Paeds Neuro Flashcards
What is the structure of the paeds neuro exam
WIPERQQ
Higher cortical functions
Cranial nerves
Limbs
Cerebellar
Cognitive
What higher cortical functions should you assess in the inspection part of p neuro exam
Observe the child during play:
Attention span
Gross and fine motor coordination
Problem-solving abilities
Observe for age-appropriate milestones
What do you assess after observation in p neuro
cranial nerves (it is unlikely you will be able to carry out a complete neurological assessment in one sitting with most children.)
What do you assess CNII in p neuro
Acuity
Fields
Reflexes
Ophthalmoscopy
How should you assess visual acuity in the p neuro exam
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
How should you assess visual fields in the p neuro exam
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).
How do you assess pupillary reflexes in p neuro
Direct pupillary reflex (afferent CN II, efferent CN III)
Consensual pupillary reflex
How do you assess CN II, IV, and VI
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.)
Name gaze abnormalities associated with paediatric neurological disease (4)
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.
What is Parinaud Syndrome?
neurological disorder characterized by the inability to move the eyes upwards, often accompanied by convergence-retraction nystagmus, due to lesions in the dorsal midbrain.
What is Joubert Syndrome?
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.
Niemann Pick Type C disease.
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.
Oculomotor Apraxia-Ataxia Syndrome
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.
How do you assess trigeminal nerve in p neuro
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.
How do you assess facial nerve in p neuro
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).
How do you assess vestibulocochlear nerve in p neuro
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.
How do you assess CN IX and X in neuro paeds (4)
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.
How do you assess CN XI in neuro paeds
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.
How do you assess CN XII in neuro paeds
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.
How do you assess the limbs in p neuro
Inspect
Gait
Tone
What should you look out for when assessing gait in p neuro
Ataxia
High stepping
Waddling
Hemiparetic
Spastic paraparesis
What does an ataxic gait look like and what does it suggest?
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.
What does an high-stepping gait look like and what does it suggest?
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).
What does an waddling gait look like and what does it suggest?
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).