neuro exam cctp papp 1-8-2019

1

Newborn Neurological Assessment

Elizabeth Papp, MSN, RN, CNS, FNP

Content Credit & Gratitude: Sue Peloquin, MS, RN, PNP

October 12th, 2018

2

Objectives

•Review components of the newborn neurological assessment

• Identify normal findings

• Identify abnormal findings

• What do these findings mean?

Value of the neonatal neurological examination

1. Detect lesions in the CNS

2. Detect lesions in the peripheral nervous system

3. Determine severity of abnormalities

4. Confirm a baby is/isn’t at risk on admission

5. To evaluate change in clinical status

6. Planning investigations/follow up

7. Predict outcomes/Parental counseling

3

Anatomy!

4

Anatomy!

5

What do we mean when we say WNL?

▪ Alert without irritability, jitteriness, or lethargy

▪ Responds appropriately to stimulation

▪ Absence of seizure activity

▪ Cry is present without hoarseness, shrillness, or weakness (or infant is intubated)

▪ Face symmetrical

▪ Moves all extremities equally and spontaneously

▪ Moro, grasp and suck reflexes are present

▪ Pupil reaction is brisk, pupil size is WNL

▪ Absence of neuro drains or monitoring devices

6

Before starting your neuro exam…▪ Gestational age at birth

▪ Gestational age now

▪ Head circumference at birth

▪ Head circumference now

▪ Head shape/sutures

▪ Dysmorphisms

▪ Respiratory support

▪ Medications

▪ Encephalopathic

7

Normal Newborn Exam

8 Newborn Neuro Exam - Normal

Systematic Neurologic Exam

9

Neonatal Neurological Assessment

General appearance

Mental status

Cranial nerves

Motor exam

Reflexes

Coordination

Sensory

Wt, Lth, HC, dysmorphismWakefulness, behaviorPupils, grimace, gag, reflexesBulk, power, toneDeep tendon & primitiveGeneral movementsLight touch, pain, temp

General Appearance

▪ Appearance: remove infant’s covers without awakening and observe the patient for:

• Weight/length proportion for gestation

• Head shape and size

▪ State

▪ Skin

▪ Dysmorphic features

▪ Symmetry

11

General Appearance

12

General Appearance

13

14

Cortical Thumb

15

Port Wine Stain

Café Au Lait

16

Sacral Skin Tag

17

Sacral Dimple

18

Head

19

Full term head circumference = 35 cm +/- 2 cm

20

Hair Whorl

21

Sutures and Fontanelles

• There are a total of 6 fontanelles

• Palpate anterior and posterior fontanelles as part of your neuro assessment

• Fontanelles are commonly used to evaluate ICP

• Size in newborns is quite variable

Bulging Fontanelle

22

Head Shapes

23

Sagittal Craniosynostosis

24

Microcephaly

25

Macrocephaly

26

27

Hydrocephalus

Hydrocephalus means water on the brain• An accumulation of CSF due to impaired flow, reabsorption or

excessive production

Symptoms• Increasing head circumference• Full/bulging fontanelle• Split sutures• Setting sun sign• High shrill cry

Treatment• Shunting

Caput vs. Cephalhematomavs. Subgaleal bleeds

28

29

Caput vs. Cephalohematoma


General appearance

Mental status

Cranial nerves

Motor exam

Reflexes

Coordination

Sensory


Assessment of Mental Status

31

Best time to examine an infant is in between feeds

Arousal can be assessed by:• Spontaneous eye opening• Movements of the face and extremities• Response to stimulation

Irritable- agitated and cries

Lethargic – cannot maintain an alert state

Jitteriness (Tremulousness)

Excessive Arousal

32

• Jitteriness (Tremulousness)

• Can be seen in normal children

• More frequently seen in babies with:

– Encephalopathy

– Drug dependent mothers

• May distinguish from seizures with EEG/aEEG

• Features are less common that seizures

– Provocation by stimulation

– Absence of eye movements

– Lack of change in respiratory pattern

33

Mental Status

Factors affecting assessment of mental status

• Infant State

• Gestational Age

• Illness

• Medications

34

Mental Status: Gestational Age

• Gestational age is an important factor

• 28 weeks = more prolonged periods of quiet alert activity

• 32 weeks = sleep-wake cycling begins to occur

• 36 weeks = very clear state changes


General appearance

Mental status

Cranial nerves

Motor exam

Reflexes

Coordination

Sensory


Cranial Nerves

Cranial Nerves

Cranial Nerve Exam - Newborn

Cranial Nerves

Abnormal Cranial Nerve Exam

CN VII

• Controls movement of the face

• Most common cause of facial asymmetry

• Birth related damage to CN VII (facial nerve)

