Module 7 Flashcards
There are three key questions when assessing an
infant:
• Is there evidence to suggest a focal lesion ?
• Has maturation and development appropriate for the
child’s age occurred ?
Is there an issue with hypotonia or hypertonia?
The examination is structured around:
Observation very, very, very
important
• Muscle tone
• Cranial nerves
• Primitive reflexes
• Muscle stretch reflexes
Scapulohumeral reflex
describe The importance of right brain
development in the infant and toddler
As the securely attached infant enters toddlerhood, his or her
interactively regulated right brain visual-facial, auditory-prosodic,
and tactile–gestural communications become holistically
integrated, allowing for the emergence of a coherent right brain
emotional and corporeal subjective sense of self.
The role of the
amygdala
Optimal relational attachment experiences allows the right
orbitofrontal cortex to regulate the right amygdala.
There is an association between enlarged right (and not
left) amygdala volume with poorer socialization and
communication development
Right amygdala enlargement may reflect “right-sided amygdala
activation in response to conditioned fear”
Research implies that autistic infants and toddlers experience
a chronic intense fear state
The finding that early developing right basolateral amygdala
enlargement, associated with amygdala hyperreactivity and
abnormal fear conditioning persists in 6-to 7-year old children
Studies on early relational trauma, disorganized attachment,
and the origins of post-traumatic stress disorder implicate the
right amygdala in states of fear conditioning
The role of the insula
The right insula, a limbic structure that has extensive
connections with the amygdala is involved in
1. emotional and facial processing
2. integrating tonal structure with a speaker’s emotions and
attitudes
3. visceral and autonomic functions that mediate the
generation of an image of one’s physical state
4. perceptual awareness of threat
5. harm avoidance
6. pain processing
7. serves as an alarm center, “alerting the individual to
potentially distressing interoceptive stimuli, investing them
with negative emotional significance”
Cortical
hemisphere
development
The first three years of life are dominated by right cortical
hemisphere development with the left cortical
hemisphere gradually catching up by 7 years of age.
• Impaired stimulation of the right cortex during the first
three years of life will have profound impact
• Early overuse of the left cortex, prior to its full
development, will have profound negative impact
what is a neonate
Neonatal period is often considered as being the first 8 weeks post term
What will we start to see at 3 months of age
A. Head control
Space orientated body control
Altered sucking
Fidgety movements develop
Visual attention
Binocular vision
Social smiling
Pleasure vocalization
Q. What are some predictors of cerebral palsy?
First, a persistent pattern of crampedsynchronized general movements.
The second predictor is the absence of fidgety
movements
What is the purpose of fidgety movements
Calibration of proprioception
What do we need to observe in an initial exam?
- Head
- Body
- Arms and legs
- Hands and feet
- Posture
- Movements
- Breathing
- Eye movement and eye contact
- Response to sounds
- Facial movement
If there is a lump on skull what should you always do?
Check that there isn’t swelling inside skull only superficial to skull by checking ?.Always measure and record the size of
the lump.
A lump that is getting bigger suggests
continued bleeding which may be
associated with a skull fracture and
intra-cranial bleeding
Refer for x-ray and ultrasound
This infant has
significant scalp edema as a result of
compression during transit through the
birth canal. The edema crosses suture
lines.
Caput succedaneum
Prediction of dyskinetic cerebral palsy
They display abnormal arm movements in circles with fingers
From 3 months lack of movent towards midline, particular foot-foot contact, is an additional specific sign.
What’s a baby skull that glows in the dark?
Damny- Walker formation, transillumination demonstrates a posterior fossa cyst
What is Hydrancephaly:
Hydranencephaly is a rare condition in which the brain’s cerebral hemispheres are absent and replaced by sacs filled with cerebrospinal fluid. An infant with hydranencephaly may appear normal at birth
Posture: Sustained opisthotonos -spasm of the muscles causing backward arching of the head, neck, and spine,
as in severe tetanus, some kinds of meningitis, and strychnine poisoning.
