Paeds Neuro

Question 1

What is the structure of the paeds neuro exam

Answer 1

WIPERQQ
Higher cortical functions
Cranial nerves
Limbs
Cerebellar
Cognitive

Question 2

What higher cortical functions should you assess in the inspection part of p neuro exam

Answer 2

Observe the child during play:

Attention span
Gross and fine motor coordination
Problem-solving abilities
Observe for age-appropriate milestones

Question 3

What do you assess after observation in p neuro

Answer 3

cranial nerves (it is unlikely you will be able to carry out a complete neurological assessment in one sitting with most children.)

Question 4

What do you assess CNII in p neuro

Answer 4

Acuity
Fields
Reflexes
Ophthalmoscopy

Question 5

How should you assess visual acuity in the p neuro exam

Answer 5

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

Question 6

How should you assess visual fields in the p neuro exam

Answer 6

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).

Question 7

How do you assess pupillary reflexes in p neuro

Answer 7

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

Consensual pupillary reflex

Question 8

How do you assess CN II, IV, and VI

Answer 8

First inspect for ptosis

Then extraocular eye movements (drawing an imaginary “H” with a brightly coloured soft toy or light and asking the child to follow it.)

Question 9

Name gaze abnormalities associated with paediatric neurological disease (4)

Answer 9

Opsoclonus: chaotic bursts of eye movements, often associated with myoclonus caused by neuroblastoma.

Up gaze paresis: associated with Parinaud syndrome.

Impaired downwards gaze: associated with Niemann Pick Type C disease.

Oculomotor apraxia: delayed initiation of eye movement and jerky pursuit movements. Associated with Joubert syndrome and oculomotor apraxia-ataxia syndrome.

Question 10

What is Parinaud Syndrome?

Answer 10

neurological disorder characterized by the inability to move the eyes upwards, often accompanied by convergence-retraction nystagmus, due to lesions in the dorsal midbrain.

Question 11

What is Joubert Syndrome?

Answer 11

rare genetic disorder characterized by the underdevelopment of the cerebellar vermis, leading to ataxia, abnormal eye movements, hypotonia, and intellectual disability, often with a distinctive “molar tooth sign” on brain imaging.

Question 12

Niemann Pick Type C disease.

Answer 12

Impaired downwards gaze

genetic lysosomal storage disorder that leads to the accumulation of cholesterol and other lipids in the brain, liver, and spleen, causing progressive neurological and systemic symptoms.

Question 13

Oculomotor Apraxia-Ataxia Syndrome

Answer 13

Oculomotor apraxia-ataxia syndrome is a neurological condition that manifests as difficulty with voluntary eye movements (oculomotor apraxia) and coordination (ataxia), often due to genetic mutations affecting brain development and function.

Question 14

How do you assess trigeminal nerve in p neuro

Answer 14

Assess sensory function
- Assess response to light touch over the three sub-divisions of the trigeminal nerve using a piece of cotton wool.
- In a baby, the presence of the rooting reflex confirms intact facial sensation.

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

Question 15

How do you assess facial nerve in p neuro

Answer 15

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).

Question 16

How do you assess vestibulocochlear nerve in p neuro

Answer 16

Infants: make a soft sound close to the ear (i.e. rustling of paper). The child should show an ‘alerting response’.

> 5-6 months: the child should be able to localise the sound to a specific quadrant.

School-age children: softly whisper 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.

Question 17

How do you assess CN IX and X in neuro paeds (4)

Answer 17

Observe the child swallowing:

Observe the child drinking or eating.
Dysfunctional 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 “Ahh” (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.
You should have an awareness of this test, however, it is not performed in routine clinical practice.

Question 18

How do you assess CN XI in neuro paeds

Answer 18

Test elevation of the 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.

Question 19

How do you assess CN XII in neuro paeds

Answer 19

Inspect the tongue when inside the mouth for fasciculations.

Ask the child to stick out their tongue: a unilateral CNXII lesion results in deviation of the tongue to the affected side.

Check whether the tongue can be equally protruded on both sides.

Question 20

How do you assess the limbs in p neuro

Answer 20

Inspect
Gait
Tone

Question 21

What should you look out for when assessing gait in p neuro

Answer 21

Ataxia
High stepping
Waddling
Hemiparetic
Spastic paraparesis

Question 22

What does an ataxic gait look like and what does it suggest?

Answer 22

broad-based, unsteady and associated with either cerebellar pathology or sensory ataxia (e.g. vestibular or proprioceptive dysfunction).

In the context of proprioceptive sensory ataxia, children typically watch their feet intently to compensate for the proprioceptive loss. If a cerebellar lesion is present the child may veer to the side of the lesion.

Question 23

What does an high-stepping gait look like and what does it suggest?

Answer 23

The child also won’t be able to walk on their heel(s).

can be unilateral or bilateral and is typically caused by foot drop (weakness of ankle dorsiflexion).

Question 24

What does an waddling gait look like and what does it suggest?

Answer 24

shoulders sway from side to side, legs lifted off ground with the aid of tilting the trunk. Waddling gait is commonly caused by proximal lower limb weakness (e.g. myopathy).

Question 25

What does a Hemiparetic gait look like and what does it suggest?

Answer 25

one leg held stiffly and swings round in an arc with each stride (circumduction). This type of gait is commonly associated with individuals who have had a stroke.

Question 26

What does a spastic paraparesis gait look like and what does it suggest?

Answer 26

similar to hemiparetic gait but bilateral, with both legs stiff and circumducting.

The child’s feet may be inverted and “scissor”.

This type of gait is typically associated with hereditary spastic paraplegia.

Question 27

What do you assess for the tone section of p neuro

Answer 27

Spasticity (“velocity-dependent”, meaning the faster you move the limb, the worse it is)

Rigidity (velocity independent” meaning it feels the same if you move the limb rapidly or slowly)

Clonus

Question 28

How do you assess clonus

Answer 28

1. 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.
2. Rapidly dorsiflex and partially evert the foot to stretch the gastrocnemius muscle.
3. Keep the foot in this position and observe for clonus. Clonus is felt as rhythmic beats of dorsiflexion and plantarflexion. If more than 5 beats of clonus are present, this would be classed as an abnormal finding.

Question 29

How do you assess cerebellar function

Answer 29

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.

Question 30

How do you do a cognitive assessment

Answer 30

Young children
Cognitive assessment in young children typically focuses on whether they are currently meeting the various milestones that would be expected of a child that age (e.g. communication abilities).

Parents should be asked about how the child is progressing in relation to their milestones. 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 for more details.

Children aged >7 years
The mini-mental state examination (MMSE) may be used, with modifications available for children of different ages/stages

Question 31

Further examinations after p neuro exam (4)

Answer 31

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).

Question 32

Further investigations post p neuro (6)

Answer 32

Vital signs
Measure and plot height and weight on a growth chart.
Lumbar puncture (e.g. meningitis, encephalitis)
Neuroimaging (e.g. CT/MRI)
EEG: if investigating possible seizures.
Nerve conduction studies (e.g. visual and somatosensory evoked potentials).