Neurological Examination of NewbornsNeurological Examination of Newborns Period of newborn is the postnatal period from Period of newborn is the postnatal period from

birth up to first 28 days. birth up to first 28 days.

Development of nervous system begins from 2-Development of nervous system begins from 2-3 weeks from fertilization.3 weeks from fertilization.On the 4On the 4thth month of embryonal development month of embryonal development the topographic structures of brain is the topographic structures of brain is completed, but formation of the biggest gyrus completed, but formation of the biggest gyrus and sulcus lasts till 7-8 months. and sulcus lasts till 7-8 months.

At theAt the period of birth period of birth the only completely the only completely developed structures are thalamopallidar developed structures are thalamopallidar system and vestibular system ( On the 6system and vestibular system ( On the 6thth month of intrauterinal period).month of intrauterinal period).

In spite of this, the myelinization of newborn In spite of this, the myelinization of newborn brain’s certain structures is not finished. brain’s certain structures is not finished.

For instance, mielinization of pyramidal tract For instance, mielinization of pyramidal tract finishes at finishes at 2-3 months2-3 months from birth, but from birth, but structural maturity occurs at the age of structural maturity occurs at the age of 7-8 7-8 years. years.

Differentiation of CNS: Differentiation of CNS: Growth, Growth, development of dendrites endings and development of dendrites endings and interneuronal synapses is extremely interneuronal synapses is extremely intensive at intensive at the age of first 3 months. the age of first 3 months.

The newborn is examined and assessed The newborn is examined and assessed by neurologist: by neurologist:

In maternal house.In maternal house. When they leave maternal house in When they leave maternal house in

the case of complicated history.the case of complicated history. After managing pediatrical problem if After managing pediatrical problem if

pediatric considers that complete care pediatric considers that complete care of this newborn requires of this newborn requires neurologist’s participation..neurologist’s participation..

Pediatric needs to apply for neurologist when: Pediatric needs to apply for neurologist when: Newborn has problem of falling asleep or Newborn has problem of falling asleep or

maintaining this sleep, he is excited and has maintaining this sleep, he is excited and has excessive crying. excessive crying.

If the newborn has frequent jerks ( Hands, legs, If the newborn has frequent jerks ( Hands, legs, body parts)body parts)

If newborn is extremely sensitive to environment If newborn is extremely sensitive to environment temperature ( In the case of raising temperature temperature ( In the case of raising temperature newborn is extremely hot, has excessive newborn is extremely hot, has excessive sweating).sweating).

If the newborn is floppy and hypotonic If the newborn is floppy and hypotonic ( Hypotonia of extremities, hypermobility, has ( Hypotonia of extremities, hypermobility, has problems of awakening, is easily tired, and sleeps problems of awakening, is easily tired, and sleeps when eating). when eating).

If pediatric or mother notice the If pediatric or mother notice the strange fixation of gaze, arresting of strange fixation of gaze, arresting of activity, episodes of apnoe activity, episodes of apnoe accompanied with vegetative accompanied with vegetative changes and cyanosis, strange changes and cyanosis, strange movements like eastern greeting movements like eastern greeting ( Salaami). ( Salaami).

Neurologist starts to assess the Neurologist starts to assess the newborn bynewborn by means of sophisticated means of sophisticated anamnesis, which is gathered from:anamnesis, which is gathered from:

ParentsParents NurseNurse CaregiversCaregivers

Course of pregnancyCourse of pregnancy The quantity of pregnancy and delivery.The quantity of pregnancy and delivery. Presence of pregnant toxicosis or Presence of pregnant toxicosis or

eclampsy, signs of placentar defficiency.eclampsy, signs of placentar defficiency. Somatic diseases of pregnant, especially Somatic diseases of pregnant, especially

viral infection accompanied by hypoxy viral infection accompanied by hypoxy and intoxication, Lysteriosis, and intoxication, Lysteriosis, Toxoplasma, Mycoplasma. Toxoplasma, Mycoplasma.

