Hammersmith Neonatal Neurological Examination NAME _ Posture and tone __ SEX__ RACE. 0.0.8. EEEcE POSTURE ame & Legs slightly flexed | legs well flexed | legs well flexed & | abnormal posture: note arms. a Score predominant aa mee xc let |e et ee extend arms parallel to the rot completely forcefully body, Count to three. Release. Repeat 3 times. $ 4. 6 exion of arms ‘AR TRACTION arms remain parm flex slighty [arm ex wall farms fox at approx Hold wrist and pull arm | straight orsome shoulder its, | 400" & maintained. | c100"; maintained Upwards. Note flexion at |R2resistance fot [resistance ft | then straighten [as shoulder ito | when body ls up elbow and resistance vile } t i t + shoulder lifts off table. @©LA Ou Gen Test each side separately. R tir LR tir LR L LEG RECOIL No flexion incomplete or ‘complete but ‘complete fast flexion | legs difficult to Tako both ankles in ono vrarabe lesion | slow flexion extend: snap back hand, flex hips + knees. Quickly extend. Release. Repeat 3 times. ron O~ fh a forcefully LEG TRACTION Grasp ankle and slowly pull eg upwards. Note flexion at knees and resistance as butlocks lift Tags straight - no resistance felt Tags fax slightly resistance felt Tage Tex well i bottom lifts up Tee foxes remains flexee when botiom up t R L Tevion says when backsbotiom up hi t = rsctonceaspatoact | © 1 | Of as R LiR L Rx L behind the ankle. Note 180 =150" =90" <90° HEAD CONTROL (T) [rose [eer at [arereae [aera Infant sitting upright. ‘seen back may wobble feck ease. | g e HEAD CONTROL (2) ‘no attempt to | infant wies: effort | raises head but | raises head: head upright or Pull infant towards sitting | Stays back but it drops back | slightly body body frists & support head ny Oa a ay” Oy ‘VENTRAL SUSPENSION [back curved, | back curved, ] back slightly | back straight, head | bacYtraight, flexion of limbs, and relation of head to trunk. If itlooks different, DRAW. MO 2) Ore Ove =,Hammers Nera Nelo Exainason 2 Tone patterns FLEXOR TONE (1) ‘score for arm [score for arm | score Tor arm flexion | Soore for arm flexion {on traction: arm versus leg) flexion less than flexion equal to | more than leg flexion | more than leg flexion Compare scores of arm leg flexion leg flexion but difference 1 but difference more traction with log traction. column or less than 1 column. FLEXOR TONE (2) jarms and legs | strong arm flexign | sirong arm flexion (arm versus leg) floxed with strong leg vith strong log Posture in supine, coxtension ‘extension intermittent continuous LEG EXTENSOR TONE ‘sbr6 orleg tadlon [soar TorlBg wacton | score forleg raion score for eg acon ‘Compare scores of leg more than score for Jequalo score for |iees than score for less than score foe traction and popitoal angle popiteat angio popliteal angle | popliteal ange, by Popel ange, by {column only mare than 1 column NECK EXTENSOR TONE score forhead | score forhead [score for head score for head (sirine) extension less | extension equal | extension more than | extension more than ‘Compare scores of head than head flexion |to head flexion | head flexion. but | head flexion but ‘control t and 2, difference 1 column | difference more than | or less ‘column INCREASED EXTENSOR score for ventral_ [Score for ventral_| score for ventral | score for ventral TONE (HORIZONTAL) suspension less_| suspension suspension more _| suspension more Compare scores of head lag than head lag | equal to head lag | than head lag but | than head lag but and ventral suspension difference 1 column | difference more than or less, 4.columa, Reflexes TENDON REFLEX absent [felt not seen seen “exaggerator™ conus Test biceps, knee, and ankle (very brisk) jerks. SUCK7GAG ‘no gag no | weak inegular | weak regular suck [strong suck mo suck Little finger into mouth with | suck ‘suck only (a) iregular but strong clenching pulp of finger upwards, (0) regular ‘No stripping _| Some stripping _| Good stripping PALMAR GRASP no short, weak — | strong flexion of | strong finger flexion, | very strong grasp; Putindex finger into the [response [flexion of | fingers. shoulder f infant can be ited off hand and gently press fingers, couch palmar surface. Do not touch dorsal surface. Test each side separately, _|R. |r ula Lr u_|r L PLANTAR GRASP 