• Muscles in the forehead and eyelids may be affected

• Facial asymmetry is evident without baby crying

Cranial Nerve VII

Vision…CN II, III, IV, VI

▪ 26 Weeks – infant blinks to light

▪ 32 Weeks – Light provokes eye closure; roving eye movement

▪ 34 Weeks – 90% infants track a fluffy red ball

▪ 37 Weeks – Infant will turn toward a soft light

▪ 38-49 Weeks – Visual Fixation and Following are well developed

Eyes… CN II, III, IV, VI

▪ Eyes – forced closure of eyelids is common

▪ Most newborns open eyes spontaneously to suck

▪ Ocular alignment in the newborn is poor

Dysconjugate

Dysconjugate eye movement

Doll’s Eyes

Normal

Persistent Eye Deviation

▪ Seizures

▪ Eyes deviate in the direction of the seizing side

▪ Stroke

▪ Eyes can deviate in the opposite direction of the weak side

▪ Can be associated with visual field defect

▪ Severe hydrocephalus

▪ Setting sun sign

▪ Medication effects

▪ Nystagmus

CNIII and Pupils

• Normal: 2-3cm, brisk equal reaction to light

• Abnormalities

• Encephalopathy

• Drug exposure

Visual functioning and GA• Eye opening (from 25 weeks

GA)

• Fixing (from 32 weeks GA)

• Following (from 34 weeks GA)

• Pupillary responses to light (~33-35 weeks GA)

Sucking & Swallowing

▪ At what gestational age do infants start to coordinate their suck, swallow and breathing?

48


General appearance

Mental status

Cranial nerves

Motor exam

Reflexes

Coordination

Sensory


Muscle Tone

▪ Tone is the resistance to stretch

▪ 2 kinds

• Phasic tone (deep tendon reflexes)

• Postural tone- trunk and limbs letting themselves be maintained against gravity

‒ Important to think of GA and state

Postural Tone

Maintenance of tone requires an intact:

• Central Nervous System

• Peripheral Nervous System

• If decreased:

• Trunks and limbs cannot maintain themselves against gravity

• Infant appears hypotonic

Hypotonia

• Common symptom of neurological dysfunction

• Occurs in diseases of

• Brain

• Spinal Cord

• Peripheral Nerves

• Neuromuscular Junctions

• Muscles

Normal toneGeneralised

hypotonia

Abn. tone distribution: flexed arms,

ext. legs

Normal tone Generalised hypotonia Increased extensor tone

The picture can't be displayed. The picture can't be displayed.

Traction Response

The picture can't be displayed.

Head Lag

Hypotonia

Hypertonia

• Less common finding in the neonate

• If present, passive manipulation of the limbs increases the tone.

• Opisthotonus (marked hypertonia) can be seen with severe HIE, tetanus, bacterial meningitis

Marked Hypertonia


General appearance

Mental status

Cranial nerves

Motor exam

Reflexes

Coordination

Sensory


Developmental Reflexes

Reflex Onset

Suck 28 weeks

Rooting 28 weeks

Palmar Grasp 28-32 weeks

Tonic Neck 35 weeks

Moro 28-32 weeks

Stepping 35-36

Truncal incurvation 28 weeks

Babinski 34-36 weeks


General appearance

Mental status

Cranial nerves

Motor exam

Reflexes

Coordination

Sensory


Abnormal Neurological Exam: Causes

▪ Hypoxic Ischemic Encephalopathy (HIE)

▪ Infection

▪ Perinatal Stroke

▪ Intracranial Hemorrhage

▪ Congenital Brain Malformations

▪ Inborn Errors of Metabolism

▪ Genetic Brain Malformations

▪ Drug Exposure

Pain?

64

What if something is abnormal?

▪ Up to 1/3 of well babies have some “abnormal” findings

• Important to do a thorough exam!

▪ If more than 2 abnormalities, do a full neuro exam

▪ If more than 3 abnormalities on full exam:

• Repeat at another time

• Consider neuroimaging

• Discuss a neuro consult

65

Competent Neonate

References

▪ Volpe, JJ, Neurology of the Newborn, Philadelphia, PA. W.B. Saunders, 2008

▪ Fenichel GM, Neonatal Neurology, Philadelphia, PA. Elsevier 2007

▪ Shellhaas et. al. Clin Neurophysiology 2007; 118: 2156-2167

▪ Silverstein, F.S., Jensen, F.E. Annals of NeurologyVol 62 (2) 2007

▪ Stanford University

▪ University of Utah

neuro exam cctp papp 1-8-2019

Documents