What is the template for performing a comprehensive neurological exam on pediatric patients across different age groups, including babies (0-12 months), toddlers (1-3 years), school-age children (4-12 years), and adolescents (13-18 years)?

Comprehensive Neurological Examination Template for Pediatric Patients by Age Group

Babies (0-12 Months)

Initial Assessment Components

Begin with growth parameters (weight, length, head circumference) plotted on appropriate growth charts, assessing overall appearance, activity level, and interaction with caregivers 1, 2. For premature infants, correct for gestational age by subtracting weeks born early from chronological age for all developmental assessments through at least 24 months 2.

Neuromotor Examination

• Evaluate passive and active muscle tone by assessing resistance to passive movement in all extremities, noting any asymmetry or abnormal patterns 1, 3.
• Test primitive reflexes including Moro, palmar grasp, plantar grasp, rooting, sucking, tonic neck, and stepping reflexes, documenting presence and symmetry 1, 4, 3.
• Assess deep tendon reflexes at biceps, triceps, knees, and ankles, noting symmetry and intensity 1, 3.
• Examine sensory status by observing responses to light touch and painful stimuli across all dermatomes 1.
• Evaluate quality of gross motor skills including head control, rolling, sitting balance, and spontaneous movements 1, 3.

Cranial Nerve Assessment

• Perform red reflex testing bilaterally using direct ophthalmoscope to detect ocular media abnormalities 2.
• Conduct Brückner test to assess symmetry of red reflexes 2.
• Examine pupillary responses to light, noting size, shape, and reactivity 2.
• Assess fixation and following behavior by moving a target horizontally and vertically 2, 3.
• Inspect external ocular and periocular structures for abnormalities 2.
• Examine tympanic membranes for appearance and mobility 2.
• Assess nares for patency and any discharge 2.
• Examine oral cavity including palate integrity, tongue movement, and gag reflex 2, 3.

Developmental Milestone Verification

• At 2 months: Verify ability to lift head and chest in prone position, make eye contact, and demonstrate social smiling 2.
• At 3 months: Apply Hammersmith Infant Neurological Examination (HINE), with scores <57 being 96% predictive of cerebral palsy 1.
• By 9 months: Document ability to sit independently; inability warrants standardized investigations 1.

Red Flags Requiring Immediate Investigation

• Inability to sit independently by 9 months 1.
• Asymmetry in hand function at any age 1.
• Inability to bear weight through plantar surface of feet when supported 1.
• Poor eye contact after 8 weeks 2.

Feeding and Autonomic Assessment

• Evaluate feeding patterns including suck-swallow coordination, choking episodes, and weight gain trajectory 1, 2.
• Assess for gastroesophageal reflux and constipation 5.

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Toddlers (1-3 Years)

Comprehensive Developmental Assessment

Monitor multiple domains including cognitive, gross motor, fine motor, communication, adaptive skills, and social/behavioral interactions 1. The American Academy of Pediatrics emphasizes rigorous vigilance for autism spectrum disorder in this age group 1.

Neurological Examination

• Assess gait pattern including base of support, arm swing, toe/heel walking, running, and ability to jump 4, 6.
• Evaluate coordination through finger-to-nose testing (modified for age), rapid alternating movements, and stacking blocks 6, 7.
• Test muscle strength by observing functional activities like climbing stairs, rising from floor, and lifting objects 6.
• Examine muscle tone in upper and lower extremities, noting any spasticity, rigidity, or hypotonia 6, 8.
• Document deep tendon reflexes and plantar responses, noting that extensor responses may still be normal in early toddlerhood 4, 8.

Cranial Nerve Examination

• Assess visual acuity using age-appropriate methods (fixation preference, picture cards) 4.
• Test extraocular movements in all directions, noting any strabismus or nystagmus 4, 8.
• Evaluate facial symmetry during spontaneous expression and voluntary movements 4, 8.
• Assess hearing through behavioral audiometry or formal testing if concerns exist 1, 4.
• Examine speech articulation and language comprehension appropriate for age 5, 1.

Behavioral and Cognitive Screening

• Use standardized measures providing scores in cognition, receptive language, expressive language, fine motor skills, and gross motor skills 1.
• Document quality of spontaneous motor behavior including fluency, variability, and complexity of movements 6.
• Assess cooperation during examination, as noncooperation is associated with increased risk for learning and behavioral problems at school age 6.

Adaptive Function Assessment

• Evaluate daily living skills including self-feeding, dressing attempts, and toileting readiness 1.

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School-Age Children (4-12 Years)

Systematic Neurological Examination

Formal neuropsychological assessment is strongly recommended for all children with risk conditions, with reevaluation approximately every 3 years due to complex and changing developmental profiles 1.

Mental Status and Cognitive Assessment

• Use Cornell Assessment of Pediatric Delirium (CAPD) as primary neurological screening tool, performing assessments at least twice daily in hospitalized patients, with scores >8 indicating delirium 9.
• Evaluate attention, memory, and executive function through age-appropriate tasks 1, 7.
• Assess language domains including comprehension, expression, and pragmatic skills 5, 1.

Cranial Nerve Examination (Systematic I-XII)

• CN I: Test smell recognition with familiar scents 4.
• CN II: Assess visual acuity, visual fields by confrontation, fundoscopic examination for papilledema (high-grade papilledema stage 3-5 indicates Grade 4 severity requiring immediate intervention) 9, 4.
• CN III, IV, VI: Examine extraocular movements, pupillary responses (size, shape, direct and consensual light reflexes), and accommodation 9, 4.
• CN V: Test facial sensation in all three divisions, corneal reflex, and jaw strength 9, 4.
• CN VII: Assess facial symmetry at rest and with movement, taste on anterior tongue 4.
• CN VIII: Evaluate hearing acuity and perform Rinne/Weber tests if indicated 4.
• CN IX, X: Examine palate elevation, gag reflex, and voice quality 9, 4.
• CN XI: Test shoulder shrug and head turning strength 4.
• CN XII: Assess tongue protrusion, movement, and fasciculations 4.

Motor Examination

• Inspect for muscle bulk, symmetry, and fasciculations 4.
• Assess muscle tone through passive movement of all extremities 4, 8.
• Test muscle strength systematically in all major muscle groups using Medical Research Council scale 4.
• Evaluate coordination with finger-to-nose, heel-to-shin, rapid alternating movements, and fine motor tasks 4, 7.
• Assess gait including casual walking, tandem walking, toe/heel walking, hopping, and running 4, 6.

Sensory Examination

• Test light touch, pain, temperature, vibration, and proprioception in all extremities 4.
• Assess cortical sensory functions including graphesthesia and stereognosis 4.

Reflex Examination

• Document deep tendon reflexes at biceps, triceps, brachioradialis, knees, and ankles using standard grading scale 4, 8.
• Test plantar responses bilaterally, noting that extensor responses are abnormal after infancy 4, 8.
• Assess for pathological reflexes including Hoffman and clonus 4.

Cerebellar Function

• Evaluate finger-to-nose and heel-to-shin testing for dysmetria 4.
• Assess rapid alternating movements for dysdiadochokinesia 4.
• Observe for tremor, ataxia, and dysarthria 4.

Special Assessments

• Screen for scoliosis using scoliometer and x-ray when clinically indicated 5.
• Reevaluate IQ and adaptive functioning particularly during transition from primary to secondary school 1.

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Adolescents (13-18 Years)

Comprehensive Assessment Framework

Adolescence is a critical period for identifying preexisting or emerging deficits, with formal assessment essential for support programs and optimizing both healthcare and educational/vocational achievement 1.

Mental Status Examination

• For patients with age-appropriate cognitive performance, utilize CARTOX-10 grading system for standardized neurological assessment 9.
• Assess orientation, attention, memory, language, and executive function systematically 1, 4.
• Screen for psychiatric conditions including autism spectrum disorder, ADHD, anxiety disorders, and psychotic disorders 5, 1.

Complete Neurological Examination

• Perform adult-style cranial nerve examination as detailed in school-age section, with full cooperation expected 4.
• Conduct comprehensive motor examination including detailed strength testing, tone assessment, and coordination evaluation 4.
• Perform thorough sensory examination including all modalities and cortical sensory functions 4.
• Document reflexes systematically with attention to symmetry and pathological signs 4.

Functional and Adaptive Assessment

• Evaluate adaptive functioning including daily living skills, social competence, and vocational readiness 5, 1.
• Assess academic functioning and learning capacities with standardized measures 5, 1.

Special Considerations

• Maintain heightened vigilance in specific clinical contexts such as post-CAR T-cell therapy (first 4 weeks high-risk period for CNS complications) 9.
• Avoid medications causing CNS depression during high-risk periods 9.

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Critical Elements Across All Age Groups

Frequency and Documentation

• Perform neurological assessments at least twice daily in hospitalized children, with first assessment at nursing shift change 9.
• Increase assessment frequency if any change from prior scores occurs or caregivers raise concerns 9.
• Track trends in assessment scores within individual patients, as trends are more important than isolated values 9.

Ancillary Testing Integration

• Obtain EEG when seizure activity is suspected or to evaluate for non-convulsive status epilepticus 9.
• Order MRI brain with and without contrast for comprehensive CNS evaluation when indicated 9.
• Perform diagnostic lumbar puncture with opening pressure measurement when appropriate 9.
• Add spinal MRI if focal peripheral neurological deficits are observed 9.

Brain Death Determination Protocol

• For term newborns (37 weeks gestation to 30 days): Perform two examinations 24 hours apart by two different attending physicians 5, 9.
• For children 31 days to 18 years: Perform two examinations 12 hours apart by two different attending physicians 5, 9.
• Systematically evaluate all brainstem reflexes including pupillary responses, corneal reflexes, gag and cough reflexes, oculocephalic and oculovestibular reflexes 5, 9.
• Perform apnea testing with documentation of PaCO2 ≥60 mm Hg and ≥20 mm Hg above baseline with no respiratory effort 5.

Multidisciplinary Team Composition

The ideal assessment team should include a psychologist, physician (developmental pediatrician, neurologist, or child psychiatrist if significant behavioral problems present), and speech-language pathologist 1.