0, partial plantar | toos curve around Press thumb on the sole | response _| flexion of toes | the examiner's, bolow the toes, finger Test each side separately. _| R lr ula L PLACING. no dorsiflexion of [ful placing Lift infant in an upright response ankle only | response with position and stroke the flexion of hip and dorsum of the foot against a knoe & placing protruding edge of a flat sole on surface surface. Test each side separately. _|R tle a L MORO REFLEX no full abduction | full abduction, | parlial abduction at | + minimal abduction or One hand suppors infant's | response, | at shoulder | but only delayed | shoulder, and adduction hhead in midline, the other the | or opening | and extension | or partial extension of arms | « no abduction or back. Raise infant to 48° and |of hands of the arms; | adduction followed by smooth | adduction; only When infantis relaxed let [only no adduction adduction, forward extension of head fail through 10°. Note i arms, jerky. ‘+ marked adduction Repeat 3 times, only or «Movements ‘Hemmer Neonatal Newlogical Examination p3 ‘SPONTANEOUS wo movement [sporadie and | requont solatod | raquont ganoralized [continuous MOVEMENT (quantity) shortisolated |moverents | movements exaggerated Wetch infant ing supine movements movements SPONTANEOUS ‘nly Sivaishes [stretches and | luent movements | fluent alfemaing | cramped, MOVEMENT (quality) random abrupt | but monotonous | movements of arms |” synchronized: Watch infant lying supine movements; + legs: + mouthing some smooth good varibity | jery or other movements onormal movements HEAD RAISING PRONE |7io response infant rolls head | infant raises chin | Infant brings head [infant brings head Infant in prone, head in over, chinnot frolishead over and chin up Up and keeps It up midline raised Abnormal signs/patterns "ABNORMAL HAND OR Tiands open, toes [ntamientfising [continuous fatng or [continuous big TOE POSTURES ‘straight most of | or thumb ‘thumb adduction; toe extension or the time adduction index ingerlexion, flexion ofall toes thumb opposition TRENOR no Wemor, of | wemor frequent tremors | continuous tremor only when | occasionally | when awake tremors crying or only | when awake ator Moro refox STARTLE Ti Starla |no spontaneous 2-3 spontaneous | more than 3 continuous evento | startle but roacts | startles spontaneous startles | startles sudden noise [to sudden noise Orientation and behaviour EYE APPEARANCES —_| does not Tull conjugated eye transient persistent open eyes movements, + nystagmus + nystagmus + strabismus + strabismus * roving eye + roving eye movements movernents + sunset sign abnormal pupiis ‘AUDITORY To reaction | auditory startle; | shifting of eyes, | prolonged head tum tums head (erkiy, ORIENTATION brightens and |head might tum | to stimulus; search abruptly) & eyes: Infant awake. Wrap infant, sti;no true towards source | with eyes; smooth _ [towards noise Hold rattle 10 to 15 om orientation every time from ear. VISUAL ORIENTATION [does not _|siils, focuses, | follows horizontally | follows horizontally | follows ina Wrap infant, wake up with |follow or | follows briefly to | and vertically; and vertically; turns | circle rattle if needed or rock |focuson | the side but | no head tum hoad gently, Note ifbaby can | stimuli loses stimuli see and follow red ball (B) or target (1) B T IB tle T t |e T "ALERTNESS: wil not when awake, | when awake, looks ‘does nat tre Tested as response to. | respond to _| looks only briefly | at stimuli but loses. | stimuli (hyper-reactive) visual stimuli (8 oF 7) stimu them IRRITABILITY quiet allthe awakes, cies | cries often cries always: ‘ios even when In response to stimuli. | time, not_—_| sometimes when | when handled when handled not handled initable to | handled any stimuli ‘CONSOLABILITY not erying; | eries briefly, eries; becomes cries; needs picking | cries; Ease to quiet infant ‘consoling not | consoling not | quiet when talked | up to be consoled | cannot be needed needed to consoled CRY no ery at all [whimpering cry | cries to stimuli but High-pitched cry; only normal pitch often continuous ‘SUMMARY OF EXAMINATION: HEAD AND TRUNK TONE: LIMB TONE: MOTILITY: REFLEXES: ORIENTATION AND ALERTNESS: IRRITABILITY: < CONSOLABILITY: LIST DEVIANT SIGNS:HAMMERSMITH SHORT NEONATAL NEUROLOGICAL EXAMINATION y A wane C008 _ No, OF EXAM aly Dos. DOE, AGE: GA. ‘SEX____._BW:, e a POSTURE fogs sigh ]iegs wo toned log wl nod & [aero Tom fame Rea Baby lying on back. Look extended” foxed but not addueted | adcuctodnoar’ legs very mainly at positon of the belly ended legs, but also note arms. You may change drawing. oOo "ARM RECOIL Trmdoes not farm flexes | armfioros | am foros and [arnaifoutTo Quick extend fox siowiy, not slowly, more | remains flexed | extn snap back (etraighten) both arms; put always. not | compotely foroetiy rnext to body. Count to completely two. Let go. Repeat 3 times. 'ARM TRACTION famTomans” Porm foxes [arm floxes wat | arm exes and [arn maine Hold wrist and pul staight-nosighty or some | ti'shouder its, | remaine loxed as | fexed wnen body Upward. Note flexion at Jfesistance” resistance fet |then stalgntons | shouderits | sup am. andressance we | yA. Shouldr its of table. Ox Qe LEG RECOIL incomplete [completo siow | compota fast | ogo afc to Take both ankles, bend flexion, not every | exon fleton tntend: snap back hips+knee. Quickly extend time forcefully. ‘when infant not pushing, a<¢ Let go. Repeat X 3 ©—wv LEG TRACTION Teg svaign no] log fexes sight | fog faxes wall | nee exes | fosion says when Hold ankle, pul leg resistence Por some bottom ts up |romaino flexed | backsbottom up upwards. Look at flexion & resistance as bottom pulled up. resistance felt al ‘when bottom up POPLITEAL ANGLE Fix knee on abdomen (belly), try to extend knee with first finger. Note distance (angle) between al oo PR. as Or as upper and lower limb. =150" = 110" HEAD CONTROL (1) ant safer | loo adios oad Baby sitting upright. better felt than | drops forward or | remains vertical, Encircle chest with both seen back ‘wobbles, hands hong shoulders Let head drop forward. HEAD CONTROL @ [roatenplio [nant ie: oft favo head but [ras hoa’ [Read pitt or Baby stung upright” [reotead” [botorlot ian" |aropottreaeor [romain verca, | wensed eonot Encircle chest with both [seen bback wobbles be passively hands holding shoulders. flexed (pushed Let head drop backward. forward) HEAD LAG [head drops & {tries tolifthead | able to lifthead | lifts head in tine | head in front of Pultbabyte shby the |toyobecr [outaepe bec [sion wag [Bea nists & suppor head Sight OY Oy ay QQ VENTRAL SUSPENSION [DaTemen [pac cavoa, —[oaccaigniy [back araignt packs, Holdbabyhorzontal [heasé tree [roadrime feavearimts [hessisievan [head ate boy Rang sagt Pouginjtores | fox body ns Hox under the belly. Look at posture of back, arms, legs, and head. if it looks different, DRAW! 3 Ore OpsMOVEMENTS ‘SPONTANEOUS MOVEMENT. Watch baby while (s)he is lying on back. no movernent few stretches, Ino other movement jetky movement, stretches, but also some ‘smooth movement ‘smooth arms + legs movements of Tits, cramped or other abnormal movements: front of the baby’s lower Jeg on edge of table. ABNORMAL HAND OR [hands open | hands fisted or ‘TOE POSTURES thumbs adduct intermittently but ‘open TREMOR ‘no tremor tiemor only some tremor when crying or | when awake after Moro reflex STARTLE no startle startle to sudden |2 or 3 Similar movements to noise or bang on | spontaneous | Spontaneous _| spontaneous Moro reflex but not doing table startles starties startles Moro test REFLEXES = test both sides [Suck & GaGa Ino gag/no | weak suck only: infant sucks well [strong suck: | no suck Walch on breast; ifno J suck (@)iregular ~~ onthe breast | (a) irregular | but strong suck is seen, put litle () regular ()regular | clenching finger into mouth with pulp No stripping Good stripping cof finger upwards. PALMAR GRASP no reaction short, weak | strong flexion of | strong finger | strong finger Stoke inside of hand. flexion of fingers | fingers flexion, flexion, whole DONOT TOUCH BACK shoulder t | body 1 OF HANDI! PLANTAR GRASP ‘no response | toes flex (bend) [Toes curve Press on sole below toes, slight around finger MORO REFLEX Roresponse full abduction of ull abduction, | arme donot | adduction Put baby in position shown the arms, litle or delayed | fully abduct but | only in drawing 1 below. Bring fextension at the | adduction good adduction |+ extension at head forward and