Neurodevelopmental Examination

Neurodevelopmental Examination Component What to do/rationale Wash hands Introduce Basics Consent Stand to the right side Sitting in parent’s lap Comment on alertness Distress Colour Pink -> perfused Responsiveness General Inspection Posture and movements Movements should be symmetrical Dysmorphic features Look for head size and shape Listen for cooing or babbling Adjuncts Ask for vitals Ask for percentiles Percentiles Comment on percentiles Hold a red ball or a bright coloured toy 30 cm away from the eyes Track slowly at both directions Before three months babies will only move their eyes After three months they will move their heads Tests for smooth pursuit and saccadic movements Object tracking and shifting focus Ensures both eyes are working together effectively Abnormalities Strabisumus/eye misalignment Struggle with maintaining fixation on a moving object One eye drifts or fails to track correctly Double vision Eyes look at different directions at the same time Closes one eye or tils head to one side Can be seen in: Cerebral palsy (affects muscle control of the eyes) Down syndrome -> weaker eye muscle coordination Hydrocephalus -> excess fluid in the brain -> impacts nerves controlling the eyes Brain tumours -> damages brainstem or CNs Congenital eye muscle abnormalities -> underdeveloped eyes Premature birth complication Nystagmus/involuntary eye movement Rapid, uncontrolled eye movements when attempting to follow a target May be jerky or oscillatory Difficult to maintain focus Can be seen in: Congenital diseases -> infantile nystagmus Horizontal vision Hydrocephalus or brain tumours Optic nerve hypoplasia, congenital cataracts or albinism Acquired causes: head trauma, medication side effects, inner disorders (BPV of childhood disorders), vestibular neuritis, labyrinthitis, perilymph fistula etc. Vertical vision Babies can track vertically after three months Best performed with the child in the parent’s lap Assistant to stand behind infant and hold a bell 40cm from one ear at a time Ask assistant to ring bell without letting infant know and test their response Test both sides Note if the child’s expression changes or turning to the sound Distract the child with any toy that does not make noise Done to: Assess auditory function Evaluate neurological development Detect early signs of hearing impairment Screen for under developmental disorders Direction testing for Can be seen in: hearing Congenital hearing loos Auditory neuropathy spectrum disorder Sound signals not well transmitted from the ear to the brain ASD Atypical response to sound Central auditory processing disorder Affects how the brain interprets sound Neurological disorders Cerebral palsy, hydrocephalus Impact sound processing and responsiveness Ear infections or fluid accumulation Chronic otitis media First look at the natural posture of the hands For the first two months their hands should be clenched. After 2 months this primitive reflex should resolve and the baby’s hands open -> ready to use them Up until 6 months the right thing to use is a raddle Should be presented in midline Test both hands together and then each hand Hold a bright coloured toy out to the child Let the child grasp the toy Assess for – pincer, palmar, transfer and asymmetry Palmar grasp is the focus in infants Pincer grasp Develops -> 9 to 12 months Small objects such as a raisin or bead Observe it child can pick it using the thumb or index finger Tests for fine motor control and hand-eye coordination Look for delayed or absent NMJ disease Cerebral palsy Spinal muscular atrophy Charcot Marie Tooth disease Congenital hand abnormalities e.g. radial dysplasia or hypoplastic thumb Transfer of objects between hands Develops between 6 to 9 months Give the child an object and watch if they transfer it from one hand to the other Reflects bilateral coordination and cognitive processing Fine Motor Skills May be due to: Cerebral palsy Hemiplegia -> due to perinatal stroke ASD – motor planning and coordination Congenital hand conditions Tests for axial tone of the neck and back and appendicular tone of the shoulder and arms Comment on head lag and sitting balance Newborns had a head lag Head falls backwards instead of following movement smoothly Should not be present after 2 to 3 months Use corrected age for premature infants -> may have a lower tone than term infants If there is too much head lag support their head with one of your hands Causes Cerebral palsy Hypotonia -> down syndrome, Prader Willi syndrome and neuromuscular disorders Spinal muscular atrophy -> progressive muscle weakness Prematurity related developmental delays Weak or absent resistance Little effort in pulling self-up Causes Pull to sit Neuromuscular -> DMD, SMA Metabolic diseases -> e.g. mitochondrial diseases Congenital myopathies Asymmetry in movement One side weaker or more delayed Causes Brachial plexus injury Hemiplegia Cerebral palsy Excessive stiffness or rigidity Spastic cerebral palsy Hypertonia -> brain injuries or genetic disease Metabolic disease Floppy or hypotonic posture SMA, DMD, congenital myopathy, MG (congenital or juvenile) Baby develops postural responses to maintain their body in an upright position The first is the forward prop Sitting Balance Develops at 6 months If the baby is placed in a tripod position they can maintain their balance for a short bit -> HENCE SHOULD BY AWAY FROM THE BED Stops the baby falling side to side Lateral props Usually appears at 7 to 8 months Gently rocking the baby from side to side Gives idea of the head control and appendicular strength In severe hypotonia child adopts a floppy C shape There may be hypertonia in children with cerebral palsy Assess neck and trunk tone Place baby in prone position Observe head position, back and extremities Ventral suspension Head should stay in the same plane as the back The back should show some resistance to gravity and not be draped over the hand on the chest The extremities should maintain some flexion tone and not dangle in extension By 4 months the baby should be holding their hand in the plane for their body. The baby may be hypotonic and unable to maintain their posture If they may be hypertonic in which case, there is back arching Hold baby in upright position with feet off the ground by placing the hands under the arms and around the chest The baby should be suspended in this position without position without slipping through the hands of the examiner If there is a should gridle weakness -> arms extend upwards, and examiner will have to reposition tier grasp of the baby to avoid baby slipping through their hands Should be in flexed position: This is the default -> they should be in flexed position The ankles and the knees in flexed position Baby should also be pushing down through their shoulders A baby that is hypertonic is quite heavy because they fall through the shoulders Vertical suspension Assesses: Grindle strength Muscle tone Postural reflex Screen for muscular disorders Hypotonia or hypertonia Slipping though hands -> may indicate hypotonia If there is hypertonia they should feel heavy Asymmetry in posture Brachial plexus injury or hemiplegia from perinatal stroke Standing response Normally appears at 6 months – baby can beat weight through straight legs Tummy time pose Child’s hands placed palms down on the bed with either side of the shoulders with elbows flexed. Idea of head control, appendicular tone and strength. Assesses for neck and upper body strength Prone Position Poor head control Hypotonia, down syndrome or SMA At 4 months – up on flexed forearms At 6 months -> up on extended forearms Once can do that -> that is the beginning of their first roll Also known as occipital-frontal circumference Measuring tape around the most prominent aspect of the frontal and occipital bones Most accurate measurements obtained with plastic tape rather than paper tape as paper can stretch Should be plotted on standardised head growth chart for the appropriate gender Measure three times Give the largest measurement Done for: Monitoring brain growth Detect abnormalities Screen for neurodevelopmental disorders Tracks growth trends Abnormalities Microcephaly Genetic conditions MCPH, Seckle syndrome, Rett syndrome, Angelman syndrome Intrauterine infections Toxoplasmosis Head Circumference Syphilis Varicella Parvovirus B19 Rubella CMV HSV Perinatal brain injury Macrocephaly Brain tumours Hydrocephalus Genetic conditions: Benign familial macrocephaly, megalencephalic, PHTS, sotos syndrome, Weaver syndrome, NF1, fragile X syndrome