Neurologic Evaluation of Children With Neurodevelopmental Disorders

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[JOV, KEESH, JESSA] 1 of 10

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Neurologic Evaluation of Children with

Neurodevelopmental Disorders

OS 211 [A]: Integration, Coordination and Behavior EXAM #2

March 1, 2016

Dr. Lukbanf

Hello! This is based on Ma’am slides, lectures, Nelson’s Pediatrics 19th ed,Bates, and pictures from the internet. We hope this helps! Focus ondevelopmental milestones daw. :PPS: Ma’am didn’t give a copy of her powerpoint to us, so we couldn ’t write a

more detailed descriptions of the videos. We tried to add pictures instead.

OUTLINE AND OBJECTIVES:

Review the components of a neurologic examination Review the emerging patterns of behavior from newborn to 5

years of age: focus on developmental milestones

Demonstrate an easy, rapid and complete neurologic examinationin small children

Emphasis on newb orns and infants less than 2 years old.

I. INTRODUCTION

Modern technology DOES NOT and CANNOT substitutefor skilled history taking (and physical/neurologicexamination)

It is...o Not a netting operation

Right now we’re used to casting out a net anddoing everything we like, hoping to findsomething and synthesizing that data

But a neurological examination of children needsto be dynamic in order to answer the questionsthat we have

o Not data to be sorted latero Data is: (Swaiman, 2006)

Dynamically synthesized when collected Used to alter the direction and depth of the

questioning (and examination) process

It aims to answer the following questions (using the historyand neurologic examination):o Is the nervous system involved?

Watch out for symptoms that hint at nervoussystem involvement, such as weakness,headaches, seizures, numbness, changes in

sensorium or consciousness. At what age did the problem occur?

Did it occur during birth, infancy, childhood,adolescence, or adulthood?

Different disorders manifest at different lifestages

o Is the process acute (ex. vascular), insidious (ex.tumor), or chronic?

o Is the process progressive (ex. IEM) or static (ex.Cerebral Palsy)?

o Is the problem familial or sporadic?o Is the involvement diffuse or localized (focal or

generalized)?

In the physical and neurological examination, the goal ofthe examiner is to get the child to be calm and cooperative

for the longest possible time.o First key principle: Have a patient that will

cooperate with you.

o Least intrusive parts done first Observe the child as he/she is playing and

interacting with the parentso Allow parents to participate in calming the baby

Don’t touch the patient right away! o Do things in stages, including undressing (all of them

should be undressed as we need to look forneurocutaneous lesions)

o PLAY!

II. DEVELOPMENTAL MILESTONES

Neurologic exam is performed in the context ofdevelopmental milestones

Developmental milestones reflects the maturation of the

child’s nervous system What are we looking for?

o Delay in obtaining developmental milestones ando Abnormal patterns of development are important

indicators of underlying neurological disease

Note: Memorize the developmental milestones

Table 1. Gross Motor Developmental Milestones

Age Gross Motor

2 wks Moves head from side to side

2 mos Holds head steady while sitting

Follows past midline

3 mos Pulls to sit, with no head lag

Brings hands together in midline

Palmar grasp

4 mos

Asymmetric tonic neck reflex gone6 mos Sits without support

6.5 mos Rolls back to stomach

12 mos Walks alone

Stoops and stands

18 mos Runs

Kicks ball

2 years Walks ups and down stairs one step at atime

Throws overhand

3 years Walks up and down steps withalternating feet

Broad jump

4 years Balances well on each foot

Hops on one foot

5 years Skips

Heel-to-toe walks

6 years Balances on each foot for 6 secs

Table 2. Fine Motor Developmental Milestones

Age Fine Motor

3.5 wks Grasps rattle

4 mos Reaches for objects

Palmar grasp gone

5.5 mos Transfers object hand to hand

8 mos Thumb-finger grasp

12 mos Turn pages of book

13 mos Scribbles

15 mos Builds tower of 2 blocks

18 mos Builds tower of 4 blocks

2 years Builds tower of 6 blocks

Copies line

3 years Builds tower of 8 blocks

Wiggles thumb

4 years Copies circle

Draws person with 3 parts

5 years Copies square

6 years Copies triangle

Draw person with 6 parts

Table 3. Communication and Language Developmental Milestones

Age Communication and Language

2 wks Alerts to bell (or voice)

