Special Considerations in the Neurologic Examination of Infants and Young Children 43

Special Considerations in the Neurological Examination of Infants and Young Children

Most of the techniques presented above for the neurological examination of adults cannot be used in infants or small children. In this age group, the important clinical indicators of nervous system function are body posture, spontaneous motor behavior, and the reflex motor responses induced by certain specific stimuli.

In taking the clinical history, the examiner must inquire about any problems that may have occurred during the child’s gestation and delivery. In the physical examination, attention should be paid to any constant, fixed postures of the limbs or asymmetry of the skull (plagiocephaly). The tension of the fontanelles should also be assessed by inspection and palpation.

Reflexes

General aspects. The primitive motor functioning of healthy infants and toddlers is mainly controlled by a number of reflex mechanisms. These reflexes can be affected by neurological disease so that they are absent, or exaggerated, or persist beyond the age at which they normally disappear.

Postural reflexes control the posture of the body and its relation to the ground. Positioning reflexes return the body to a “normal” position after a perturbation; the vestibular system plays an important role in these reflexes. Finally, statokinetic reactions and equilibrium reactions provide the body in motion with important protective movements and righting responses.

The manner of eliciting the reflexes described in this section is illustrated in Fig. 3.33.

Reflexes reflecting the state of maturation of the infantile CNS. A wide variety of reflexes can be pathologically altered in developmental disorders of the CNS. We will only present the more important ones here.

The doll’s-eyes phenomenon is induced by turning the head from side to side or up and down, in an awake, supine infant. The eyes make a compensatory movement in the opposite direction and thus stay in their original position with respect to outside space. This vestibular reflex is demonstrable at birth and persists for the first six weeks of life.

The foot placement reflex is elicited by holding the infant upright under the axillae (while supporting the head) and allowing the dorsum of a foot to touch the edge of the table. A normal newborn infant will flex the hip and knee and put the foot on the table. This reflex disappears in the first few weeks of life.

a

b

c

d

45°

3

The Neurological Examination

Fig. 3.33 Reflexes in the infant. a Moro reflex: the infant is held by the examiner in a diagonal, half-supine position, with one hand under the trunk and one hand supporting the head. When the examiner suddenly tips the infant toward the horizontal, momentarily reducing the supportive pressure on the occiput, the infant extends its upper and lower limbs. b The same response can be induced in a supine infant if the examiner suddenly strikes and depresses the mattress. c Parachute reflex: the examiner suddenly tips the infant

forward, from a vertical position toward the horizontal. Normally, the arms are extended, as if to break the infant’s fall. d Landau reflex: an infant held around the trunk in a prone position tends to keep the limbs extended and the head tilted upward. When the head is passively tilted downward, the normal response is flexion of the limbs (positive Landau reflex). (Modified from Lietz, R.: Klin- ische-neurologische Untersuchung im Kindesalter, 2nd edn, Deutscher Ärzteverlag, Cologne, 1993).

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44 3 The Neurological Examination

	The stepping reflex is seen when the examiner holds		In the Landau reflex, the examiner first lifts the infant
	the infant under the axillae so that the soles of the feet	into the air in a prone position; the infant will respond
	just touch the surface of the examining table and then	by extending the limbs and head. The examiner then
	slowly moves the infant forward. The infant will then	flexes the infant’s head, and the infant flexes the limbs
	make stepping movements with the feet. This reflex,	as well (Fig. 3.33d). This reflex should be demonstrable
	too, is elicitable only in the first few weeks of life.	from the fourth to the 18th month. In infants with cere-
	In the tonic hand-grasp reflex, the infant forcefully	bral damage, the Landau reflex appears late or not at all,
	grasps the examiner’s index finger when it is placed in the	or else it persists longer than normal.
	palm of the hand. The grasp is so tight that the infant can		To elicit the asymmetric tonic neck reflex (nuchal re-
	even be held up by the examiner’s finger. In the analogous	flex), the examiner slowly turns the supine infant’s head
	foot-grasp reflex, there is tonic flexion of the toes on	to one side, while preventing any movement of the
	stimulation of the sole of the foot. The tonic hand-grasp	shoulders. The arm and leg are then extended on the
	reflex is present in the first two months of life, then	side to which the head is turned and flexed on the other
	gradually diminishes till it totally disappears, usually in	side (fencing posture). This reflex is present in new-
	the third month of life, and no later than the fourth.	borns and disappears at the age of four months. Per-
	To elicit the Moro reflex, the examiner holds the infant	sistence after the sixth month is pathological.
	in a diagonal, half-supine position, with one hand under		The Babinski sign (p. 38) is normally present in infants
	the trunk and one hand supporting the head. The infant is	and usually disappears when the child learns to walk. It
	then suddenly tipped toward the horizontal, while the	is absent in all healthy children from the age of two
	support under the occiput is momentarily released. The	years onward.
	body flexes as if in fright and the arms are first extended		The diagram in Fig. 3.34 represents the stages of nor-
	and then brought forward as if in a hug (Fig. 3.33a). A sim-	mal motor development in infancy and early childhood.
	ilar response can be elicited in a supine infant by sud-	Some abnormal findings that may suggest a cerebral
	denly striking and depressing the mattress (Fig. 3.33b).	motor disorder at different times in the first year of life
	The Moro reflex is no longer seen after the third or fourth	are listed in Table 3.11.
	month of life. Its absence in the first few months of life is
	usually associated with severe brain damage.	Table 3.11 Findings suggesting a cerebral motor disorder in
	Support reactions are tested by pressing on the infant’s
	palms or soles. The infant extends the corresponding	the first year of life
	limb as if to support its weight with it. Support reactions	High-risk birth (prematurity, cyanosis at birth, abnormal Apgar
	are present at birth in the legs and develop in the arms		scores)
	over the first four or five months of life. Cerebral lesions		Abnormal flaccidity or fixed lumbar lordosis
	make these reactions abnormally intense.		Tendency to opisthotonus
		Feeding difficulties
	The positioning reflexes are evoked by a combination
		Spasticity with resulting difficulty in changing diapers
	of afferent input from the vestibular system and from re-
			Squint
	ceptors in the skin, joints, and muscles. In the parachute		No head lifting in the prone position at age three months or
	reflex, the vestibular system plays the most important		older
	role: the examiner holds the infant around the trunk with		No head control in the sitting position at age four months or
	both hands, lifts it off the examining table, holds it at		older
			Persistence of certain reflexes

	about a 60° angle, and then suddenly tips the infant for-	No free sitting or flattening of the lumbar kyphosis at age
	ward into a horizontal position, near the surface of the
		nine months or older
	table (or crib). Infants aged about four months or older
	will extend their arms, downward and in mild abduction,
	and open their hands, as if to break the fall (Fig. 3.33c).

	Months 1	2	3	4	5	6	7	8	9	10	15	Fig. 3.34 Stages of normal motor
												development in infancy and early
												childhood.
	Head,
	spine
	Crawling,
	standing, walking

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