Paediatric Neurological Examination – OSCE Guide


Examining the neurological system is different in young children compared with older children and adults. The components of the complete exam are extensive and usually cannot be performed in a classical fashion. This approach may be carried out on a cooperative school-aged child – but always be mindful of keeping the examination fun.

Observation is key. Make the most of every opportunity to examine the child. See how they play, taking into account handedness and motor deficits. These observations, especially in younger children, will ultimately give you the best insight into their daily functioning and paint a broad picture of their neurological function.

Tips include:

  • Using items such as a tennis ball, small toys (including a toy car), bells, bubbles and an object that will attract the child’s attention (like a pinwheel).
  • Be mindful to postpone uncomfortable tasks until the end, such as head circumference, fundoscopy and sensory testing.

You can access the Paediatric Neurological Examination OSCE Mark Scheme here.


Introduction

  • Wash your hands
  • Introduce yourself to both the parents and the child
  • Explain what the neurological examination will involve
  • Gain consent from the parents/carers and/or child before proceeding.

Today I’d like to perform a neurological examination, which will involve me testing the nerves that supply different parts of the body.

Are you happy for me to carry out the examination?


General Inspection

With toddlers – the initial phase of observation is best done with the child in the parent’s lap. Through minimising apprehension, assessment of higher cortical function, muscle tone and tendon reflexes becomes easier.

Higher cortical functions

Observe the child during play:

  • Attention span
  • Gross and fine motor coordination
  • Problem-solving abilities

Observe for age-appropriate milestones (see our guide on Developmental Milestones)

Developmental milestone
General inspection 1

Cranial Nerves

Testing in infants is often by observation for specific movements and responses, which is ultimately less reliable. In older children, it may be possible to formally assess at least some cranial nerves, however, this very much depends on the exact age of the child, their current state and the environment. We have provided a guide to each of the cranial nerves below, however, it is unlikely you will be able to carry out a complete neurological assessment in one sitting with most children.

Olfactory nerve (I)

The olfactory nerve is responsible for the sense of smell.

Assessment

  • Test the ability to detect a smell with eyes closed (i.e. chocolate).
  • This is not checked in small children or infants.
  • Olfaction can be impaired after closed head injury and in infants with arhinencephaly-holoprosencephaly.

Optic Nerve (II)

The optic nerve is responsible for vision and afferent pupillary light reflexes

Testing visual acuity

  • Infant – observe the infant reach for objects of varying size
  • >6 months old – observe reaching for scraps of paper less than 5mm in size when placed on a dark background
  • Older children – standard recognition of letters, numbers or shapes on a Snellen chart (see our guide to visual assessment)

Visual fields

  • Introduce objects into the peripheral field of vision as the child focuses on an object held directly in front of them.
  • Note if the child becomes aware of the peripheral object (e.g. turning head towards it).

Pupillary reflexes

To best see pupillary reflexes the room should be dimly lit.

Direct pupillary reflex (afferent CN II, efferent CN III):

  • Shine a light into the pupil and observe constriction of that pupil.
  • Sluggish reaction or lack of constriction may suggest pathology (optic nerve, brainstem, drugs)

Consensual pupillary reflex:

  • Again shine a light into the pupil, but this time observe the contralateral pupil.
  • A normal consensual response involves the contralateral pupil constricting.
  • Lack of a normal consensual response may suggest damage to one/ both optic nerves or damage to the Edinger-Westphal nucleus

Fundoscopy

Often difficult, requiring patience. If in doubt, it is often best to arrange for a specialist to do this examination using equipment designed specifically for children.

Assess for red reflex:

  • Position yourself at a distance of around 30cm from the child’s eyes.
  • Looking through the ophthalmoscope and ensure the light is directed into the pupil. Observe for a reddish/orange reflection in the pupil.
  • An absent red reflex may indicate the presence of cataract, or in rare circumstances neuroblastoma.

Move in closer and examine the eye with the ophthalmoscope::

1. Move in closer whilst maintaining the red reflex and examine the retina with the ophthalmoscope. You may need to change the focus wheel to account for the difference in glasses prescription between the child and yourself. Approach from an angle slightly temporal to the child.

2. Begin by identifying a blood vessel and then follow the branching of this blood vessel towards the optic disc (the branches point like arrows towards the optic disc).