A: Late sign of meningitis. look for maple syrup smelling urine , persistent icterus neonatorum , poor feeding habits , microcephally , microphthalmia , hydrocephally , lymphadenopathy , fever or a macular rash . Refer immediately
Fixed postures with Clinical significance.
- Fisting with thumb adduction
- Scissoring of legs
- Frogleg position
Fisting with thumb adduction :
If persistent and present after 8 weeks of age
This is an early sign of central motor lesion and requires referral
Scissoring of legs : this is an early sign of spasticity and should be monitored for improvement with treatment , if sign persists patient should be referred
Frogleg position
with abducted arms is typical of the hypotonic infant
hypotonia under 12 months of age may respond well to chiropractic treatment
if the hypotonia persists then referral is warranted as 75% of children presenting with hypotonia between 6 months and 21 years of age have “cerebral palsy”.
Babys cry
A high pitched piercing cry may indicate
- A very hoarse cry may indicate
- A feeble cry,
A high pitched piercing cry may indicate increased intracranial pressure or subluxation .
• A very hoarse cry may indicate cretinism which is associated with
1. respiratory difficulty
2. excessive sleeping
3. poor feeding
4. general sluggishness
immediate referral for thyroid evaluation is required
• A feeble cry, areflexia and hypotonia may have Werding - Hoffman disease.
Babinski sign and Plantar response
Babinski reflex –
It is generally accepted that an extensor plantar response matures to a flexor plantar response by 12 months of age in most infants
Positive if extension of the big toe along with flexion of the other toes occurs .
Is of no clinical significance in infancy (prior to 2 years of age) but if it is consistently easy to elicit , asymmetrical or associated with other motor signs then it should be considered abnormal .
May be more accurately elicited by performing from toe to heel.
Hypertonicity and hypotonicity
How to check and measure
Scarf Sign - measure the angle produced when the upper arm is held across the chest.
Heel to Ear - measure the angle between the trunk and legs with the hips in full flexion
Popliteal Angle - measure the angle formed at the knee with the hips in full flexion and abduction.
also
PulltoSittingtest VerticalSuspension VentralSuspensionandLandauTest Ankle dorsiflexion
Abnormal https://www.youtube.com/watch?v=bOh5tkdUwC0
Normal: https://www.youtube.com/watch?v=zCcoGGzacUk
Pull to sit test
From3to4monthsheadisheldintheplane of the body and the arms extended
• From4to5months head is flexed and arms extended
• 5 months onwards expec the adflexed and arms flexed
- Note the degree of head lag
- Note any head tilt
- Note any head rotatopm
- note use of arms
Development of head control on the pull-to-sit maneuver.
• A,At 1 month of age the head lags after the shoulders.
• B At 5to6months the child anticipates the movement and raises the head before the shoulders.
Assess the pull to sit
- Note the degree of head lag
- slight
- moderate
- severe/ full
Is the degree of head lag age appropriate
Note any head tilt (always abnormal) Left or right
Note any head rotation and amount of head rotation (always abnormal) Slight, mild, moderate, sever
Note use of arms and degree of elbow flexion
- poor tone (Abnormal)
- Fully extended normal tone
- partial elbow flexion
- full elbow flexion
Is arm use symmetrical
Is degree of elbow flexion n age appropriate
Cranial nerve Assessment
How to test each cranial nerve on a baby?