If the pregnant needed treatment with If the pregnant needed treatment with antibiotics, immunosupresive drugs, antibiotics, immunosupresive drugs, sedative drugs. sedative drugs.

Maternal psychiatric trauma.Maternal psychiatric trauma. Maternal social and ordinary conditions Maternal social and ordinary conditions

( Use of alchohol or drug addiction).( Use of alchohol or drug addiction).

The important issues when The important issues when gathering family history are: gathering family history are:

Congenital disorders, like Congenital disorders, like autosome-dominant, autosome-autosome-dominant, autosome-recessive, chromosome-linked.recessive, chromosome-linked.

Neuropsychiatric disorders.Neuropsychiatric disorders. Psychomotor development of Psychomotor development of

parents.parents.

Course of deliveryCourse of delivery Rapid deliveryRapid delivery If drug stimulation or surgical If drug stimulation or surgical

implication was conducted.implication was conducted. Newborn was born full term or Newborn was born full term or

preterm or was excessive fetal preterm or was excessive fetal maturity.maturity.

If newborn cried at the moment If newborn cried at the moment of the birth.of the birth.

His/her condition ( weight, sizes)His/her condition ( weight, sizes)

Course of initial period of newbornCourse of initial period of newborn When was brought to maternal When was brought to maternal

breastbreast The presence of jaundice and its The presence of jaundice and its

durationduration When he/she leaved maternal When he/she leaved maternal

house.house. If he/she tries to hold headIf he/she tries to hold head If parents noticed smiling, If parents noticed smiling,

bubbling sounds, fixation of gaze.bubbling sounds, fixation of gaze.

When making case history When making case history neurologistneurologist tries to tries to observeobserve newborn’s newborn’s consciousness, expression of face, consciousness, expression of face, mimics, reaction to enviroment.mimics, reaction to enviroment.

Neurologist has to take into Neurologist has to take into consideration the condition of newborn: consideration the condition of newborn: If he/she is just awakened, if he/she If he/she is just awakened, if he/she requires feeding. requires feeding.

By observation easily can be recognized:By observation easily can be recognized: Hydro, -mycrocephaly.Hydro, -mycrocephaly. Flattening of skull bones.Flattening of skull bones. Prominent skull bones.Prominent skull bones. Expression of venous system.Expression of venous system.

Congenital defects like:Congenital defects like:

A)A) Hernia of brainHernia of brain

B)B) Hernia of spinal cordHernia of spinal cord

C)C) Palsy of Plexus BrachialisPalsy of Plexus Brachialis

D)D) Carpopedal SpasmsCarpopedal Spasms

E)E) Hand of obstretric. Hand of obstretric.

Very important is to give an attention to mild Very important is to give an attention to mild developmental anomalies so called developmental anomalies so called Dysembriogenic stigmas:Dysembriogenic stigmas:

MicrophtalmyMicrophtalmy EpicantusEpicantus Deformation of ear or its atopic location.Deformation of ear or its atopic location. Anomalies of fingers and toes.Anomalies of fingers and toes. Gothic high palatinumGothic high palatinum Polymorphic tonguePolymorphic tongue Hemangiomas on various parts of body Hemangiomas on various parts of body

(especially head and so on)(especially head and so on)

From anthropometric evidences From anthropometric evidences neurologist needs to assess neurologist needs to assess skull’s skull’s sizes: sizes:

The circumference of head is identified The circumference of head is identified between most prominent point of between most prominent point of occipital bone and forehead up to occipital bone and forehead up to eyebrows.eyebrows.

The head circumference in The head circumference in full term full term infants is 34-36 cm.infants is 34-36 cm.

The head circumference increases by 1-The head circumference increases by 1-1.5 cm in first months of life. Thus, by 1.5 cm in first months of life. Thus, by the end of the year the head is 46 cm.the end of the year the head is 46 cm.

ReflexesReflexes

The only reflexes which newborn The only reflexes which newborn have are those the reflex arch of have are those the reflex arch of which is closed in spinal cord which is closed in spinal cord and basal ganglias and they are and basal ganglias and they are called unconditioned reflexes.called unconditioned reflexes.

