{"id":60,"date":"2010-06-09T10:18:35","date_gmt":"2010-06-09T09:18:35","guid":{"rendered":"https:\/\/cloverock.info\/mockosce23\/new\/newborns-0-4-weeks-old\/"},"modified":"2023-01-11T23:59:11","modified_gmt":"2023-01-11T23:59:11","slug":"newborns-0-4-weeks-old","status":"publish","type":"post","link":"https:\/\/www.qpercom.com\/sim\/index.php\/the-neurological-examination\/newborns-0-4-weeks-old\/newborns-0-4-weeks-old\/","title":{"rendered":"Newborns: 0-4 weeks old"},"content":{"rendered":"<p><strong>Introduction<\/strong><br \/>\nJust as the neurological examination in adults is preceded by the history-taking, the neurological examination of a newborn should also be preceded by taking the history from a third party, enquiring about familial diseases, conditions that arose during the course of the pregnancy and any problems surrounding the birth.<br \/>\nTopical diagnostic work-up, in other words determining the site of a potential lesion in the peripheral or central nervous system by means of a neurological examination, is often not possible in a newborn. In a number of cases (for example, spina bifida or a brachial plexus lesion) this will, of course, be possible.<br \/>\nDuring the examination you should aim to answer the following question: \u2018Is there any sign of a nervous system condition?\u2019 Apart from focusing on a number of more or less visible morphological abnormalities, the examination should aim to rule out or demonstrate the following phenomena:<\/p>\n<ul>\n<li>increased, decreased or asymmetric sensitivity.\n<ul>\n<li>Are there any convulsions or tremors? For the latter,&nbsp;slow or rapid wide-amplitude tremors are particularly&nbsp;relevant as they may indicate increased sensitivity.<br \/>\nNB: convulsions are rarely complete in newborns, and&nbsp;often only consist of slow, stereotypical shock-like or&nbsp;twitching movements in part of a body (eyelid, hand, foot etc.).<\/li>\n<li>Has the threshold value or intensity of the reflexes&nbsp;increased, decreased or is it asymmetric?<\/li>\n<\/ul>\n<\/li>\n<li>increased, decreased or asymmetric motility.<\/li>\n<li>increased, decreased or asymmetric muscle tone.<\/li>\n<\/ul>\n<p>To be able to determine whether muscle tone, motility and reflexes have increased or decreased, it is essential to be experienced in the neurological examination of newborn infants.<br \/>\nYou should be aware that:<\/p>\n<ul>\n<li>in a newborn infant the central and peripheral nervous systems are still developing.<\/li>\n<li>the time the examination is carried out (particularly in relation to feeds) will affect your findings. A good time to carry out the examination is generally about 2 hours after a feed.<\/li>\n<li>a single examination is often not sufficient!<\/li>\n<li>observation is essential: you can learn a great deal about how the infant is functioning before you examine them, for example while taking the history from a third party.<\/li>\n<li>you should carry out the examination in a warm, well-lit, child-friendly environment.<\/li>\n<li>the position of the head can influence the posture and muscle tension of the limbs.<\/li>\n<\/ul>\n<h2>Procedure<\/h2>\n<p>The infant should be lying on their back.<\/p>\n<p><strong>Inspection<\/strong><br \/>\nHave the parent gently undress the infant, while you watch from a distance.<\/p>\n<ul>\n<li>The infant should be lying on their back, undressed.<\/li>\n<li>Note the condition of the infant during your examination:<br \/>\n1 = eyes closed, gentle respiration, no movements<br \/>\n2 = eyes closed, irregular respiration, gentle movements<br \/>\n3 = eyes open, minimal movements<br \/>\n4 = eyes open, active movements, not crying<br \/>\n5 = eyes open or closed, crying<br \/>\n6 = other, namely \u2026 (describe)<\/li>\n<\/ul>\n<p>Note the infant\u2019s condition should this change during your examination.<\/p>\n<ul>\n<li>Assess the shape and size of the head (microcephaly, macrocephaly, cephalohaematoma).<\/li>\n<li>Assess the position of the head and trunk (note any preferred position e.g., torticollis, fixed head posture or extension of the neck and back, opisthotonus).<\/li>\n<li>Assess the shape and position of the eyes and ears (epicanthus, hypertelorism, low-set ears).<\/li>\n<li>Assess the colour of the skin and sclerae (jaundice).<\/li>\n<li>Assess the size and clarity of the cornea (glaucoma).<\/li>\n<li>Assess the position of the eyes (strabismus).<\/li>\n<li>Look for signs of nystagmus.<\/li>\n<li>Assess the shape and size of the pupils. If the infant\u2019s eyes are closed, you will have to carefully open them, without exerting pressure on the eyeball.<\/li>\n<li>Note the spontaneous motor function. Assess whether the right and left arms and legs move to the same extent and are held in roughly the same position when the head is lying is a straight position.<\/li>\n<li>Check whether the hips are flexed and in maximum abduction (hypotonia). Assess whether the infant is hypotonic (premature, essential hypotonia, neuromuscular condition, metabolic disorder, diffuse cerebral conditions).