1.5 mos Smiles in response to face, voice

2 mos Cooing

Searches for sounds with eyes

4 mos Laughs and squeals6 mos Monosyllabic babble

7 mos Inhibits to “no”

Follows one-step command with gesture

9-10 mos Follows one-step command withoutgesture

Says “mama” or “dada”

2-syllable sounds

Points to objects

12 mos Speaks first real word

15 mos Speaks 4-6 words

18 mos Speaks 10-15 words

OUTLINE

I. IntroductionII. Developmental Milestones

III. Key Principles: ReflexesIV. The Neurologic Examination A. Sequence of ExamB. Overview of the Stages of the ExamC. Instruments and ToolsD. Components of the Exam

V. Important RemindersVI. Summary


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OS 211 [A]: Neurologic Evaluation of Children

2 years Speaks 2-word sentences (ex: Mommyshoe)

Points to pictures

Knows body parts

3 years Names pictures

Speech understandable

Says 3-word sentences

4 years Names colors

Understands adjectives5 years Counts

Understand opposites

6 years Defines words

Table 4. Social/Cognitive Developmental Milestones Age Social/Cognitive

2 wks Regards face

2 mos Smiles responsively

Lack of object permanence

4 mos Stares at own hand (self-discovery)

Cause and effect

6 mos Feeds self

Holds bottle

8 mos Bangs 2 cubes (active comparison ofobjects)

Object permanence

9 mos Waves bye-bye

Plays patty cake

12 mos Begins symbolic thought

Egocentric symbolic play

Drinks from cup

Imitates others

15 mos Uses spoon and fork

Helps with housework

17 mos Able to link actions to solve problems

Symbolic thought

Pretend play

2 years Washes and dries hands

Brushes teeth

Puts on clothes

3 years Uses spoon well, spilling little

Puts on t-shirt

4 years Brushes teeth without help

Dresses without help

III. KEY PRINCIPLES: REFLEXES

Development of motor control proceeds in a head to toefashiono A child who has not learned to control his/her head

will not be able to sit and achieve truncal control. Achild who has not learned to sit, will not be able tostand and walk.

Figure 1. Primitive and Postural Reflexes. Primitive reflexes disappear at

about 6 months and postural reflexes appear. Additional reflexes develop over

time.

Primitive reflexes:

o Reflex actions originating in the central nervoussystem that are exhibited by normal infants, but notneurologically intact adults, in response toparticular stimuli

Postural reflexes:o Automatic movements that control the equilibration

(balance, posture, and movement) we require onceupright and moving and having to combat the effectsof gravity

In infants, absence or presence of primitive reflexes aredetermined to evaluate the maturation stage of thenervous system

On the other hand, the segmental reflexes of the musclestretch reflexes and the superficial reflexes are elicited todetermine the site of affection of the nervous system,i.e. location of lesion.

Persistence of primitive reflexes (Moro, grasp) and thelack of development of the postural reflexes (Landau,parachute) are the hallmarks of an upper motor neuronabnormality in the infant.