3. Assess the optic disc (colour/margin/cupping).

4. Assess the retinal vessels for pathology (e.g. arteriovenous nipping/neovascularization/haemorrhages).

5. Finally, assess the macula by asking the patient to look directly into the light:

  • Drusen are typically noted in macular degeneration
  • A cherry-red spot is typically noted in central retinal artery occlusion

Oculomotor, Trochlear & Abducens nerves (III, IV, VI)

Functions of CNII, CNIV and CNVI

  • III: Eyelid elevation, eye elevation, ADduction, depression in ABduction, efferent to pupil
  • IV: Depression in ADduction
  • VI: Eye abduction

Inspect for ptosis

  • Look for evidence of eyelid asymmetry suggestive of ptosis
  • Causes include sympathetic paralysis from lesions of cranial nerve III, Horner’s syndrome, myopathies, myasthenia gravis and structural eye lesions (e.g. neurofibroma).

Assess extraocular eye movements

  • Test horizontal, vertical and oblique planes of eye movement (drawing an imaginary “H” and asking the child to “follow my finger” achieves this)
  • Tested by assessing the child’s ability to track brightly coloured soft toy or soft light

Abnormal eye movement findings:

  • Down and out – paralysis of the inferior oblique muscle (III)
  • Laterally – paralysis of medial rectus (III)
  • Upwards – paralysis of inferior rectus (III)
  • Down and inwards – paralysis of superior rectus (III)
  • Upwards and out – paralysis of superior oblique (IV)
  • Inwards – paralysis of lateral rectus (VI)
  • Opsoclonus: Occult neuroblastoma – chaotic bursts of eye movements, often associated with myoclonus
  • Up gaze paresis: Parinaud syndrome
  • Impaired down gaze: Niemann Pick Type C disease
  • Oculomotor apraxia: Delayed initiation of eye movement and jerky pursuit movements. Seen in Joubert syndrome or oculomotor apraxia-ataxia syndrome.

Trigeminal nerve (V)

The trigeminal nerve provides facial and corneal sensation, in addition to motor innervation to the muscles of mastication.

Assess sensory function

  • Assess response to light touch over the 3 divisions of the face using a piece of cotton wool
  • In a baby, the presence of the rooting reflex confirms intact facial sensation
  • Assess the corneal reflex (afferent V, efferent VII) – this is rarely performed in practice

Assess motor function

  • Ask the child to open their mouth against resistance
  • Jaw jerk reflex (tests sensory and motor function) – rarely performed

Facial nerve (VII)

The facial nerve provides motor innervation to the muscles of facial expression and is also involved in taste sensation.

Inspection

  • Inspect the child’s face for asymmetry
  • Compare the nasolabial folds to identify subtle asymmetry

Assess motor function

  • It is difficult to formally assess the power of the facial muscles, particularly in children.
  • Instead, observe their facial expressions for any asymmetry (e.g. when smiling, crying etc)
  • In older children, you may be able to ask them to copy your facial expressions (e.g. blowing out your cheeks, showing teeth, screwing up eyes, wrinkling forehead)

Vestibulocochlear nerve (VII)

The vestibulocochlear nerve is responsible for balance and hearing.

Assessment

  • Infants: Make a soft sound close to the ear (i.e. rustling of paper). The child should show an ‘alerting response’.
  • >5-6 months: Localise the sound to a specific quadrant.
  • School-age children: Softly whispering a number approximately 30 cm from the ear. Rinne and Weber’s can also be used.
  • Vestibular function: Poor head control, truncal unsteadiness, gait ataxia, nausea, vomiting and horizontal nystagmus may indicate vestibular system dysfunction.
  • See our guide to hearing assessment for more details

Glossopharyngeal, Vagus nerve (IX, X)

The glossopharyngeal (IX) and vagus (X) nerves have various functions including:

  • IX: Sensation from soft palate, taste fibres
  • X: Palatal movement, vocal cords, cough

Assessment

Observe the child swallowing:

  • Observe the child drinking or eating
  • Dysfunction swallowing may present with salivary drooling, pooling of saliva and coughing during feeding

Observe the movement of the soft palate:

  • Observe the uvula and ask the child to say “AAH” (if possible)
  • Unilateral CNX lesions result in deviation of the uvula to the side contralateral to the lesion

Listen to the child’s voice:

  • Hoarseness may be due to unilateral dysfunction of the recurrent laryngeal nerve (X)
  • Bilateral dysfunction results in a bovine cough

Gag reflex

  • Assesses both the afferent pathway of CN IX and efferent pathway of CN X
  • Be aware of this test, however, it is rarely performed in practice

Accessory nerve (XI)

The accessory nerve provides motor innervation to the trapezius and sternocleidomastoid muscles, which assist with head-turning and shoulder shrugging.

