ABSTRACT
Growth parameters (height, weight, head circumference) Dysmorphic features, resting posture and any obvious neurological problems Vision and hearing Language, speech and social interaction (observe during examination) Fine motor Gross motor (infant – 180º [‘flip over’] examination; older child – gait) Including primitive reflexes and responses (infants), and movement and coordination
NB: Always measure the blood pressure
Infant or disabled child Older child
1. General Growth parameters Weight, height, head circumference As for infant/disabled child Dysmorphic features Head size, shape and fontanelle, Head size ? ex-prem appearance (dolicocephalic ? Dysmorphic appearance i.e. ‘narrow tall’ head) Resting posture Obvious neurological problems, As for infant/disabled child e.g. floppy, hemiplegic posturing, involuntary movements
2. Development Vision Acuity Fixing and following Reading ability Pick up raisin or hundreds and thousands Formal testing if necessary (see p. 409) Squint testing See p. 414 Hearing Enquire of parents As for infant/disabled child Formal testing if necessary (see p. 112) Language and Ask parents, observe As for infant/disabled child, speech talk to child
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Infant or disabled child Older child Social interaction Ask parents, observe As for infant/disabled child,
observe interaction Fine motor control ? Milestones achieved on time As for infant/disabled child Gross motor control 180º examination (flip over) Gait examination 1. Lying down – posture and Walking – normally, heel-movement toe – on toes, on heels, on outsides of feet Running, hopping
2. Pull to sitting (look for head control)
3. Ability to sit unaided
4. Up to weight bearing (lower limb 4. scissoring, stiffness, weakness)
5. In ventral suspension (head, trunk 4. and limb posture)
6. Lay prone (ability to raise head and 4. extend limbs)
Standing – with feet together, on each foot Touching toes
Squatting and rising again Lying on floor and rising again (children < 3 years roll onto tummy first. If this continues, suggests weakness [Gower’s sign, see p. 386-7])
Abnormalities: ■ Knee locking gait (weak
knees) ■ Trendelenburg gait (weak
hip muscles) ■ Wide base (weakness or
ataxia) ■ Toe-heel walk (pyramidal
dysfunction, e.g. cerebral palsy)
■ Foot drop (superficial peroneal nerve lesion)
NB: If unsure of gait, look at shoe soles to see if worn unevenly
Ask child to run and this may unveil a mild hemiplegia as the affected leg will go into flexion at knee and plantar flexion at ankle, and arm will flex at elbow and wrist
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Infant or disabled child Older child 3. Limbs Inspection Resting posture, e.g. floppy, or As for infant/disabled child scissoring of legs in cerebral palsy Muscle wasting, e.g. cerebral palsy, or hypertrophy (muscular dystrophy) Involuntary movements Limb length discrepancies, growth arrest Scars, skin changes, e.g. port-wine stain Check neck and back for scars, scoliosis, stigmata of spina bifida, flat buttocks (sacral agenesis) Palpation Muscle bulk, tenderness, ? peripheral As for infant/disabled child nerve hypertrophy Tone Truncal tone and head lag Take weight of leg or arm in Limb tone hand and bend it to assess Hypotonia (floppy baby) tone Spasticity, rigidity (hip adductors in cerebral palsy) Power Difficult in babies Formal testing > 4 years: Observe antigravity movement Graded out of 5 (see below) motor function, and mobility If weakness: If weakness: as for infant/ ■ Symmetrical? Proximal or distal? disabled child ■ A specific nerve root or muscle group? ■ Upper or lower motor neurone pattern? Reflexes Deep tendon reflexes Deep tendon reflexes Primitive reflexes NB: Plantars unreliable < 1 year Brisk – ? UMN dysfunction, ? Anxiety Brisk/absent: as for infant/ Absent-? Lower motor neurone disabled child Coordination Build pile of bricks Finger-nose test Finger-nose to teddy’s nose Dysdiadokinesis (eyes open = cerebellar; Hold arms out in front eyes closed = proprioception) (? Drifting – seen in weakness, proprioception loss and cerebellar hypotonia) Sensation Difficult in infants Proprioception Withdraw if tickled Vibration (has the buzzing stopped?) Light touch ¬In (cotton wool)
distribution blunt pin)
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Infant or disabled child Older child
4. Cranial nerve Cannot be tested formally in young Formal testing is possible assessment infants > 4 years I Smell Not possible in infants Ask parents can they smell things? II Visual acuity Fixing and following Read a paragraph Pick up hundreds and thousands See p. 409 for formal test Direct and consensual, With pen torch As for infant/disabled child pupillary reflexes to light, and accommodation Visual fields Directly facing child, both index fingers out: wiggle each finger in high, low and halfway positions III, IV, VI Voluntary eye Get child to follow a face or toy Follow a pen (as for infant/ movements (up, down, left, right, figure of 8) disabled child) Squint testing Nystagmus? V Motor function Bite Clench teeth, move jaw side to side VII Motor function Smiles symmetrically Smile, close eyes tightly Face symmetrical Closes both eyes normally VIII Hearing Ask parents (see p. 111 formal As for infant/disabled child testing) IX Levator palate Observe crying Say ‘ahh’ X Recurrent ? Hoarse cough/voice ? Hoarse voice laryngeal nerve XI Trapezius and Turns head to both sides Shrug shoulders sternomastoid XII Hypoglossal Tongue moves symmetrically Stick out tongue and move
side-to-side
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0 – Complete paralysis 1 – Flicker of contraction 2 – Movement possible but not against gravity 3 – Antigravity movement, but not against resistance 4 – Movement against some resistance 5 – Normal power
Memory guide (None) (Minuscule) (V. little) (Antigravity) (Antiresistance, not quite normal) (Normal)
Indications
Electroencephalogram (EEG) Brain activity assessment, seizure investigation Neuroimaging: CT or MRI brain scan Soft tissue imaging Skull X-ray Bony defects, pituitary fossa outline Cranial USS Soft tissue imaging (infants with patent fontanelle only) Angiography, MRA scan Intracranial vessel outline Lumbar puncture Possible meningeal infection Metabolic disorders
Lumbar puncture Indications ■ Severely sick child if cause unapparent ■ First febrile convulsion in a child < 12 months age ■ Investigation of metabolic disorder
Technique 1. Good positioning imperative: – Restraint needed for young children – Curled tightly, back at right angles to bed 2. Sterile technique: – Hands well scrubbed; sterile surgical gloves and gown 3. Point of entry (skin markings): – Skin overlying lower lumbar spine – Highest points of iliac crests line passes over 4th lumbar spine – Introduce needle just below or just above 4th lumbar spine 4. Anaesthetic: – Skin and tissues to the dura where needle to be introduced 5. Spinal needle introduction – at right angles to the skin 6. Obtain CSF samples: – Take fluid and measure pressure – Send for: microscopy, bacterial and viral culture (± PCR); glucose
and protein
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Complications Bloody tap (hit vascular plexus surrounding the cord) – attempt space above. Send off bloody sample if only one obtained.