Stable automatisms, Stable automatisms, those which those which exist lifelong: corneal, exist lifelong: corneal, conuctivalis, pharynx, conuctivalis, pharynx, swallowing, sneezing, tendon swallowing, sneezing, tendon ( knee, elbow, achilevsis).( knee, elbow, achilevsis).

Transitory, Transitory, which reflect the specific which reflect the specific level of development of motor level of development of motor centers. They gradually dissapear.centers. They gradually dissapear.

Oral segment automatisms.Oral segment automatisms. Spinal segment automatisms.Spinal segment automatisms. Myelencephalic positonic reflexes.Myelencephalic positonic reflexes. Mesencephalic automatismsMesencephalic automatismsMesencephalic automatisms Mesencephalic automatisms appears appears

after birth. Thus it doesn’t exist in after birth. Thus it doesn’t exist in every newborn –Labyrinthe, neck every newborn –Labyrinthe, neck and body simple and chain reflexes. and body simple and chain reflexes.

Stable automatismsStable automatismsFull term infants have well developed Full term infants have well developed

feeding, sucking and swallowing reflexes. feeding, sucking and swallowing reflexes. Feeding reflex is such strong that it Feeding reflex is such strong that it

creates feeding dominant in cortex. creates feeding dominant in cortex. That’s why during feeding all other That’s why during feeding all other motor reactions controlled by cortex are motor reactions controlled by cortex are inhibited. This reflex is not developed inhibited. This reflex is not developed only in very severe preterms. only in very severe preterms.

Stable automatisms are: corneal and Stable automatisms are: corneal and conuctival reflexes. Newborns can also conuctival reflexes. Newborns can also have Peiper’s reflex ( irritation by have Peiper’s reflex ( irritation by strong light causes pupillar constriction, strong light causes pupillar constriction, closing of eyes and extension of head).closing of eyes and extension of head).

Oral Segment AutomatismsOral Segment Automatisms

Reflex of Reflex of seekingseeking Reflex of Reflex of suckingsucking Elephant trunkElephant trunk reflex reflex OropalmarOropalmar reflex ( Reflex of reflex ( Reflex of

Babkin)Babkin)

Spinal Segment autotaismsSpinal Segment autotaisms MoroMoro reflex reflex GraspingGrasping ( (Robinson’s)Robinson’s) reflex reflex Climbing ( Bauer’s)Climbing ( Bauer’s) reflex reflex Paravertebral ( Galant’s)Paravertebral ( Galant’s) reflex- reflex-

irritation of paravertebral from neck to irritation of paravertebral from neck to coccygeal area causes arch like flexion of coccygeal area causes arch like flexion of body, sometiemes with extension of legs.body, sometiemes with extension of legs.

Vertebral (Peres’s)Vertebral (Peres’s) reflex- irritation of reflex- irritation of vertebral column from coccygeal area to vertebral column from coccygeal area to neck causes:neck causes:

lumbar lordosis, flexion of arms and lumbar lordosis, flexion of arms and legs, involuntary urination and legs, involuntary urination and defecation ( It diseapears at age of 4 defecation ( It diseapears at age of 4 months).months).

Khvostek’sKhvostek’s sign: knocking at the sign: knocking at the cheek by neurological hammer cheek by neurological hammer causes constriction of nose, causes constriction of nose, mouth and eyes muscles.mouth and eyes muscles.

Heel ( Arshavsky)Heel ( Arshavsky) reflex: reflex: pressing on heel causes pressing on heel causes constriction of face muscles constriction of face muscles ( Disseapears at 5-6 ( Disseapears at 5-6 months).months).

StandingStanding reflex. reflex. Reflex of Reflex of automatic stepping. automatic stepping.