elbow, no the elbow only suddenly let it fall back adduction 7 C8 [O86 188 PLACING Tothing baby flexes | baby flexes hip, Hold infant upright. Stroke | happens ankle knee, and ankle & stops on table ORIENTATION AND BEHAVIOUR EYES does nat open | normal eye fabnormal eye eyes ‘movement, eyes | movements: move together [DESCRIBE ‘AUDITORY ORIENTATION [noreaction brightens Tums eyes and | turns eyes and | turns head and Must not be asleep. Wrap (wakes up) sometimes tums |head fully to | eyes strongly infant. Hold rattle 10-15 headabit also |side of noise | to noise; does ‘om (4-6 inches) from ear. not tire VISUAL ALERTNESS — [does not follow J stils, focuses, _ | follows with eyes | follows with | follows ina | Wrap infant, wake up with Jorfocus on red follows very | to the side and | eyes to the side | circle rattle if needed or rock ball or target briefly to side | up, may tum _| and up; tums baby a bit. Look if baby and up but loses | head head always ‘can see and follow red ball it quickly (R) ora target (1). R TI tT IR tlr T ‘ALERTNESS jwhen awake, |when awake, | keeps interest | does not tire Tested as response to red looks only brietly | looks at red ball in red ball ball (R) or target (1). How but loses it long infant interested. R T R t_ Ip 1 |p Tr PEAK OF EXCITEMENT awakes briefly, | awakes briefly, |eries always | cries always Circle "H" i high-pitch cry does not cry | cries sometimes | when handled 4 H H H ‘CONSOLABILITY awake but never [becomes quiet | needs picking | cannot be” | How easy is it to make ries, consoling | when talked to | up to console _| consoled baby quiet? not needed COMMENT: EXAMINER: Marmmrsmt Set Naot NowolaalExaninaton 2HAMMERSMITH INFANT NEUROLOGICAL EXAMINATION Name: Date of birth: Gestational age: Date of examination: SUMMARY OF EXAMINATION No of asymmetries in section 1: Neurological items score: Behavioural score: COMMENTS: Cranial nerves functions Posture Movements Tone Reflexes and reactions Behaviour SECTION 1 : NEUROLOGICAL ITEMS Assessment of cranial nerve function ‘column + (score 2) [c. 2 (ec. 1.8)| column 8 (score 1) [column 4 (ecore 0) | A [comment] Facial appearance ‘smiles or reacts ‘loses eyes but not tightly; | expressionless, (atrest and when to stimul by closing ‘poor facial expression does not react crying or stimulated) _| eyes and grimacing to stimuli Eye appearance ‘normal conjugated intermittent continuous ‘eye movements, deviation of ayes or | deviation of eyes or abnormal movements _| abnormal movements ‘Auditory response | reacts fo stimuli on Toubtiul reaction to stimull] does not react test the response to both sides ‘or asymmetrical to stimuli rattle or bell Visual response [follows the object fora Tollows the object for an | does not follow test the abilly to follow a | complete arc incomplete arc, the object red ball or moving object or asymmetry ‘Sucking/swallowing | 900d suck and ‘poor suck andlor who sucking reflex, watch the infant suck on swallowing ‘swallowing no swallowing breast or bollec column (SORA) [| CP EELS) | columns eaore 1) | colin 4 esore O) A Head in sitting zz Caan oe) Or; strat I slighty to side orbackward | markedly to side or backward cece ‘or forward or forward, Trunk ining e € Ox. straight slightly curved or very rocking _bent bent to side rounded “back _ sideways “Arms slight marked aitee! in neural poston internal rotation or intemal rotation or conta, extemal rotation extemal rotation or straight or sghty bent dystonic posture hemiplogis posture _| Hands intermittent. persistent hands open adducted thumb adducted thumb or fisting or fisting Legs Die to a wih aaigt Siiwievaight back but | unable st shaight unos inating back, and legs knees bent at 15-20" knees markedly bent straight or sgt bent (no lng sting) tong sting) in supine and slight marked in standing legsinnouial | internat | intemal rotation or intemal rotation or positon rotation or | “extemal tation extemal rotation stralght or extemal at hips or slighty bent — | rotation {xed extension oF texon or contractures at hips and knees Feet aight marked jin supine and central; in neutral internal rotation or intemal rotation or in standing poston ‘extemal rotation extemal rotation atthe ankle intermittent persistent tendency