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Neurological Examination of Newborns

Period of newborn is the postnatal period from


birth up to first 28 days.
Development of nervous system begins from 23 weeks from fertilization.
On the 4th month of embryonal development
the topographic structures of brain is
completed, but formation of the biggest gyrus
and sulcus lasts till 7-8 months.

At the period of birth the only completely


developed structures are thalamopallidar
system and vestibular system ( On the 6 th
month of intrauterinal period).
In spite of this, the myelinization of newborn
brains certain structures is not finished.
For instance, mielinization of pyramidal tract
finishes at 2-3 months from birth, but
structural maturity occurs at the age of 7-8
years.

Differentiation of CNS: Growth,


development of dendrites endings and
interneuronal synapses is extremely
intensive at the age of first 3 months.
The newborn is examined and assessed
by neurologist:
In maternal house.
When they leave maternal house in the
case of complicated history.
After managing pediatrical problem if
pediatric considers that complete care
of this
newborn requires
neurologists participation..

Pediatric needs to apply for neurologist when:

Newborn has problem of falling asleep or


maintaining this sleep, he is excited and has
excessive crying.
If the newborn has frequent jerks ( Hands, legs,
body parts)
If newborn is extremely sensitive to environment
temperature ( In the case of raising temperature
newborn is extremely hot, has excessive
sweating).
If the newborn is floppy and hypotonic
( Hypotonia of extremities, hypermobility, has
problems of awakening, is easily tired, and sleeps
when eating).

If pediatric or mother notice the


strange fixation of gaze, arresting of
activity, episodes of apnoe
accompanied with vegetative
changes and cyanosis, strange
movements like eastern greeting
( Salaami).
Neurologist starts to assess the
newborn by means of sophisticated
anamnesis, which is gathered from:
Parents
Nurse
Caregivers

Course of pregnancy

The quantity of pregnancy and delivery.


Presence of pregnant toxicosis or
eclampsy, signs of placentar defficiency.
Somatic diseases of pregnant, especially
viral infection accompanied by hypoxy
and intoxication, Lysteriosis,
Toxoplasma, Mycoplasma.
If the pregnant needed treatment with
antibiotics, immunosupresive drugs,
sedative drugs.
Maternal psychiatric trauma.
Maternal social and ordinary conditions
( Use of alchohol or drug addiction).

The important issues when


gathering family history are:
Congenital disorders, like
autosome-dominant, autosomerecessive, chromosome-linked.
Neuropsychiatric disorders.
Psychomotor development of
parents.

Course of delivery
Rapid delivery
If drug stimulation or surgical
implication was conducted.
Newborn was born full term or
preterm or was excessive fetal
maturity.
If newborn cried at the moment
of the birth.
His/her condition ( weight, sizes)

Course of initial period of newborn


When was brought to maternal
breast
The presence of jaundice and its
duration
When he/she leaved maternal
house.
If he/she tries to hold head
If parents noticed smiling,
bubbling sounds, fixation of gaze.

When making case history neurologist tries


to observe newborns consciousness,
expression of face, mimics, reaction to
enviroment.
Neurologist has to take into consideration
the condition of newborn: If he/she is just
awakened, if he/she requires feeding.
By observation easily can be recognized:
Hydro, -mycrocephaly.
Flattening of skull bones.
Prominent skull bones.
Expression of venous system.


A)
B)
C)
D)
E)

Congenital defects like:


Hernia of brain
Hernia of spinal cord
Palsy of Plexus Brachialis
Carpopedal Spasms
Hand of obstretric.

Very important is to give an attention to mild


developmental anomalies so called
Dysembriogenic stigmas:
Microphtalmy
Epicantus
Deformation of ear or its atopic location.
Anomalies of fingers and toes.
Gothic high palatinum
Polymorphic tongue
Hemangiomas on various parts of body
(especially head and so on)

From anthropometric evidences


neurologist needs to assess skulls sizes:
The circumference of head is identified
between most prominent point of
occipital bone and forehead up to
eyebrows.
The head circumference in full term
infants is 34-36 cm.
The head circumference increases by 11.5 cm in first months of life. Thus, by
the end of the year the head is 46 cm.

Reflexes
The only reflexes which newborn
have are those the reflex arch of
which is closed in spinal cord
and basal ganglias and they are
called unconditioned reflexes.
Stable automatisms, those which
exist lifelong: corneal,
conuctivalis, pharynx,
swallowing, sneezing, tendon
( knee, elbow, achilevsis).

Transitory, which reflect the specific


level of development of motor
centers. They gradually dissapear.
Oral segment automatisms.
Spinal segment automatisms.
Myelencephalic positonic reflexes.
Mesencephalic automatisms
Mesencephalic automatisms appears
after birth. Thus it doesnt exist in
every newborn Labyrinthe, neck
and body simple and chain reflexes.

Stable automatisms
Full term infants have well developed
feeding, sucking and swallowing reflexes.
Feeding reflex is such strong that it creates
feeding dominant in cortex. Thats why
during feeding all other motor reactions
controlled by cortex are inhibited. This
reflex is not developed only in very severe
preterms.
Stable automatisms are: corneal and
conuctival reflexes. Newborns can also
have Peipers reflex
( irritation by
strong light causes pupillar constriction,
closing of eyes and extension of head).

