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Pediatric Neurological Examination

  • Overview

    Our researchers are evolving increasingly sophisticated MRI technology that's helping us gain a better understanding of cognitive disorders in children.

    David K. Urion, MD, Director, Learning Disabilities/Behavioral Neurology Program

    The central nervous system (CNS) – brain and spinal cord – is a workhorse. It allows you to stay balanced in your chair, move your eyes across this sentence and understand the words you’re reading. It can also tell you that you’re chilly and need a sweater, alert you to the smell of something burning or help you catch a glass before it falls to the floor.

    That’s why your child’s doctor is careful to see if the CNS may be involved if your child is having symptoms like headaches or changes in her behavior, cognition or motor skills, or if she’s having changes in how she sees, hears, tastes, smells or responds to tactile sensations.In any of these cases—or any time her doctor thinks the brain, spinal cord, nerves or muscles may be affected—we may recommend a neurological exam.

    During a neurological exam, your child’s doctor observes her central nervous system in action. It’s a quick and most often painless series of “tests,” but it can provide us with a lot of information. We may test your child’s:

    • mental status
    • motor skills
    • sensory skills
    • balance and coordination
    • reflexes
    • functioning of the nerves

    These exams are most often painlessand are usually performed right in the doctor’s office.

    How Boston Children's Hospital approaches neurological exams

    The Department of Neurology at Children's is the oldest, largest and best-known program in pediatric neurology in the world.

    Our department includes child neurologists with special expertise in such areas as epilepsy, learning disabilities and other developmental disabilities, attention deficit disorders, sleep disorders, neuromuscular disorders, brain tumors, neurogenetic disorders, neonatal neurology, intellectual disability and cerebral palsy, pediatric neuro-immunology, and pediatric multiple sclerosis and related disorders, among other neurological disorders in children. You and your child are in good hands with us.

    Top ranking
    Boston Children's Hospital has been ranked #1 in Neurology and Neurosurgery by U.S. News & World Report.

    Neurological exam: Reviewed by David K. Urion, MD
    © Children’s Hospital Boston, posted in 2011

    Boston Children's Hospital 
    300 Longwood Avenue
    Fegan 11 and Hunnewell 2
    Boston MA 02115

     617-355-6388
  • In-Depth

    We understand that you may have a lot of questions when you learn that your child needs a neurological exam:

    • What is it?
    • Will my child need to be hospitalized?
    • Will it hurt?
    • What do the results mean?

    We’ve tried to provide some answers to those questions here, and your child’s doctor can talk more about the exam with you when you meet.

    What is a neurological exam?

    A neurological exam is a simple series of tests that allows your child’s doctor to watch her nervous system in action and can asses her:

    • mental status (level of awareness and interaction with the environment)
    • motor and sensory skills
    • balance and coordination
    • reflexes

    There are different parts to a standard neurological exam, and the ones that your child’s doctor focus on depends on factors including your child’s symptoms, age and health.

    Why does my child need a neurological exam?

    If your child’s nervous system isn’t working properly, it can cause delays in her normal development and functioning. Early detection means that we have a better chance of identifying the cause, quickly treating her and decrease the chance that she’ll have long-term complications.

    Your child’s doctor may request a neurological exam if your child:

    • complains of symptoms including:
      • headaches
      • blurry vision
      • fatigue
      • fever of unknown cause
      • change in balance or coordination
      • numbness or tingling in the arms or legs
      • decrease in movement of the arms or legs
      • tremor
    • has had an injury to her head, neck or back
    • is experiencing a change in behavior, or in balance or coordination
    • has any type of birth defect to her head or spine
    • is currently being treated for a disease or condition

    Neurological exams may also be performed during a routine physical exam, either right after birth, or later in childhood or adolescence, in order to investigate possible problems or rule something out.

    Where is the exam performed?

    They’re done right in a doctor’s office, usually a neurologist. If your child is in the hospital being treated for something else, it can often be done in her room, too.

    How long does the exam take?

    The first thing the doctor will do is talk to you and your child about her symptoms, in order to get a good idea of which areas to concentrate on. After that part, the actual exam takes about 30 minutes. 

    What happens during a neurological exam?