to stand on | tendency to stand on tiptoes Tploes: or or toes straight midway toes up or toes up or between flexion and curling under curling under ‘extension Movements Quantity wath infant normal excessive or minimal or lying in the ‘sluggish none supine i ‘Quality > erampad & synchronous free, Jerky, * extensor spasms: aternatng, sight tremor 2 athetois ‘smooth * giaxe + very tremulous + myoclonic spasm dystonic Henmesrth nant Neola! Eniatin 92Tone column (score 2) 0.2 (50.4.5) ‘column 3 (score 1) column 4 (score 0) [Al Scarf sign Take the infant's hand and pull the arm across the chest nti there is resistance. Note the postion ofthe elbow. Range: & RL ROL § RoL & 5 Passive shoulder elevation Lift arm next to the infant's head. Note resistance at shoulder and elbow. Tesistance, but 8 ROL ho resistance B ROL Tesistance,nat overcome ‘6 Rent Pronation/supination ‘Steady uppor arm while pronating and supinating forearm. Note resistance. Tull pronation and supination, no resistance, Tull pronation and ‘supination but resistance to be Tull pronation and ‘supination not possible, ‘marked resistance ‘Adductors With the infant's legs extended, ‘open them as far &s possible. The angle formed by the legs is, noted Range: 150°-60" 150-160" Ret >170" <0" Popliteal angle Logs are flexed at the hip simultaneously on tothe side of the abdomen, then extended at the knee until there is resistance. Note angle between lower and upper leg. 750-160" ON RL 4 Rate aat ome RL Pulled to sit ul infant to sit by wrists, On Ventral suspension Hold infant in ventral ‘suspension; note position of back, imbs, and head Oye OY Oi Reflexes and reactions Tendon Reflexes easily elctabie biceps knee ankle rilldly brisk bicknee ank risk biceps knee ankle ‘lonus or absent bicops kno ankle ‘Arm protection ull the infant by one arm from the supine position and note the reaction of the opposite side, arm & hand extend Re arm semiiexed One arm fully flexed Vertical suspension Hold infant under axilla. Make sure legs do not touch any surface, Ba kicks symmetrically BB kicks one leg more, or oF no kicking even if poor kicking stimulated, cnsussorra Tateral ting (describe side up). Infant held vertically, Gar sake ohacona no Ons] Gea pio, ibs, and Read R ciao son ufor L Forward parachute Infant hel vertcaly snd or o<~ Suddenly tted forward Note reaction of th arms (ater 6 months) (ater 6 months) « onmosmth fan Newolgcl anion 93SECTION 2: MOTOR MILESTONES Head tunable to WwoDDIeS all the time control ‘maintain maintained head upright upright (normal <3 | (normal at 4 mo) | (normal at 5 mo) mo) cannot sit_ | sits with support props: Stable sit Pivols (rotates) | Obseved: at hips 2 g. SB Reported (age): (normal at 4 mo) | (normal at 6 mo) | (normal at7-8 mo) | (normal at’8 mo) Voluntary | nograsp | uses whole hand | index finger and | pincer grasp ‘Observed: grasp thumb but immature grasp Reported (age): ‘Ability to | no Kicking | Kicks horizontally | upward Touches leg Touches toes | Observed kick legs do not lift (wertically) (in supine) ard oX aX Reported (age): (normal at 3 mo) | (normal at 4-5 mo) | (normal at 5-6 mo) Rolling ‘no rolling | rolingto side | prone to supine | supine to prone Observed: Reported (age): (oormal at 4mo) | (normal at mo) | (normal at mo) Crawling | doesnotlift’ | onelbow | on outstretched | crawing flat on | crawiing on hands | Observed: head hand ‘abdomen and knees a 9 One | GT [once (normal at3 mo) _| (normal at 4mo) | (normal at 8 mo) _| (normal at 10 mo) Standing | doesnot [auppors weight [stands wih [stands unaided ‘ObsaT tepport ‘support weert Reported (age): (0ormalat 4 me) | (normal at 7 mo) | (normal at 12 mo) Walking Bouncing cruising walks | walling Onsen holding on) | indopendeatiy Reported (age): (normal at 6 mo) | (normal at 12 mo) | (normal at 15 mo) SECTION 3: BEHAVIOUR 1 2 3 4 5 6 Comment State of Sleepy but | awake but | loses | maintains anseousrens unrousabie | drowsy | wakes easily | no interest | interest | interest Emotional state initable, Titable neither | happy, initable, not | mothercan | when happy or | smiling consolable_| console _| approached | unhappy Social orientation | 2voiding, | hesitant |~ accepts | friendly withdrawn approach Score for behaviour: