination of motor movements
     Presence/absence of involuntary movements
     Gait
     Contracture of joints
    Size of Muscles
     Wasting / hypertrophy
     Asymmetry
     Distribution of wasting
     Localised to a limb, segment of limb, 1 side
     Generalised
     Proximal
     Distal
    Motor Power Assessment
     Grade muscle power (0 – 5)
     In a younger child, to evaluate
     Head control, weight bearing, independent
    sitting, standing and walking
     In an older child, evaluate:
     Walking, running, jumping, climbing and hopping
     Patterns of weakness
     Proximal: Suggestive of myopathy
     Distal: Suggestive of peripheral neuropathy
    Muscle Tone

    Move limbs passively around the joints

     Hypotonia  Hypertonia
     LMN disease  Spasticity:
     Cerebellar disease  Pyramidal
     Acute UMN lesion  Rigidity:
     Extrapyramidal
    Reflexes
     Superficial  Deep (tendon)
    reflexes reflexes
     Plantar reflex  AJ, KJ, BJ, TJ, SJ
     Superficial  Jaw jerk
    abdominal  Clonus
     Conjunctival
     Pupillary  Sphincteric reflex
     Palatal  Anal reflex
    Assessment of Gait
     A patient well enough should to made
    to walk in a straight line for 4-5 metres,
    turn and walk back to the starting point
     Walk on tiptoes forwards
     Walk on heels backwards
     Hop across the room on one foot and
    then on the other
     Walking in tandem
    Gait Assessment –
    Points to note
     Posture of the body while walking
     Position and movement of the arms
     The relative ease and smoothness of
    movement of the legs
     The distance between the feet both in
    forward and lateral directions
     The regularity of the movement
     The ability to maintain a straight course
     The ease of turning and of stopping
    Coordination of Motor Movement
    Signs of Cerebellar Dysfunction
     Ataxia – titubation,
    truncal, gait
     Upper limb  Lower limb
    incoordination
    incoordination
     Finger-nose test
     Heel sliding
     Building tower with
     Heel tapping
    blocks
     Rapidly repeated

    /alternating
    movements
    Tests for Coordination
    of Upper Limbs
    Pinching thumb and
    little finger together

    Finger-nose-finger
    testing

    One hand
    clapping
    Tapping one
    hand on back
    of the other
    Tests for Coordination
    of Upper Limbs

    Rapid alternating prone-supine-prone position of the hand on the thigh


    Test for Coordination in Lower Limbs

    Heel

    Sliding
    Test for Coordination in Lower Limbs

    Heel

    Tapping
    Tandem Walking

     Tandem walking
    (in older child >6
    years)
    Abnormal
    Muscular Movements
     Fasciculation
     Stereotypies
     Involuntary movements
     Dystonia
     Myoclonus
     Chorea and athetosis
     Tremor
     Tics
    Examination of
    Sensory Functions
    In a child, this is only done when relevant
     For cord lesions
     Touch, pain, temperature
     For posterior column lesions
     Position sense, vibration sense, joint sense
     For cortical sensation
     Stereognosis, two point discrimination,
    graphaesthesia, sensory inattention
    Technique in Testing Sensation
     Move from areas of reduced to normal
    sensation when testing cutaneous
    sensitivity
     Understanding of pattern of cutaneous
    distribution of sensory loss in cord lesion
    vs peripheral nerve lesion
     Recognition of sensory abnormalities
    which suggest non-organic sensory loss
    Recognition of Pattern (1)
     Weakness: proximal < distal
     Wasting (± fasciculations)
     Hypotonia
     Hypo-reflexia
     Normal sensation
    LOWER MOTOR NEURON LESION
    Recognition of Pattern (2)
     Weakness
     Wasting
     Spasticity
     Hyper-reflexia
     Sensory level
     Bladder and bowel dysfunction

    CORD LESION
    Recognition of Pattern (3)
     Weakness
     Spasticity
     Hyper-reflexia
     Normal sensation
     Babinski’s sign

    UPPER MOTOR NEURON LESION


    Recognition of Pattern (4)
     Hypotonia
     Hyper-reflexia
     No weakness
     Developmental delay

    CEREBRAL DYSFUNCTION
    Recognition of Pattern(5)
     Hypotonia
     Hyporeflexia
     Fine motor incoordination
     No weakness

    CEREBELLAR DYSFUNCTION
    Recognition of Pattern (6)
     Rigidity
     Dystonia
     Variable deep tendon reflexes
     Involuntary movements

    EXTRAPYRAMIDAL DYSFUNCTION
    Recognition of Pattern (7)
     Wasting
     Weakness: distal > proximal
     Sensory disturbance (pain, numbness)
     Lack of coordination
     Absent reflexes
     Autonomic dysfunction

    PERIPHERAL NEUROPATHY

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