See Appendix for Primitive and Postural Reflexes

IV. THE NEUROLOGIC EXAMINATIONA. Sequence of Exam

Observation

Inspection

Palpation

Manipulation

B. Overview of the Stages of the ExamTable 5. Stages of Neurologic Examination

Stage 1 Observation Inspection

Child allowed to play around, baby carried bymother in the lap

Stage 2 Palpation

Manipulation

Baby on examination tableStage 3 Intrusive tests

Ex: Fundoscopy, head circumferenceStage 4 Special maneuvers to elicit function

*Sequence of examination is FLEXIBLE as compared to adults andolder children (but report like in Adult neuro exam)

C. Instruments and Tools

Neuro kit

Stethoscope

Toyso Ex. rattle, plush toys, pretty/colorful toys

Children's books

Colorful pens, pencils, drawing materials

D. Components of the Exam

1. Physical ExamSomatic Growth

Check for the following:o Height

o Weighto Head circumference

>+2 or >-2 Z-score is abnormalo Check centiles.

Use standard tables (See appendix)o Compare with chest circumference and parents’ head

Fontanels and Sutures (From 2017 and 2018)Table 6. Development of fontanels and sutures

Age Development

3mo Posterior fontanel closed

6mo Fibrous union of suture lines occurs & serratededges interlock

20mos Anterior fontanel closed (others close at 18 mos.)

8 yrs Ossification of craniobasal bones is complete

12 yrs Sutures cannot be separated by raised intracranialpressure more dangerous

20 yrs Sutures still visible on radiographs

8t

decadeSolid bony union of all sutures is complete* check for symmetry of the head

Closure:o Anterior fontanel – 18-20 mos o Posterior fontanel – 3 mos

Craniosynostosis microcephaly (complete closure ofall sutures)


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Example of Dysmorphic features

Crouzon's syndrome

Figure 2, 3, 4. Children with Crouzon’s syndrome. Usually present withcraniosyntosis and midface hypoplasia. May also present withexophthalmos (bulging eyes due to shallow eye sockets after early fusion ofsurrounding bones), hypertelorism (greater than normal distance betweenthe eyes), and psittichorhina (beak-like nose), external strabismus,hypoplastic maxilla (insufficient growth of the midface) results in relativemandibular prognathism (chin appears to protrude despite normal growth ofmandible) and gives the effect of the patient having a concave face.

Down syndromeo Macroglossia and Mongolian slant of eyes

Figure 5, 6, 7. Children with Down syndrome. Usually present with asmall chin, macroglossia, “Mongolian slanted eyes”, flat nasal brigde, flatand wide face, with a short neck.

Eye examination

“The eye is the window to the brain”

Check the fundus and retina.o Congenital TORCH infection – retinitis pigmentosa

Skin search

Look for stigmata of neurocutaneous syndromes

Table 7. Example of Neurocutaneous lesions.

Disorder Lesion Figures 8, 9, 10

Tuberous sclerosis

with infantile spasms

At least 3 spots

Often come in othershapes, althoughmost are polygonal

Usually 0.5-2 cm indiameter, andresemble athumbprint

Watch out forbecause might bewith seizures

Ashleaf

patch

Sturge Weber

Caused by vascularanomaly

Watch out forbecause might bewith seizures

Facial port-

wine stain

Neurofibromatosis

Hyperpigmented

May be present atbirth or developwithin the first1-2years of life.

At least 6 spots

Watch out fortumors in the earsand eyes

Café au lait

spots

Abdomen

Check for visceromegalyo Storage diseases

Back and Spine

Scoliosis

Sacral abnormalities

2. StagesStage 1: Mostly Observation

Starts during history taking

Children 2 to 5 years old - can participate in the history

taking, gives us an idea of his intellectual and languageskills, as well as behavioro Ex. Extend your arm to a child as in “Pinapamano mo

yung bata” or ask the child “How old are you?” If childdoes not respond or does not look directly at you(examiner), screen for possible autism. Two-step behavior, acknowledging examiner and

doing the action. Child with autism will not acknowledge the hand. Alternatively, can also ask them to “look at the

light”. Through asking a child how he/she is, you can

also start to asses IQ.o From 2018. Assess child for

Cooing- 6 mos, “mama‟ - 9 mos. Mama is mama, papa is papa- 1 year/13 mos. Complete sentence- 2 years old