CN 1
Cannot be tested
• CN 2
Flash a bright light in the eyes and look for blinking – tests CN 2 and 7
CN3,4and6
CN 3 opens the eyelid so look for ptosis
Hold baby’s head and look for eye movement following face
CN 6 innervates lateral rectus
Most should track well by 4 weeks of age
Better response with high contrast object such as a bull’s eye
• CN5
Mandibular division with root reflex Ophthalmic with corneal reflex
Maxillary not tested
CN 7
Sucking reflex and facial expression
CN 8
Clap and look for blink or >8 months turning to rattle or soft
voice
CN 9
Intact swallowing, look for excessive drooling and salivary pooling Examine dental eruption pattern routinely ;
incisors
first molars cuspids second molars
5 -10 months 10 - 16 months 16 -20 months 20 -30 months
Facial ptosis :
• ifassociatedwithgeneralizedhypotonia then refer for immediate specialist evaluation
( myasthenia gravis - Tensilon test )
• if it exists as a single (unilateral) finding is probably due to CN 7 involvement ( Bell’s palsy ) which may respond well to chiropractic treatment
Often is the result of forceps trauma
• CN10
Gag reflex
• CN11
direct evaluation is difficult , but a measure of its patency can be gained by testing the LANDAU and NECK RIGHTING REFLEX .
• CN12
Examine the tongue for signs of atrophy, deviation and fibrillations
Which side is affected?
Facial nerve palsy. This infant incurred injury to the right facial nerve, resulting in loss of the nasolabial fold on the affected side and asymmetrical movement of the mouth. The side of the mouth that appears to droop is the normal side.
Assess external appearance
Assess for strabismus
Assess extra occular motility
Assess pupils
Assess visual acuity
Assess visual fields
Perform fundoscopic examination
DDx Blue sclera
• Inaninfant,thescleraisthinandtranslucent,witha bluish tinge.
Osteogenesis imperfecta
Glaucoma
Ehlers-Danlos syndrome
Marfan syndrome
Russell-Silver syndrome
Hallermann-Streiff syndrome
Development of Vision
Absence of fixation and following by 3 months of age requires referral
Persistent deviation of an eye in an infant requires evaluation
Assess for the presence of STRABISMUS
5% of normal and 50% of brain damaged children have strabismus
Tropia - exo or eso in the horizontal plane, hyper or hypo in the vertical plane, will be constantly present.
Phoria - this is a latent condition which is only apparent as a result of fatigue or testing.
What is this?
What is this?
Infantile esotropia with asymmetrical corneal light reflexes.
Is this also strabismus?
This infant has pseudostrabismus, caused by a flat nasal bridge, wide epicanthal folds, and closely placed eyes.
What do you look for when checking extra-occular motility?
Assess EXTRA-OCCULAR MOTILITY
Cranial nerves 3, 4 and 6
In infant test by eyes following face of examiner
In older child use object and watch eyes follow
CN 3 Palsy
Third cranial nerve palsy
Test by forced opening of closed eyelids
What are we looking for when assessing the pupils?
Assess the PUPILS
(Anisocoria) is a condition characterized by unequal pupil sizes. It is relatively common, and causes vary from benign physiologic anisocoria to potentially life-threatening emergencies. Thus, thorough clinical evaluation is important for the appropriate diagnosis and management of the underlying cause.
aniscoria in which the pupil difference is not changed by altered light levels is generally not pathological, if the aniscoria alters with a change in light levels it should be considered pathological.
Assess direct and consensual reflexes
- Constricted pupils can indicate brainstem dysfunction
- Dilated poorly responsive pupil or pupils indicate brainstem dysfunction often from increased intracranial pressure (CN3 compression)
- Doll’s eye reflex – failure of eyes to maintain midposition with head turning indicates brainstem dysfunction. (Need voluntary gaze fixation)
Fundoscopic examination
Evenwithcare,onlyalimitedamountofthefundus can be seen with a direct or handheld ophthalmoscope. For examination of the far periphery, an indirect ophthalmoscope is used, and full dilation of the pupil is essential.
Make sure that you are able to elicit a red reflex in all patients
What can you see here?
• Leukokoria. The patient’s left eye has a white pupillary reflex produced by reflection of light from a retinoblastoma. Leukokoria is the most common presenting sign (60%) of retinoblastoma.
An abnormal cause of loss of red reflex
Retinoblastoma.
Retinoblastoma is a rare type of eye cancer that usually develops in early childhood, typically before the age of 5.
The tumor mass of retinoblastoma usually is elevated and yellow or white in color.
Dilated feeding vessels of the tumor may be visible.
Seeding into the vitreous from the tumor may produce a cloudy vitreous.
What is this?
What is this?
• Retinal detachment.
The inferior retina is detached, and a demarcation line between the attached and detached retina is visible.
Fluid beneath the detached sensory retina shifts with movement of the eye and causes the detached retina to move or undulate.
Retinal detachments (RDs) in the pediatric population are relatively uncommon. Their etiology includes both congenital and acquired disorders.
What is this?
Unilateral congenital ptosis with lid covering pupil.
What causes an opaque eye?
Congenital glaucoma.
- The right cornea is hazy and opaque resulting from cornea ledema.
- Break down of the corneal epithelium has caused ocularirritation, and the conjunctiva is slightly infected.
- Epiphora is present because of reflex tearing caused by the pain of epithelial breakdown and increased intraocular pressure.
What three findings can you see here?
What finding should also be there but can’t be seen?
Horner syndrome (right side) with iris heterochromia.
DEF (Heterochromia is different colored eyes in the same person. Heterochromia is the presence of different colored eyes in the same person. Heterochromia in humans appears either as a hereditary trait unassociated with other disease, as a symptom of various syndromes or as the result of a trauma.)
The right upper lid is slightly ptotic, and the right lower lid is slightly higher than its mate.
Anisocoria is present. The right pupil is smaller than the left.
The iris on the side affected by Horner syndrome is lighter in color than the iris of the fellow eye. (Heterochromia)
There will also be loss of sweating response on the right side of the face
Primitive Reflexes
What are we mainly looking for?
Primitive reflexes assessment (Automatisms)
1 • Bilateralreflexabsenceordiminution
indicates general depression of the central or peripheral motor function . May also be a result of a subluxation complex .
• 2. Asymmetrical responses, unilateral absence or hyper irritability (increasedresponse) suggests focal motor lesion , always differentiate from a local spinal subluxation complex .
3 • Persistence of the primitive reflexes
indicates general developmental lag or central motor lesions
Rule out focal CNS lesions before attributing to subluxation complex
Routinely test the following
- MORO REFLEX
Startle reaction
Is a flexion response not extension
Could not be elicited in anencephalic infants but Moro could always be elicited
Habituates in prem infants but Moro does not
Best elicited by head drop method
Moro reflex.
A, To elicit the reflex, the head is supported and allowed to drop to the level of the bed.
The initial extension response to vestibular stimulation is shown in B.
The complete response includes secondary flexion and cry.
Normal Response
Fully present at birth (not able to be elicited in-utero)
Extension and abduction of the arms with extension of the fingers followed by flexion and
adduction of the arms elicited by sudden head extension or a loud noise
Inhibited progressively from 8 to 12 weeks, no longer present after 12 weeks
Habituation does not occur in clinical setting
Triggers
Sudden change in head position (Vestibular) Sudden movement or change of light (Visual) Pain or temperature change (Sensory)
Sudden noise (Auditory)
Activates fight or flight response (Sympathetic nervous system) Release of adrenaline and cortisol
Increased respiration rate
Increased heart rate
Increased blood pressure Increased skin circulation
Is NOT related to the infant startle, adult startle or Strauss reflex (Futagi et al 2012)
Is principally mediated by the vestibular nuclei and the centre of the Moro reflex seems to be in the lower region of the pons to the medulla
Proprioceptive inputs from the neck also contribute to elicitation of the reflex as well as vestibular inputs
It is difficult to elicit a strong Moro response if neck movement is prevented
Moro response Phase 1and 2
First phase of the Moro response.
Symmetrical abduction and extension of the extremities follow a loud noise or an abrupt change in the infant’s head position.
Moro response
Phase 2
Second phase of the Moro response.
Symmetrical adduction and flexion of the extremities, accompanied by crying.
Abnormal Moro Response- what are factors that can be abnormal? Discuss them
Asymmetrical response – with phase 1 or 2
commonly occurs with shoulder subluxations
may occur with upper cervical or lower cervical subluxations Peripheral nerve damage
Cervical cord damage
fracture
Look for persistent fisting – may be unilateral or bilateral Usually associated with strong pain issue
Persistence beyond 3 months is abnormal
Absence or decreased response under 3 months of age may be
abnormal
Increased response under 3 months of age seen with neonatal withdrawal from maternal drug abuse e.g. heroin, opioids and volatile substances
Persistence at 5 to 6 months of age indicates need for referral to paediatrician for assessment
Absence during 0-3 moa
Birth injury
Severe birth asphyxia
Intracranial haemorrhage
Infection
Brain malformation
Generalmusclular weakness
Spastic CP
Hyperactive response
- Neonatal withdrawal from maternal drug abuse Volatile substances
Heroin
Opoids - Hydranencephaly
• Persistence
Mental retardation – persistent Moro commonly seen
Down’s syndrome
Athetoid CP
Athetoid cerebral palsy (also known as “dyskinetic cerebral palsy”) is a movement disorder caused by damage to the developing brain. This type of cerebral palsy is characterized by abnormal, involuntary movement. Children with athetoid CP fluctuate between hypertonia and hypotonia.
See below:
https://www.youtube.com/watch?v=U1gy_anS2DE
Primitive Reflexes - Moro The baby has a Moro reflex with the arms fully abducted and extended but he doesnt bring the arms back to the midline. So the Moro is present, but not as complete as it should be.
- Note the degree of response
- Note the symmetry of arm response
- Note symmetry of leg response
- NOte any fisting
- Note any crying or dislike
How do we test fine Motor control in Children?
Tested by stringing beads with the eyes open and then closed, note the degree of ability when tested at own pace then when tested as fast as possible.
Test using pincer grip to pick up paper clips, time this task, compare left and right for speed, accuracy and quality
Obtain sample of writing
Finger imitation
examiner opposes thumb to a finger on the same hand and holds for 5 seconds while the child imitates, there are five trials
Most 4-6 year olds are correct on 3-4 trials
Note any mirror movements, dyskinesia, excessive visual input.
Lindgren(1978) found that finger localisation skill at age 4-5 predicted reading and arithmetic achievement at the end of the first grade.
See positive clonus and babinski
(Upper motor neuron damage)
Babinski:
https://www.youtube.com/watch?v=XMKEAm63SoM
Positive Hoffman’s sign, positive Babinski test, clonus, hyperreflexia in a C5-6 injury
https://www.youtube.com/watch?v=ezZQPVJnJhs
describe what abducens nerve palsy would look like? (CN6)
CN3: Oculomotor nerve palsy
https: //www.youtube.com/watch?v=Pl2ozPSWfHs
https: //www.youtube.com/watch?v=AEL0xeJ_NSw
What are the 2 types of deafness and how do we assess it?
• Conduction deafness-
Middle ear disease i.e. chronic otitis media
Obstruction of the external ear canal i.e. wax
• Sensorineural deafness-
Lesion of the cochlear i.e. Meniere’s disease, drug or noise induced damage
Lesions of the nerve i.e. tumours or meningitis
Lesions in the nucleus in the pons i.e. stroke or demyelination (very rare)
Weber Test:
- Hold512cpstunningforkonthetopofthepatient’s head in the midline.
- Normal: The sound/vibration is perceived as being in the middle of the head
- Abnormal: the sound/vibration is perceived as being more to one side of the head.
Rinne Test
(no need to perform if the Weber Test is normal)
Hold a 512 cps tuning fork firmly on the patient’s mastoid process
When the patient can no longer hear the sound, place the tuning fork in front of the EAM
Normally the sound should still be audible and heard for a longer period of time than when held on the mastoid process
If the sound is not audible in front of the ear, a conduction deafness is indicated
A hearing loss of 12-20 dB will be detected by this test
The “U” side of the tuning fork should face forwards
https://www.youtube.com/watch?v=FgF91K7dU8Y