<\/li>\n<\/ul>\n<p><strong>Circumference of the head<\/strong> [Figure 104]<\/p>\n<ul>\n<li>Measure the occipitofrontal circumference. Compare your findings with the graph [Figure 105].<\/li>\n<li>If the infant is premature, base your measurement on the full-term date.<\/li>\n<\/ul>\n<p><span class=\"jce_caption\" style=\"display: inline-block;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-48\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-104.jpg\" alt=\"\" width=\"400\" height=\"299\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-104.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-104-300x224.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><span style=\"width: 400px; display: block;\">Figure 104<\/span><\/span><\/p>\n<p><span class=\"jce_caption\" style=\"display: inline-block;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-49\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-105.jpg\" alt=\"\" width=\"400\" height=\"604\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-105.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-105-199x300.jpg 199w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><span style=\"width: 400px; display: block;\">Figure 105<\/span><\/span><\/p>\n<p><em><strong>Resistance to passive movements (head held in midline position)<\/strong><\/em><br \/>\nThe resistance upon passive movement should be examined while the baby is in<br \/>\nstate 3 or 4.<\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li>Take hold of the baby\u2019s hands and gently bend and stretch the infant\u2019s elbows a number of times. Assess the resistance or muscle tone. Take hold of the infant\u2019s feet and gently bend and stretch the legs at the hips and knees a number of times.<\/li>\n<li>Assess the resistance or muscle tone.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><em><strong>Reactions to stimuli<\/strong><\/em><br \/>\n<em>Pupillary light reaction<\/em><br \/>\nIt is not advisable to shine bright light directly into a newborn\u2019s eyes to assess the pupillary reaction. Unless the infant is blind, they will close their eyes tightly in a reflex reaction.<\/p>\n<ul>\n<li>Briefly cover the eye with your hand. Then remove your hand and note the pupillary contraction of the previously covered eye, as well as the indirect reaction in the other pupil.<\/li>\n<li>Compare left and right and note any asymmetry.<\/li>\n<li>The corneal reflex (refer to&nbsp;&#8216;The cranial nerves&#8217;).<\/li>\n<li>The rooting reflex (see here under), normally only present in infants up to 4-6 months old.<\/li>\n<\/ul>\n<p>At this point you can also examine the baby\u2019s palm creases. Look for a continuous palm crease. This is not proof of a congenital abnormality, but does constitute a strong indication of one. If the baby\u2019s fists are clenched, you can easily open then by stroking the ulnar side of the back of the hand or by flexing the wrists. The baby will usually open their hands by themselves.<br \/>\nThe biceps reflex, the triceps reflex, the abdomen reflex, the patellar reflex and the Achilles reflex can be elicited in the same way as for a (supine) adult. The optimal condition for examining these is state 3 (open eyes, minimal movements). Note the threshold value and any extension of the reflexogenous zones.<\/p>\n<p><em><strong>The rooting reflex<\/strong><\/em><br \/>\nUsing your finger stroke along the patient\u2019s mouth a few times [Figures 106, 107].<br \/>\nThe patient will seek your finger with their mouth and try to take it in their mouth.<\/p>\n<p><span class=\"jce_caption\" style=\"display: inline-block;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-50\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-106.jpg\" alt=\"\" width=\"400\" height=\"299\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-106.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-106-300x224.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><span style=\"width: 400px; display: block;\">Figure 106<\/span><\/span><\/p>\n<p><span class=\"jce_caption\" style=\"display: inline-block;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-51\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-107.jpg\" alt=\"\" width=\"400\" height=\"299\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-107.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-107-300x224.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><span style=\"width: 400px; display: block;\">Figure 107<\/span><\/span><\/p>\n<p><strong><em>The sucking reflex<\/em><\/strong><br \/>\nThis is normally only present in infants up to 11-12 months old. Once the patient finds your finger, they will suck on it [Figure 108].<\/p>\n<p><span class=\"jce_caption\" style=\"display: inline-block;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-52\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-108.jpg\" alt=\"\" width=\"400\" height=\"299\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-108.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-108-300x224.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><span style=\"width: 400px; display: block;\">Figure 108<\/span><\/span><\/p>\n<p><strong><em>The palmar grasp reflex<\/em><\/strong><br \/>\nThis is normally only present in infants up to 5-6 months old.<\/p>\n<ul>\n<li>Place your finger firmly in the patient\u2019s open hand, from the ulnar side<br \/>\n[Figure 109].<\/li>\n<li>The patient will bend their fingers and firmly grasp your finger.<\/li>\n<\/ul>\n<p><span class=\"jce_caption\" style=\"display: inline-block;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-53\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-109.jpg\" alt=\"\" width=\"400\" height=\"299\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-109.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-109-300x224.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><span style=\"width: 400px; display: block;\">Figure 109<\/span><\/span><\/p>\n<p><em><strong>The plantar grasp reflex<\/strong><\/em><\/p>\n<ul>\n<li>Firmly press a thumb or finger on the ball of the baby\u2019s feet [Figure 110].<\/li>\n<li>Note whether all toes make a grasping movement.<\/li>\n<li>Look for any left \/ right differences again.<\/li>\n<\/ul>\n<p><em>If these reflexes are found in an adult patient, they indicate diffuse cerebral conditions. These reflexes should only be examined in adults if you have reason to suspect the presence of cerebral conditions.<\/em><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-54\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-110.jpg\" alt=\"\" width=\"400\" height=\"299\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-110.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-110-300x224.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><br \/>\n<span class=\"jce_caption\">Figure 110&nbsp;<\/span><\/p>\n<p><em><strong>The Babinski\u2019s reflex<\/strong><\/em><\/p>\n<ul>\n<li>Using a semi-sharp object such as your thumb nail, stroke the lateral edge of the foot starting at the heel and ending at the little toe. Look for dorsal flexion of the big toe and spreading apart of the other toes (Babinski\u2019s reflex).<br \/>\n<em>Note:<\/em> bilateral absence of this reflex as an isolated finding does not indicate pathology; note any left\/right differences in particular [Figure 111].<\/li>\n<\/ul>\n<p><span class=\"jce_caption\" style=\"display: inline-block;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-55\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-111.jpg\" alt=\"\" width=\"400\" height=\"299\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-111.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-111-300x224.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><span style=\"width: 400px; display: block;\">Figure 111<\/span><\/span><\/p>\n<p><em><strong>Ankle clonus<\/strong><\/em><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li>With your thumb on the ball of the baby\u2019s foot, quickly push the ankle into dorsal flexion and keep it in this position for a few seconds. If a clonus of a few beats is present on both sides, there is no pathology. A persistent clonus is, however, pathological.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><em><strong>Head balance<\/strong><\/em><\/p>\n<ul>\n<li>Bring the baby into the sitting position by pulling it up by its wrists from a supine position until it is sitting [Figure 112].<\/li>\n<li>Assess whether the infant\u2019s head follows reasonably well when the baby is raised upwards.<\/li>\n<li>Provide good support.<\/li>\n<li>Assess whether the infant is able to keep the head more or less straight for at least three seconds.<\/li>\n<\/ul>\n<p><em>NB: head balance is poor for the first three days, but after this time the infant should be able to carry out this test.<\/em><\/p>\n<p>Now place the baby on their stomach<\/p>\n<ul>\n<li>Now carefully inspect and palpate the back.<\/li>\n<li>Look for any dimples and swellings.<\/li>\n<li>Note the head movements. After the first few days, the infant is able to lift their head for a few seconds now and again. If the baby can hold their head up for longer than 10 consecutive seconds, hypertonia may be present. A hypotonic baby will not lift their head at all.<\/li>\n<li>Look for crawling movements with the arms and legs. If you do not see any spontaneous crawling movements, these can be stimulated by pressing your thumb against the infant\u2019s soles. If concomitant pressure is exerted against both soles, the baby will stretch both legs at the same time and push forwards (Bauer\u2019s reflex) [Figure 113].<\/li>\n<\/ul>\n<p><span class=\"jce_caption\" style=\"display: inline-block;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-56\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-113.jpg\" alt=\"\" width=\"400\" height=\"299\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-113.