Pediatric Neurological Examination


Pertinent general examination


·          Head and neck

o         Head circumference – microcephaly vs. macrocephaly

o         Fontanelles – open vs. closed, size, fullness

o         Dysmorphisms, symmetry of head/face

o         Skin lesions – congenital or rashes

o         Cranial and neck bruits – carotid, vertebral, temporal, orbital

·          Cardiovascular

o         Heart sounds, murmurs

·          Abdominal

o         Hepatosplenomegaly

·          Musculoskeletal

o         Joint swelling

o         Muscle bulk

o         Spine – scoliosis, neural tube defects

·          Integument

o         Hair, skin


Mental status


·          Consciousness

·          Appearance

·          Behaviour, including abnormal movements

·          Language

o         Expressive – aphasia vs. dysphasia

o         Receptive

·          Orientation

o         Time, place, person

·          Memory

o         Bibliographical memory

o         Short-term, long-term memory


Cranial nerves


·          I – Olfactory nerve


·          II – Optic nerve

o         Pupils, acuity, colour (red), visual fields, fundoscopy


·          III – Oculomotor nerve

o         Medial rectus, superior rectus, inferior rectus – “down and out”

o         Levator palpebrae superioris muscle

o         Pupil constriction in accomodation

·          IV – Trochlear nerve

o         Superior oblique – “up and out”

·          V – Trigeminal nerve (V1-3)

o         Facial sensation – corneal reflex

o         Motor: masseter, temporalis, medial pterygoid, lateral pterygoid, tensor veli palatini, mylohyoid, anterior belly digastric, tensor tympani

·          VI – Abducens nerve

o         Lateral rectus


·          VII – Facial nerve

o         Muscles of facial expression

·          VIII – Vestibulocochlear nerve


·          IX – Glossopharyngeal nerve

o         Afferent portion of gag reflex

o         Sensory posterior 1/3 of tongue, tonsils, pharynx, middle ear, carotid body

o         Parasympathetic fibres to the parotid gland

o         Motor fibres to stylopharyngeus muscle and the upper pharyngeal muscles.

·          X – Vagus nerve

o         Muscles of pharynx/larynx

o         Parasympathetic innervation of all the organs except the suprarenal glands, from the neck down to the second segment of the transverse colon


·          XI – Accessory nerve

o         Spinal accessory – sternocleidoid muscle, trapezius muscle

o         Cranial accessory – joins with vagus

·          XII – Hypoglossal nerve

o         Muscles of the tongue


Motor exam


·          Bulk

o         Compare left vs. right, distal vs. proximal, upper vs. lower limbs

·          Tone

o         Hypertonia, hypotonia, spasticity, dystonia

o         Truncal and limb tone

·          Strength

o         Pronator drift – subtle arm weakness, proprioception

o         Power gradations:

·          0/5           no muscle activation

·          1/5           ineffective muscle activation

·          2/5           gravity removed

·          3/5           against gravity (3+ slight resistance)

·          4/5           some resistance (4- and 4+ gradations)

·          5/5           full power

o         Common muscles tested:

·          Deltoid                                    C5           Axillary n.

·          Biceps                                     C6           Musculocutaneous n.

·          Brachioradialis                        C6           Radial n.

·          Triceps                                   C7           Radial n.

·          Ext Carpi Ulnaris                    C7           Radial n.

·          Ext Digitorum                         C7           Radial n.

·          First Dorsal Interossious        T1           Ulnar n.

·          Abductor Pollicis Brevis         T1           Median n.

·          Psoas                                       L1,2         Lumbosacral Plexus

·          Tibialis Anterior                     L4,5         Deep Peroneal n.

·          Ext Hallucis Longus                L5            Deep Peroneal n.

·          Ext Digitorum Brevis              L5            Deep Peroneal n.

·          Gastrocnemius                        S1            Tibial n.

·          Hamstrings                             S1            Sciatic n.

·          Reflexes

o         Reflex gradations:

·          0              absent reflexes

·          1+            diminished reflexes, reinforcement

·          2+            normal reflexes

·          3+            increased reflexes

·          4+            increased reflexes with clonus

o         Common reflexes tested:

·          Brachioradialis        C6

·          Biceps                     C6

·          Triceps                    C7

·          Patellar                    L4

·          Gastroc-soleus        S1

o         Plantar responses:

Babinski                          Chaddock                                Oppenheim


o         Other reflexes:


o         Abdominal reflexes


Sensory exam


·          Spinothalamic - light touch and pin-prick

·          Dorsal columns - vibration and proprioception

·          Landmarks:

o         C5           Deltoid area

o         C6           Thumb

o         C7           Index finger

o         C8           Small finger

o         T4-5        Nipple Line

o         T10         Umbilicus

o         L5            Great Toe

o         S1            Lateral Foot





·          Dysmetria – finger-to-nose, heel-to-shin

·          Dysdiadochokinesia – rapid alternating movements

·          Influenced by strength




·          Regular gait, running

·          Toe walking – plantar flexion strength

·          Heel walking – dorsiflexion strength

·          Tandem gait – difficulty if wide-based gait