Oral Segment Automatisms


Reflex of seeking
Reflex of sucking
Elephant trunk reflex
Oropalmar reflex ( Reflex of
Babkin)

Spinal Segment autotaisms


Moro reflex
Grasping (Robinsons) reflex
Climbing ( Bauers) reflex
Paravertebral ( Galants) reflex- irritation
of paravertebral from neck to coccygeal
area causes arch like flexion of body,
sometiemes with extension of legs.
Vertebral (Peress) reflex- irritation of
vertebral column from coccygeal area to
neck causes:
lumbar lordosis, flexion of arms and legs,
involuntary urination and defecation ( It
diseapears at age of 4 months).

Khvosteks sign: knocking at the


cheek by neurological hammer
causes constriction of nose,
mouth and eyes muscles.
Heel ( Arshavsky) reflex:
pressing on heel causes
constriction of face muscles
( Disseapears at 5-6
months).
Standing reflex.
Reflex of automatic stepping.

Mesencephalic automatism reflexes


Labyrinthe reflex
Neck symmetric tone reflex
Neck asymmetric tone reflex
Body pose maintaining reflex- standing
on surface ( table) causes correction of
head and body ( expresses after 1 month
from birth).
Landau upper reflex- when lying on the
abdomen infant tries to raise head, chest
and support on the surface by hands. He
can maintain this pose for several
minutes. ( Reveals from 4 months)

Landau lower reflex- when lying on the


abdomen infant tries to flex legs and
raise them ( reveals from 5-6 months).
Neck simple and body direction reflex
rotation of head causes rotation of body
in the same direction- at first chest and
then lower part of body. ( This reflex
can be elicited at the moment of birth
and then became stable).
Chain direction reflex- rotation of arms
causes rotation of body and lower
extremities ( appears at age of 6-7
months).

Babinski reflex
Kerningi sign ( it seems to be
normal sign before 4 month of age).
Examination of reflexes gives us an
information about the state of CNS.
If these reflexes exist at the age
when they have not to be it indicates
on the pathology of CNS.
Abnormality is also if they are
absent at the age when they have to
be.

Examination of cranial nerves.


Nervus olfactorius doctor gives to
infant various substances with
different smells
( rose, almond), which dont irritate
nasal cavities. In newborns
neurologist can notice the changes of
mimics and emotions.
Nervus Ophtalmicus- In newborns
assessing of this nerves is conducted
by shining objects when newborn
fixes the gaze.

Nervus oculomotorius, nervus trochlearis


and nervus abducens. Doctor assess
functions of these nerves by shining
objects and newborn tries to follow this
object left, right, up and down.
Nervus trigeminalis damage of the first
branch causes disseapearance of corneal
reflex, damage of the second branch
causes disseapearance of sneezing reflex,
demage of the lower branch causes
disseapearance of the tasting on the 2/3
front part of tongue, but detection of this
disturbance is difficult in newborns.
Damage of motor part of this nerve results
in dusturbance of chewing.

Nervus Facialis neurologist assesses


mimic muscles, closing and opening of
eyes, closing and opening of mouth.
Vestibular nerve Doctor is ringing a
bell, which causes jerking of newborn.
Nervus glossopharyngeus, nervus
vagus and nervus hypoglossus. Damage
of these nerves cause bulbar palsy,
which can be revealed by difficulties of
swallowing.
Damage of nervus accesorius causes
lower position of arm and signs of
muscle atrophy.

Laboratory approaches of
investigation of nervous system.
Analysis of blood sample on
bacterias and viruses.
Analysis of blood on metabolic
processes.
Biochemical analysis of urine.
Genetic investigation
Bacterial-viral analysis of CSF.
Biopsy of neural tissue.

Instrumental approaches of
investigation of nervous system

Ophtalmological
Audiometry
Neurosonoscopy
Echoscopy
EEG
X-Ray
EMG
Angiography, myelography
CT
MRI

Ophtalmological Approaches
In newborns the mostly used method is
investigation of eye fundus.
As a result neuroophtalmologist can see
haemmorages, neuritis of disc of
ophtalmical nerve, intracranial
hypertension, revealing by oedema of disc,
widening of venous system, nerve atrophy
( color loss of disc, reducing of size).
Otoneurologic investigation- assessing of
hearing in newborn by means of
audiometry.

Neurosonoscopy-is method by which


radiologist conducts scanning of
brains structure, sizes of
ventricles, echogenity of CSF, also
it helps to detect hypoxy,
hemmorage, leikomalacy,
inflammation, development defect,
hypertension, calcification of
brain.
Ultrasound Dopplerography- helps
to investigate vessels of the brain.

Electroencephalography ( EEG)- is an
extremely valuable method to identify
epileptic seizures and mental
retardation signs as well. In recent
years the researchers started to use it
for evaluation of brain death in order to
stop artificial respiration and
emergency help in terminal stage
patients.
Craniography- serves to detect
congenital and acquired defects of
skull: micro,- and macrocephaly,
craniostenosis, intracranial
hypertension.

CT is high sensitive method. It


shows brain slices in various
projections. It is very valuable in
different neurological diseases
such as ischemic brain lesions,
hemmorages, abscesses,
atrophy, edema, tumors.
MRI- is more sensitive method
than CT, which helps to detect
different cerebral and spinal
diseases.

Analysis of CSF
Is extremely informative in certain
neurological diseases. The
important characters are
transparency, color, pressure,
inclusion and number of cells,
proteins, glucose, chlorides.
Sometimes neurologist needs to
identify bacteries and viruses in
CSF.

After using all these methods and


assessing approaches experienced
neurologist can make precise
diagnosis and plan of effective
treatment.
If newborns condition requires
additional assessing of different
profile doctors he/she has to inform
parents or other caregivers or in the
case if neurologist exclude
neurological disturbance, it is
obligatory to identify which profile
doctor is needed.