Child less than 2 years old (usually in their mother's lap)

o Motor and verbal abilities in developmental historyo Observe & ask mother state of alertness, awareness

of surroundings, vocalization, behavior, facial andocular movements, symmetry of limb movements

Newborns and pretermso Observe facial and motor movements during awake

and sleep stateso Inspect and palpate the head and the sutures

By observation:o Detect abnormal involuntary movementso Assess facial and eye movementso Allow the child to play (should be appropriate for

his/her age) – check for motor skills

Stage 1: Mental Status and Cranial Nerve Exam

Mental status: Alertness and responses to visual, tactile,and auditory stimuli

Motor function: Muscle bulk, posture, limb position,symmetry of movements, presence of abnormal andinvoluntary movements

Cranial nerves

Table 8. Strategies to Assess Cranial Nerves in Newborns and Infantsfrom Bates Guide to Physical Examination and 2018 (in italics)

CN Strategy

II Have baby regard your face and look for facial response andtracking. Response to light while head is in midline.

II andIII

Darken room, raise baby to sitting position to open eyesUse light and test for optic blink reflex (blinking in responseto light). Use otoscope to assess papillary response.

III, IV,VI

Observe tracking as the baby regards your or mother’ssmiling face move side-to-side.

V Test rooting reflex. Test sucking reflex. Eye blinking asresponse after visual threat.

VII Observe baby crying and smiling, note symmetry of face andforehead.

VIII Observe response to sound, turning of the head to thesource. Test acoustic blink reflex (blinking of both eyes in

response to noise).IX, X Note the quality and strength of the cry. Observecoordination during swallowing.

XI Observe symmetry of shoulders. Observe head and truncalcontrol

XII Observe coordination of swallowing, sucking, and tonguethrusting. Pinch nostrils, and observe reflex opening ofmouth with tip of tongue midline.

V, VII,

IX, X,

XII

Observe how the patient sucks and swallows milk


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Notes from the videoNormal Term Newborn Inspection

Baby is awake, alert

CN 2 function intact: Baby able to follow examiner’s face.

CN 3, 4, 6 function intact: Baby able to track.

CN 7: symmetrical

Symmetry in movement of both hands

Examiner is trying to test for sensation of the face

Cranial Nerves, motor function and moro reflex

Baby extends hands

Legs are symmetrical

Asymmetrical tonic head reflex

Abnormal Newborns Inspection1. Normalo No facial symmetryo Arms are extendedo Abdominal breathingo But legs are in a flexed position

2. Abnormalo Baby with Down syndromeo Hypotonic

4 months

Smiling

No facial asymmetry

Symmetrical movement of hands and legs

Should already be able to turn over and lift the chest withhands when placed on a prone position

Figure 11. Sample picture of baby in prone position. (Not from video)

9 months (abnormal)

Hands are extended

Legs are in a frog-leg position, very weak

Unable to do pull-to-sit maneuver (head lag, arm justextend unable to flex to help achieve sitting position)

Presence of head lag when trying

Unable to follow things (normal)

Figure 12. Sample picture of baby with frog-leg position. (Not from

video)

Figure 13. Sample picture of baby with head lag during the pull-to-sit

maneuver. (Not from video)

18 months

Just crying

Reaching out hands

Poor head control, muscles look thin

Asked to take tape measure, but did not perform

Some inversion of foot

Unable to run, just sitting with assistance

4 year old

Able to go up and down the stairs without assistance

Able to throw a ball in hyperbolic direction (in contrast to 2yo who will just throw it downwards or release it)

Stage 2: Palpation and Manipulation – Ventral position

Motor function: Posture, tone, motor strength and

abilities, fine motor skills and handedness, visuo-motorcoordinationo Note: When testing for motor function, make sure that

the head is midline or else you might get falselyasymmetric results.

Developmental Reflexes and Deep Tendon Reflexes:keyword is symmetry. Use fingers to elicit reflexes! Lookat Appendix for more reflexes!

Cranial Nerves – refer to Table 8.

Cerebellar Function – use a toy in finger-to-nose testing,identifying his/her body parts.

Some notes:o Preterm

Prone – C-shaped spine, hypotonic Upper and lower extremities extended

o 6 mos Ventral suspension – the examiner suspends

infant in prone position by supporting abdomen ofbaby on his palm and assessing extension ofneck and flexion of extremities.

o 9 mos Pull-to-sit maneuver normal response: infant’s

head will follow and arms will flex to help pullitself up

In the video, there was head lag and extension ofarms.

o 18 mos In the video, the 18 month-old was unable to

maintain a standing position with an inversion offoot, which suggests a weakness in thehamstrings.

Figure 14. Sample picture of baby with in ventral position (Not from

video)

Figure 15. Sample picture of baby with normal pull-to-sit maneuver

response. (Not from video)

Stage 3: Intrusive Tests

Head circumference measuremento Perform twiceo Glabella and most prominent part of occiput

Fundoscopic examination and pupillary light reflex

Examination of the ears, mouth, throat, and teeth.

Examination of the anal sphincter reflex

Palpation of abdomen for hepatosplenomegaly

Stage 4: Maneuvers (Observation and Manipulation)

Motor functiono Gait and balance abnormalities – walk on toes,

walk on heels, stand on one feet, tandem gait,Romberg's test

o Motor strength – traction or pull to sit maneuver,parachute response, wheelbarrow maneuver,crawling

o Fine motor skills – test hand function (give child

crayon, observe how he grasps it while scribbling)


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Figure 16. Parachute reflex. This occurs in slightly older infants when thechild is held upright and the baby's body is rotated quickly to face forward

(as in falling). The baby will extend his arms forward as if to break a fall,

even though this reflex appears long before the baby walks

Figure 17. Palmar, Intermediate, and Pincer Grasps.

Sensory function

Notes from videoRett Syndrome

Loss of ability to use hands

A genetic disorder of neurodevelopmental arrest ratherthan a progressive process

Physical findings vary according to the clinical stage ofdisorder. Common findings include:o Stage 1: Gross motor delay, loss of eye contacto Stage 2: Autistic-like behavioro Stage 3: Hand stereotypies, rigidityo Stage 4: Dystonia, muscle wasting, quadriparesis

Teenager with Nystagmus

Has horizontal and lateral nystagmus

Tandem walk abnormal

Diagnosis: Cerebellar Tumor

Viral encephalitis

Mask-like facies

Dystonic gait when walking

Basal ganglia lesion

From 2017 The plantar response is plantar flexor in direction in all

children with normal CNS function. According to Paine andOppe, a bilateral Babinski sign is seen normally in themajority of 1 year old children and in many up to 2 1⁄2years of age but if asymmetrical, there is a problem

How to elicit: stroke the lateral border of the sole forwardcrossing over the distal end of metatarsals toward thebase of the great toe. You may use your thumb and applyfirm pressure (Nelson‟s) (Ma‟am mentioned on using abroken tongue depressor for this).

Normal (negative) response: plantar flexion

Positive Babinski reflex: Dorsiflexion of the big toe andfanning of the other toes. (Ma’am said if big toedorsiflexion was only observed, it’s considered positive)

Absence of Babinski in neonates is normal.

Notes from videos

Childhood cerebral palsyo

Spastic Hemiplegic Asymmetric legs Learn to walk on tiptoes as compensation Spasticity due to tightening of Achilles tendon

o Spastic Quadriplegic

Tightness of adductors Scissoring

3. Notes from BatesNeurologic Examination of Newborns and Infants

neurologic screening examination of all newborns shouldinclude assessment of:o Mental statuso Gross and fine motor functiono Tone

First by carefully watching their position at restand testing their resistance to passive

movement. Move each major joint through its range of

motion, noting any spasticity or flaccidity.o Cryo Deep tendon reflexes and primitive reflexes