Assessment

Test elevation of shoulders:

  • If the child is old enough, ask them to scrunch their shoulders up towards their ears (demonstrate for them)

Test turning the neck against resistance:

  • If the child is old enough, ask them to look over their shoulder whilst you observe the sternocleidomastoid muscle
  • Small child: When supine, gently push the head laterally while supporting the shoulder.

Hypoglossal nerve (XII)

The hypoglossal nerve is responsible for the movement of the tongue.

Assessment

  • Inspect the tongue when inside the mouth for fasciculations
  • Ask the child to stick out their tongue – unilateral lesion results in deviation of the tongue to the affected side
  • Check whether the tongue can be equally protruded on both sides

Upper and Lower Limb Examination

This portion of the examination requires an assessment of muscle tone, strength, reflexes and sensation of the upper and lower limbs.

Upper motor neuron (UMN) lesions

Lesions result in loss of muscle strength and dexterity distal to the injury, hypertonia and hyperreflexia.

Due to the corticospinal tract crossing at the pyramidal decussation, UMN lesions will present with contralateral deficits for lesions above the pyramids and ipsilateral defects for lesions of the spinal cord.

Spinal cord lesions will also present with LMN findings at the level of the injury due to damage to the ventral root or ventral nerve at that level.

Lower motor neuron (LMN) lesions

Lesions result in muscle fasciculations and atrophy, loss of strength, decreased tone and absent deep tendon reflexes.

Inspection

Begin by inspecting the limbs for symmetry, muscle bulk and posture.

Look for any evidence of abnormalities:

  • Asymmetry at rest in infants – may suggest hemiparesis
  • Opisthotonus – persistent arching of the neck and trunk due to bilateral cerebral cortical dysfunction
  • Abducted hips or ‘frog-legged’ posture – hypotonia
  • Making a fist with the hand or holding the thumb adducted across the palm during quiet wakefulness – suggesting corticospinal tract involvement
  • Tremor – rhythmic, fine amplitude flexion-extension movements of the distal extremity
  • Myoclonus – quick, non-stereotyped jerks around a segment of the body
  • Athetosis – slow, sinuous movement of the distal extremity with pronation of the distal extremity
  • Chorea – rapid, quasi-purposive, non-stereotyped movements of a segment of the body that is generally proximal
  • Tics – highly stereotyped and repetitive movements
  • Muscle atrophy – may be segmental or generalised – neuropathy, myopathy or disuse
  • Pseudohypertrophy – bulky appearance of muscle with associated weakness  
  • Fasciculations – ripple-like movements of the muscles that accompany degeneration of anterior horn cells
  • Stereotyped hand wringing movements and bruxism – may be seen in Rett syndrome

Muscle tone

Muscle tone is assessed by passively taking the limb through a range of motion – including the shoulder, elbow and wrist bilaterally in the upper limb and the hip, knee and ankle bilaterally in the lower limb.

Spasticity

  • Felt as an increase in tone varying with the force applied and the velocity of movement
  • Often considered ‘clasp knife’ and tends to accompany pyramidal tract lesions

Rigidity

  • Increased tone that does not vary with velocity or position
  • Suggests an extrapyramidal lesion

Clonus

  • Position the child’s leg so that the knee and ankle are slightly flexed, supporting the leg with your hand under their knee, so they can relax.
  • Rapidly dorsiflex and partially evert the foot
  • Keep the foot in this position
  • Clonus is felt as rhythmical beats of dorsiflexion/plantarflexion (>5 is abnormal)
  • Sustained clonus is abnormal at all ages

Power

Much of this assessment may not be possible in the majority of young children, however, we have provided it for older children who are capable of following instructions.

The assessment of muscle power in young children is less formal and involves comparing the strength of their natural movements between sides.

The MRC scale for muscle power is used to formally score the strength of particular muscle groups, however, it is less useful in the context of young children and therefore we have not included details.

Upper limb power

  • Assess power one side at a time and compare like for like.
  • Remember to stabilise and isolate the joint when testing.
  • The following are a test of some of the main movements of the upper limbs, sufficient to show most pathology.

