Neurological Exam for Children

What is a neurological exam?

A neurological exam is also called a neuro exam. It's an evaluation of your child's nervous system. It can be done in the healthcare provider's office. It may be done with instruments, such as lights and reflex hammers. It usually does not cause any pain to the child.

The nervous system consists of the brain, the spinal cord, and the nerves from these areas, as well as the muscles (the neuromuscular system). There are many aspects of this exam, including an assessment of:

• Motor and sensory skills

• Balance and coordination

• Mental status (the child's level of awareness and interaction with the environment)

• Reflexes

• Nerve function

The extent of the exam depends on many factors. This includes the initial problem that the child is having, the child's age, and their condition.

Why is a neurological exam done?

A complete and thorough evaluation of your child's nervous system is important if there is any reason to think there may be an underlying problem.

Damage to the nervous system can cause delays in the child's normal development and functioning. Early identification may help find the cause and decrease long-term complications. A complete neurological exam may be done:

• During a routine physical

• During a newborn physical

• To follow the progression of a disease

• Following any type of birth defect to the head or spine

• If the child has any of these complaints:

  • Headaches

  • Blurry vision

  • Change in behavior

  • Severe tiredness (fatigue)

  • Change in balance or coordination

  • Numbness or tingling in arms or legs

  • Decrease in arm or leg movement

  • Injury to the head, neck, or back

  • Temperature of unknown source

  • Seizures

  • Slurred speech

  • Weakness

  • Tremor

What is done during a neurological exam?

During a neurological exam, your child's healthcare provider will test the functioning of the nervous system. The nervous system is very complex and controls many parts of the body. The nervous system consists of the brain, spinal cord, 12 nerves that come from the brain, and the nerves that come from the spinal cord. The nervous system regulates the muscles. The circulation to the brain, arising from the arteries in the neck, is also frequently examined. In infants and younger children, a neurological exam includes the measurement of the head circumference. The following is an overview of some of the areas that may be tested and evaluated during a neurological exam:

• Mental status. Mental status (the child's level of awareness and interaction with the environment) may be assessed by watching the infant interact with the parent, or by asking the older child to follow directions or answer questions appropriately. The older child will also be watched for clear speech and making sense while talking. This is usually done by your child's healthcare provider just by observing the child during normal interactions.

• Motor function and balance.  This may be tested by having the older child push and pull against the healthcare provider's hands with their arms and legs. The child may be asked to squeeze fingers or hop, skip, or jump. Balance may be checked by assessing how the child stands and walks or having the older child stand with their eyes closed while being gently pushed to one side or the other. Your child's joints may also be checked simply by passive (done by the healthcare provider) and active (done by the child) movement.

• Sensory exam. Your child's healthcare provider may also do a sensory test that checks your child's ability to feel. This may be done by using different instruments, such as dull needles, tuning forks, alcohol swabs, or other objects. The healthcare provider may touch the child's legs, arms, or other parts of the body and have them identify the sensation (for instance, hot or cold, sharp or dull).

• Newborn and infant reflexes.  There are different types of reflexes that may be tested. In newborns and infants, reflexes called infant reflexes (or primitive reflexes) are evaluated. Each of these reflexes disappears at a certain age as the infant grows. These reflexes include:

  • Blinking. An infant will close their eyes in response to bright lights.

  • Plantar reflex (also known as Babinski reflex). Normally, as an infant's foot is stroked, the toes will extend upward. This response usually disappears after a year of age. It is considered abnormal for this reflex to remain present after 2 years.

  • Crawling. If the infant is placed on their stomach, they will make crawling motions.

  • Moro reflex (or startle reflex). A quick change in the infant's position will cause the infant to throw the arms outward, open the hands, and throw back the head. This reflex normally is gone after 6 months of age.

  • Tonic neck reflex. The newborn is tested lying down with face up. If the head is passively turned to one side, the arm on that side will extend, with the other arm flexing at the elbow and shoulder. This reflex normally goes away after 6 months of age.

  • Palmar and plantar grasp. The infant's fingers or toes will curl around a finger placed in the area.

• Muscle stretch reflexes in the older child.  These are sometimes called deep tendon reflexes. They are often checked using a reflex hammer.

  The reflex hammer is used at different points on the body, such as the knee or elbow. It tests the reflex arc between the nerves that cause the muscle contraction and those that send signals back to the brain. This checks both the peripheral nerves and the spinal cord. If the peripheral nerves are impaired, this test causes a reduced or absent response. If the spinal cord is injured, this test tends to cause an exaggerated response.

• Evaluation of the cranial nerves.  There are 12 main nerves of the brain, called the cranial nerves (CN I-XII). During a complete neurological exam, most of these nerves are evaluated to help determine the functioning of the brain:

  • Cranial nerve I (olfactory nerve). This is the nerve of smell. Your child may be asked to identify different smells with their eyes closed.

  • Cranial nerve II (optic nerve). This nerve carries vision to the brain. A visual test may be given. Your child's eye may be examined with a special light.

  • Cranial nerve III (oculomotor). This nerve is responsible for pupil size and certain movements of the eye. Your child's healthcare provider may examine the pupil (the black part of the eye) with a light and have your child follow the light in various directions. Cranial nerves III, IV, and VI are tested together.

  • Cranial nerve IV (trochlear nerve). This nerve also helps with the movement of the eyes, in combination with CN VI. 

  • Cranial nerve V (trigeminal nerve). This nerve allows for many functions, including the ability to feel the face, inside the mouth, and move the muscles involved with chewing. Your child's healthcare provider may touch the face at different areas and watch your child as they bite down.

  • Cranial nerve VI (abducens nerve). This nerve helps with the movement of the eyes. Your child may be asked to follow a light or finger to move the eyes.

  • Cranial nerve VII (facial nerve). This nerve is responsible for various functions, including the movement of the muscles of facial expression and taste from the front of the tongue. Your child may be asked to identify different tastes (sweet, sour, bitter), asked to smile, move the cheeks, forehead, or eyelids, or show the teeth.

  • Cranial nerve VIII (acoustic nerve). This nerve is the nerve of hearing and vestibular function. A hearing test may be done on your child. Your child may undergo specialized testing for vestibular function.

  • Cranial nerve IX (glossopharyngeal nerve). This nerve is involved with taste and swallowing. Once again, your child may be asked to identify different tastes on the back of the tongue. The gag reflex may be tested. Cranial nerves IX and X are tested together.

  • Cranial nerve X (vagus nerve). This nerve is mainly responsible for the ability to swallow, the gag reflex, some taste, and part of speech. Your child may be asked to swallow. A tongue blade may be used to elicit the gag response.

  • Cranial nerve XI (accessory nerve). This nerve is involved in the movement of a muscle of the shoulders and neck. Your child may be asked to turn their head from side to side against mild resistance or to shrug the shoulders.

  • Cranial nerve XII (hypoglossal nerve). This nerve is responsible for movement of the tongue, along with CN IX and X. Your child may be asked to stick out their tongue and speak.