If you suspect any abnormalities from the history orscreening, a more detailed examination is indicated.o Cranial nerve functiono Sensory functiono Less common primitive reflexes

V. IMPORTANT REMINDERS

Throughout the Examination, testing for mental abilities:

o Degree of alertness and interest in surroundingso Verbal and nonverbal language functiono Intelligence – ability to learn and follow instruction,

picture and object identification, memory andcalculation

Things NOT to do with Childreno Do not test the CORNEAL reflex for CN 5.o Do not GAG to test CN 9 and 10.o Do not inflict pain in sensory exam.o All of these are done only on a stuporous or a

comatose child.From 2018

Term Newborn

Behavior

Cranial nerves Resting posture

UE tone

Arm traction

Arm recoil

Scarf sign

Hand position

LE tone

Leg traction

Leg recoil

Popliteal angle

Heel to ear

Neck tone

Head lag

Head control Prone

Vertical and ventral suspension

Deep tendon reflex

Plantar reflex

Sucking and rooting reflex

Moro reflex

Stepping reflex

Grasping reflex

Head shape and sutures

Head circumference (last)

Six-month old infant

Behavior

Cranial nerves

Motor – sitting, hand, tone

Position – prone

Reflexes – deep tendon, plantar

Primitive reflexes – should be absent

Postural reflexes (refer to Appendix)

Head appendix

2 to 4 years old

Behavior

Motor tone

Fine motor coordination

Reflexes

Motor

VI. SUMMARY Neurologic exam should always be a part of the

developmental and routine evaluation of a child

The success in obtaining a good result is dependent onthe cooperation of the child

A significant part is made thru observation

Neurologic exam is NOT DIFFICULT to do!!

END OF TRANSCRIPTION

Hi! Let’s watch Mediscene! :D #detoxFrom Ma’am: http://library.med.utah.edu/pedineurologicexam


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VII. APPENDIX

Appendix A: Cheers1. Which of the following motor developmental milestones are expected to be performed by a 24-monthold child?

A. Walks up and down stairs one step at a timeB. Walks up and down stairs with alternating feetC. Stands on one footD. Imitates circular strokes

2. Which of the following motor developmental milestones IS NOT expected to be performed by a 36- month old child? A. Walks up and down stairs with alternating feetB. Rides tricycleC. Hops on one footD. Imitates circular strokes

3. What is the EARLIEST developmental age of a child who is able to do the following movements: stands with assistance and cruises aroundholding on to furniture, waves “bye-bye”, holds toys and transfers objects from one hand to the other?

A. 6-8 monthsB. 9-11 monthsC. 12-15 monthsD. 15-18 months

4. Which of the following primitive reflexes normally persists at 7 months of age A. Moro reflexB. Palmar grasp reflexC. Plantar grasp reflexD. Asymmetric tonic neck reflex

5. Which of the following reflexes is NOT expected in a normal newborn term baby? A. Positive supporting actionB. Placing reactionC. Cross extensor reflexD. Neck righting reflex

6. The following cranial nerves can be assessed by observing the patient’s ability to suck and swallow? A. Cranial nerves II, V, VII, IX, XB. Cranial nerves V, VII, IX, X, XIIC. Cranial nerves V, VII, IX, X, XID. Cranial nerves VII, IX, X, XI, XII

7. The following postural reflexes can be normally performed by a 6 month old child EXCEPT? A. Positive supportiveB. LandauC. Lateral proppingD. Parachute

Answers: A, C, B, C, D, C, D

Appendix B: Examining Newborns (Bates)

Appendix C: Developmental Milestones During Infancy


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Appendix D: Primitive Reflexes That Should Be Part of Routine Neurologic Examination of Infants (Bates)Primitive

ReflexFigure Maneuver Age Notes

PalmarGraspReflex

Place your fingers into the baby’s hands andpress against the palmar surfaces.

The baby will flex all fingers to grasp yourfingers.