    Our pediatric neurologists talk to you and your child, and take your child’s medical history. Based on what we learn, we form theories about what may be causing the symptoms. Then, we perform a series of “tests” that let us do two things: gain more information about how your child’s central nervous system is functioning, and test the theories we’ve made from the interview.

    The most common neurological tests look at:

    1. Mental status. We’ll assess your child’s level of awareness and how she interacts with the environment. As you can imagine, the way we do this is highly dependent on her age. For older children, we ask them to follow directions or answer questions. For younger children, we watch how they interact with their parents.

    2. Motor function and balance. If your child is old enough, we may ask her to:

    • push and pull against the doctors hands with her arms and legs
    • hop, skip or jump
    • walk on tip-toes, walk on heels, walk on outsides of feet or walk on insides of feet
    • squeeze fingers
    • stand with her eyes closed while being gently pushed to one side

    We may check how her joints move. If your child isn’t old enough to follow instructions, we may just observe how she moves.

    3. Sensory perception. This examines your child’s ability to feel. We may touch your child's legs, arms or other parts of her body and have her identify the sensation (hot/cold, sharp/dull).  

    4. Reflexes. If your child is older, we examine her reflexes by gently tapping a small, soft reflex hammer on different points on her body.

    5. Cranial nerves. There are 12 main nerves of the brain, called the cranial nerves, each of which has a number. During a complete neurological exam, we evaluate most of them, but we may choose to concentrate on certain areas, depending on her symptoms. Here’s a breakdown of the cranial nerves, what they’re responsible for and how we test them:

    Cranial nerve(s) and number

    Helps with

    We may ask your child to

    olfactory nerve (I)

    • smell

     

    • identify different smells with her eyes closed

     

    optic nerve (II)

    • vision
    • identify letters, shapes or pictures on a chart
    • perhaps identify different colors

     

    oculomotor (III)
    trochlear nerve (IV)

    abducens nerve (VI)

    • moving the eyes
    • keeping them “connected,”
    • controlling the size of the pupil

     

    • use her eyes to follow a moving light or a moving finger while her doctor examines her eyes with a different light

    acoustic nerve (VIII)

    • hearing
    • balance

     

    • identify when she hears certain sounds

     

    glossopharyngeal nerve (IX)

    • taste
    • swallowing

     

     

    • identify different tastes placed on the back of her tongue
    • swallow while her doctor watches her palate moves

     

    trigeminal nerve (V)

    • touch
    • movement of jaw muscles

     

    • bite down while doctor touches different areas of her face
    • chew
    • close her jaw against slight resistance
       

    facial nerve (VII)

    • taste
    • movement of facial muscles
    • identify different tastes (sweet, sour, bitter)
    • smile
    • move her cheeks
    • show her teeth

     

    vagus nerve (X)

    • taste
    • movement
    • swallow
    • her doctor may use a tongue blade to elicit the gag response

     

    accessory nerve (XI)

    • movement
    • turn her head from side to side against mild resistance
    • shrug her shoulders

     

    hypoglossal nerve (XII)

    • movement of tongue
    • stick out her tongue
    • speak

     

    Can you give a neurological exam to an infant?

    Yes — newborns and infants have a special series of reflexes that we can test, including:

    • blinking—your infant will close her eyes in response to bright lights
    • Babinski reflex—as your infant's foot is stroked, her toes will extend upward
    • crawling—if your infant is placed on her belly, she’ll make crawling motions
    • Moro's reflex—a quick change in your infant's position will cause her to throw her arms outward, open her hands, and throw back her head
    • startle—a loud noise will cause your infant to extend and flex her arms while her hands remain closed in a fist
    • palmar and plantar grasp—her fingers or toes will curl around a finger placed in the area

    Each one of these reflexes disappear at a certain age.

    When do we get the results of the exam?

    Right after the exam. Your child’s doctor will talk with you about the initial hypothesis, what the exam showed, and what your next steps should be. The exam may indicate that another test is needed, such as a blood test, an MRI or a nerve conduction study. Your child’s doctor will be happy to answer any questions you may have.

    Better ways to look at kids’ brains
    Research led by P. Ellen Grant, MD, director of our Fetal-Neonatal Neuroimaging and Developmental Science Center, is building non-invasive imaging systems safe for preschoolers, babies and even fetuses still in the womb, which may allow us to detect injuries before delicate developing brains are irreversibly harmed.
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