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-113-300x224.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><span style=\"width: 400px; display: block;\">Figure 113<\/span><\/span><\/p>\n<p>A normal baby should be strong enough to move their body along.<br \/>\n<em>NB: Both crawling movements and head movements will, of course, only be visible if the baby is in state 4 or 5.<\/em><\/p>\n<p>Now lift the baby up [Figure 114].<br \/>\nThe infant should be lying on their stomach across the examiner\u2019s hand or hands.<\/p>\n<ul>\n<li>Note whether the infant tries to raise their head. In the case of a hypotonic baby, the head will hang down limply and their arms will be stretched out.<\/li>\n<\/ul>\n<p><span class=\"jce_caption\" style=\"display: inline-block;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-57\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-114.jpg\" alt=\"\" width=\"400\" height=\"299\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-114.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-114-300x224.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><span style=\"width: 400px; display: block;\">Figure 114<\/span><\/span><\/p>\n<p><em><strong>The Moro reflex<\/strong><\/em><\/p>\n<ul>\n<li>Place the baby in an almost sitting position, supporting the head. Make sure the head is in the neutral position. The arms and legs should be flexed symmetrically [Figure 115].<\/li>\n<li>Ensure that the infant can freely move their arms and that the head is kept straight (if the head is even just slightly turned, it can result in asymmetrical arm movements).<\/li>\n<li>Now suddenly drop the hand on which the baby\u2019s head is resting by about 10 cm and abruptly stop the falling motion.<\/li>\n<li>Under normal circumstances, the infant will abduct both arms, stretching the elbows and fingers. This should be followed by gentle adduction of the arms and flexion of the elbows and fingers [Figure 116]. Complete abduction and extension may indicate hypotonia, while very brief abduction and extension indicates hypertonia.<\/li>\n<li>Note the threshold value. A low threshold may indicate increased sensitivity.<\/li>\n<li>Look for any tremors during abduction.<\/li>\n<\/ul>\n<p>The Moro reflex is best seen in a normal child in state 3 or 4.<\/p>\n<p><span class=\"jce_caption\" style=\"display: inline-block;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-58\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-115.jpg\" alt=\"\" width=\"400\" height=\"299\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-115.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-115-300x224.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><span style=\"width: 400px; display: block;\">Figure 115<\/span><\/span><\/p>\n<p><span class=\"jce_caption\" style=\"display: inline-block;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-59\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-116.jpg\" alt=\"\" width=\"400\" height=\"299\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-116.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-116-300x224.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><span style=\"width: 400px; display: block;\">Figure 116<\/span><\/span><\/p>\n<h3>Interpretation<\/h3>\n<p>Newborns are often examined routinely. The aim of this examination is to rule out genetic abnormalities or those incurred during pregnancy or birth. If the results of the examination described above are good, a condition involving the peripheral or central nervous system can, for the time being, be ruled out. Should you find anything slightly different to the norm, you should be aware that a one-off examination is often not sufficient. You should examine the infant again at a later stage. If the abnormalities are persistent, further specialist diagnostic examinations are usually essential.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Introduction Just as the neurological examination in adults is preceded by the history-taking, the neurological examination of a newborn should also be preceded by taking the history from a third party, enquiring about familial diseases, conditions that arose during the course of the pregnancy and any problems surrounding the birth. Topical diagnostic work-up, in other [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[14],"tags":[113],"class_list":["post-60","post","type-post","status-publish","format-standard","hentry","category-newborns-0-4-weeks-old","tag-the-neurological-examination"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Newborns: 0-4 weeks old - Qpercom | Skills in Medicine<\/title>\n<meta name=\"description\" content=\"Online Mock OSCEs with examiners, patient actors, instant results and personalised feedback. 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