Shoulders:

  • ABduction (C5) – “Don’t let me push your shoulders down”
  • ADduction  (C6/7)– “Don’t let me pull your arms away from your sides”

Elbow:

  • Flexion(C5/6) – “Don’t let me pull your arm away from you”
  • Extension(C7) – “Don’t let me push your arm towards you”

Wrist:

  • Extension (C6) – “Cock your wrists back and don’t let me pull them down”
  • Flexion (C6/7) – “Point your wrists downwards and don’t let me pull them up”

Fingers: 

  • Finger extension (C7) – “Put your fingers out straight and don’t let me push them down”
  • Finger ABduction (T1) – “Splay your fingers and don’t let me push them together”
  • Thumb ABduction (C8/T1) – “Point your thumbs to the ceiling and don’t let me push them down”

Lower limb power

  • Assess one side at a time and compare like for like.
  • Remember to stabilise the joint whilst testing power.

Hip:

  • Flexion (L1/2) – “raise your leg off the bed and stop me from pushing it down”
  • Extension (L5/S1) – “stop me from lifting your leg off the bed”
  • ABduction (L4/5) – “push your legs out”
  • ADduction (L2/3)  – squeeze your legs in”

Knee:

  • Flexion (S1)  “bend your knee and stop me from straightening it”
  • Extension (L3/4) – “kick out your leg”

Ankle:

  • Dorsiflexion (L4) – “keep your legs flat on the bed…cock your foot up towards your face…don’t let me push it down “
  • Plantarflexion (S1/2) – “push down like on a pedal”
  • Inversion (L4) – “push your foot in against my hand”
  • Eversion (L5/S1) – push your foot out against my hand”

Big toe:

  • Extension(L5) – “don’t let me push your big toe down”

Reflexes

Upper limb reflexes

For each of the reflexes, ensure the child’s upper limb is completely relaxed

Hold the tendon hammer at the end of the handle and allow gravity to aid a good swing onto your finger.

If a reflex appears absent: make sure the child is fully relaxed and then perform a reinforcement manoeuvre – ask the child to clench their teeth together, whilst you hit the tendon.

1. Biceps reflex (C5/6) – located in the antecubital fossa

2. Triceps reflex (C7) – place forearm rested at 90º flexion – tap your finger overlying the triceps tendon

3. Supinator reflex (C6) – located 4 inches proximal to the base of the thumb

Lower limb reflexes

1. Knee jerk (L3/4)

2. Ankle jerk (L5/S1)

3. Plantar reflex (S1):

  • Run a blunt object along the lateral edge of the sole of the foot, moving towards the little toe, then medially under the toes
  • Observe the great toe
  • Normal result = Flexion of the great toe and flexion of the other toes
  • Abnormal (Babinski sign) = Extension of the great toe and spread of the other toes – upper motor neuron lesion

Sensation

Sensory information is carried by 2 major pathways and should be tested systematically through examining Touch, Pain, Temperature, Vibration and Proprioception in the upper limb and lower limb.

It’s easy to get bogged down in examining sensation. Check at least one modality each from the dorsal columns and spinothalamic tracts. Demonstrate normal sensation on the child’s sternum and ask them if it feels the same on the limb.

Much of the detailed assessment below is not possible in younger children and therefore gross assessment of sensation should be adopted.

Light touch sensation

Light touch sensation assesses the dorsal/posterior columns and spinothalamic tracts.

1. Touch the child’s sternum with the wisp of cotton wool to confirm they can feel it

2. Ask the child to say yes when they are touched

3. Using the wisp of cotton wool, gently touch the skin

4. Assess each of the dermatomes of the upper and lower limbs

5. Compare left to right, by asking the child if it feels the same on both sides

Pin-prick sensation 

Pink-prick sensation assesses the spinothalamic tracts.

  • Repeat the previous assessment steps, but this time using the sharp end of a neuro-tip.
  • If loss of sensation is noted distally, test for “glove” distribution of sensory loss (peripheral neuropathy) by moving distal to proximal. 

Vibration sensation

Vibration sensation assesses the dorsal/posterior columns.

1. Ask the child to close their eyes

2. Tap a 128 Hz tuning fork

3. Place onto the child’s sternum and confirm they can feel it buzzing

4. Place onto the distal interphalangeal joint of the forefinger/distal phalanx of the great toe and ask them if they can feel it buzzing

5. If vibration sensation is impaired, continue to assess the bony prominence of more proximal joints (interphalangeal joint of thumb → carpometacarpal joint of thumb → elbow → shoulder)

Proprioception

Proprioception assesses the dorsal/posterior columns.