Birth to3 –4 mos

Persistence beyond 4 mossuggests cerebral dysfunction.

Persistence of clenched handbeyond 2 mos suggests central

nervous system damage.

PlantarGraspReflex

Touch the sole at the base of the toes.The toes curl.

Birth to6 –8 mos

Persistence beyond 8 mossuggests cerebral dysfunction.

Moro Reflex

Hold the baby supine, supporting the head,back, and legs. Abruptly lower the entire bodyabout 2 feet.

The arms abduct and extend, hands open, andlegs flex. Baby may cry.

Birth to4 –6 mos

Persistence beyond 4 mossuggests neurologic disease;beyond 6 mos strongly suggestsit.

Asymmetric response suggestsfracture of clavicle or humerus or

brachial plexus injury.

AsymmetricTonic Reflex

With baby supine, turn head to one side, holding jaw over shoulder.

The arms/legs on side to which head is turnedextend while the opposite arm/leg flex.

Repeat on other side.

Birth to2 mos

Persistence beyond 2 mossuggests neurologic disease.

Positive

supportreflex

Hold the baby around the trunk and lower untilthe feet touch a flat surface.

The hips, knees, and ankles extend, the babystands up, partially bearing weight, sags after20 –30 seconds.

Birth or2 mosuntil

6 mos

Lack of reflex suggests hypotoniaor flaccidity.

Fixed extension and adduction oflegs (scissoring) suggestsspasticity due to neurologicdisease.

Appendix E: Additional Primitive Reflexes That Should Be Tested If Neurologic Abnormality is Suspected (Bates)Primitive

ReflexFigure Maneuver Age Notes

RootingReflex

Stroke the perioral skin at the corners of themouth.

The mouth will open and baby will turnthe head toward the stimulated side and suck.

Birth to3 –4 mos

Absence of rooting indicatessevere generalized or centralnervous system disease.

Galant’sReflex(Trunk

Incurvation)

Support the baby prone with one hand, andstroke one side of the back 1 cm from midline,from shoulder to buttocks.

The spine will curve toward the stimulated side.

Birth to2 mos

Absence suggests a transversespinal cord lesion or injury.

Persistence may indicate delayeddevelopment.

Placing and

SteppingReflexes

Hold baby upright from behind as in positivesupport reflex. Have one sole touch the tabletop.

The hip and knee of that foot will flex and theother foot will step forward.

Alternate stepping will occur.

Birth (bestafter 4days).

Variableage to

disappear

Absence of placing may indicateparalysis.

Babies born by breech deliverymay not have placing reflex.

LandauReflex

To test for the reflex, the doctor will hold theinfant face down horizontally. The baby's headwill raise up, while her trunk will be straight andher legs extended. When the doctor pushes thebaby's head downward, her legs should drop aswell. When the doctor releases the baby's head,both her head and legs should return to theiroriginal positions.

Birth to6 mos

Persistence beyond 2 mossuggests neurologic disease.


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ParachuteReflex

Suspend the baby prone and slowly lower thehead toward a surface.

The arms and legs will extend in a protectivefashion.

4 –6 mosand does

notdisappear

Delay in appearance may predictfuture delays in voluntary motordevelopment

Appendix F: Postural Reflexes

Appendix G: Ballard Score For Neuromuscular Maturity

The Ballard Maturational Assessment, Ballard Score, or Ballard Scale is a commonly used technique of gestational age assessment. It assigns a score tovarious criteria, the sum of all of which is then extrapolated to the gestational age of the baby. These criteria are divided into Physical and Neurological criteria.This scoring allows for the estimation of age in the range of 26 weeks-44 weeks.

Each of the above criteria is scored from -1 through 5. The scores were then ranged from -10 to 50, with the corresponding gestational ages being 20 weeks and44 weeks. An increase in the score by 5 increases the age by 2 weeks.


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Appendix H: Growth Charts


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Neurologic Evaluation of Children With Neurodevelopmental Disorders

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