1. Hold the distal phalanx of the thumb/great toe by its sides

2. Demonstrate movement of the thumb/great toe “upwards” and “downwards” to the child (whilst they watch)

3. Then ask the child to close their eyes and state if you are moving the thumb/great toe up or down

4. If the child is unable to correctly identify the direction of movement, move to a more proximal joint (finger > wrist > elbow > shoulder)

Dermatome map
Dermatome map

Gait

Observe the child walking (if able) – posture, arm swing, stride length, speed, symmetry, balance and abnormal movements

Some common types of gait abnormality to observe for:

  • Ataxic: broad-based and unsteady. As if drunk. From cerebellar pathology or sensory ataxia. Often won’t be able to tandem gait either. With sensory ataxia, the child will watch their feet intently to compensate for proprioceptive loss. In a cerebellar lesion, they may veer to one side.
  • High-stepping: (either unilateral or bilateral) caused by foot drop (weakness of ankle dorsiflexion). Also won’t be able to walk on their heel(s).
  • Waddling gait: shoulders sway from side to side, legs lifted off ground with the aid of tilting the trunk. Caused by proximal lower limb weakness (e.g. myopathy).
  • Hemiparetic: one leg held stiffly and swings round in an arc with each stride (circumduction).
  • Spastic paraparesis: similar to above but bilateral – both are stiff and circumducting. Feet may be inverted and “scissor”.

Cerebellar Examination

Cerebellar function should be assessed as part of a complete neurological examination.

If the child is unable to follow instructions – noting how a child reaches for and manipulates toys can be used as a crude assessment of coordination.

See our Cerebellar Examination guide for more information (adapting it as appropriate to the age of the child).


Neurological Examination of the Infant and Primitive Reflexes

See our guide to the Newborn Infant Physical Examination (NIPE), which covers basic neurological assessment of the infant, including primitive reflexes.


Cognitive Assessment

Younger children

  • Has the child met appropriate developmental milestones?
  • Careful questioning of parents – a history of loss or plateauing of developmental milestones is a red flag that should be investigated in greater detail.
  • See our Developmental Milestones guide.

Children aged >7 years:

  • The mini-mental state examination (MMSE) may be used, with modifications available for children of different ages/stages (e.g. MMSPE for preschool-aged children).

To Complete the Examination…

  • Ensure the child is re-dressed after the examination
  • Thank the child and/or parents
  • Explain your findings to the parents and/or child
  • Ask if the parents and/or child have any questions
  • Wash your hands

Further clinical assessments to consider

  • Skin assessment – both the skin and the nervous system develop from ectoderm during embryogenesis, so dermatological findings can sometimes relate to underlying neurological disease (e.g. Café au lait spots in neurofibromatosis and Ash-leaf spots in tuberous sclerosis)
  • Assessment of the back – scoliosis or a patch of hair which may indicate an undetected vertebral anomaly (e.g. spina bifida)
  • Cardiovascular examination – important if considering causes of loss of consciousness or a thromboembolic source of stroke
  • Abdominal examination – important if considering metabolic diseases (e.g. hepatomegaly in glycogen storage disorders)

Further investigations

  • Record a full set of vital signs
  • Plot the height and weight on a growth chart
  • Blood tests – FBC, U&Es, CRP, Autoantibodies
  • Lumbar puncture (e.g. meningitis, encephalitis)
  • Neuroimaging (CT/MRI)
  • EEG (seizures)
  • Nerve conduction studies

Reviewer

Dr Sunil Bhopal 

Senior Paediatric Registrar


References

  • Acedillo, R (2011). Pediatric Neurological Exam Checklist. Learnpediatrics.com Narration. The University of British Columbia. [LINK](Accessed 20 Mar 2019)
  • Bishop & Statham (2011). Neurology Examination. Learnpediatrics.com Narration. The University of British Columbia. [LINK](Accessed 20 Mar 2019)
  • Hills, W. Pediatric and Infant Neurologic Examination. OHSU. [LINK] (Accessed 20 Mar 2019)
  • Kotagal (2019). Detailed neurologic assessment of infants and children. Nordli Jr. (ed). UpToDate. Waltham MA. [LINK](Accessed 20 Mar 2019).
  • Lissauer, T., Clayden, G., & Craft, A. (2012). Illustrated textbook of paediatrics. Edinburgh: Mosby.
  • Miin Lee (2014). Neurological Examination Guide. MRCPCH Clinical Revision. Trainees Committee, London School of Paediatrics. [LINK](Accessed 20 Mar 2019)
  • Snowdon, D (2006). Neurological examination.
  • Tasker, R. C., McClure, R. J. & Acerini, C. L. (2013). Oxford handbook of paediatrics. Oxford: Oxford University Press.

Image references

  1. Photo by Caleb Woods on Unsplash
  2. Photo by Christian Bowen on Unsplash

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