Mesencephalic automatism reflexesMesencephalic automatism reflexes LabyrintheLabyrinthe reflex reflex Neck symmetric toneNeck symmetric tone reflex reflex Neck asymmetric toneNeck asymmetric tone reflex reflex Body pose maintainingBody pose maintaining reflex- standing reflex- standing

on surface ( table) causes correction of on surface ( table) causes correction of head and body ( expresses after 1 month head and body ( expresses after 1 month from birth).from birth).

Landau upperLandau upper reflex- when lying on the reflex- when lying on the abdomen infant tries to raise head, chest abdomen infant tries to raise head, chest and support on the surface by hands. He and support on the surface by hands. He can maintain this pose for several can maintain this pose for several minutes. ( Reveals from 4 months) minutes. ( Reveals from 4 months)

Landau lowerLandau lower reflex- when lying on the reflex- when lying on the abdomen infant tries to flex legs and abdomen infant tries to flex legs and raise them ( reveals from 5-6 months).raise them ( reveals from 5-6 months).

Neck simple and body directionNeck simple and body direction reflex reflex – rotation of head causes rotation of – rotation of head causes rotation of body in the same direction- at first body in the same direction- at first chest and then lower part of body. chest and then lower part of body. ( This reflex can be elicited at the ( This reflex can be elicited at the moment of birth and then became moment of birth and then became stable). stable).

Chain directionChain direction reflex- rotation of reflex- rotation of arms causes rotation of body and arms causes rotation of body and lower extremities ( appears at age of lower extremities ( appears at age of 6-7 months). 6-7 months).

BabinskiBabinski reflex reflex Kerningi Kerningi sign ( it seems to be sign ( it seems to be

normal sign before 4 month of age). normal sign before 4 month of age).

Examination of reflexes gives us an Examination of reflexes gives us an information about the state of CNS. information about the state of CNS. If these reflexes exist at the age If these reflexes exist at the age when they have not to be it when they have not to be it indicates on the pathology of CNS. indicates on the pathology of CNS. Abnormality is also if they are Abnormality is also if they are absent at the age when they have to absent at the age when they have to be.be.

Examination of Examination of cranial nerves. cranial nerves. Nervus olfactoriusNervus olfactorius – doctor gives to – doctor gives to

infant various substances with infant various substances with different smells different smells

( rose, almond), which don’t irritate ( rose, almond), which don’t irritate nasal cavities. In newborns nasal cavities. In newborns neurologist can notice the changes neurologist can notice the changes of mimics and emotions. of mimics and emotions.

Nervus Ophtalmicus- Nervus Ophtalmicus- In newborns In newborns assessing of this nerves is conducted assessing of this nerves is conducted by shining objects when newborn by shining objects when newborn fixes the gaze. fixes the gaze.

Nervus oculomotorius, nervus trochlearis Nervus oculomotorius, nervus trochlearis and nervus abducens. and nervus abducens. Doctor assess Doctor assess functions of these nerves by shining functions of these nerves by shining objects and newborn tries to follow this objects and newborn tries to follow this object left, right, up and down.object left, right, up and down.

Nervus trigeminalisNervus trigeminalis damage of the first damage of the first branch causes disseapearance of corneal branch causes disseapearance of corneal reflex, damage of the second branch reflex, damage of the second branch causes disseapearance of sneezing reflex, causes disseapearance of sneezing reflex, demage of the lower branch causes demage of the lower branch causes disseapearance of the tasting on the 2/3 disseapearance of the tasting on the 2/3 front part of tongue, but detection of this front part of tongue, but detection of this disturbance is difficult in newborns. disturbance is difficult in newborns. Damage of motor part of this nerve Damage of motor part of this nerve results in dusturbance of chewing. results in dusturbance of chewing.

Nervus Facialis – Nervus Facialis – neurologist assesses neurologist assesses mimic muscles, closing and opening of mimic muscles, closing and opening of eyes, closing and opening of mouth. eyes, closing and opening of mouth.

Vestibular nerve Vestibular nerve – Doctor is ringing a – Doctor is ringing a bell, which causes jerking of newborn. bell, which causes jerking of newborn.

Nervus glossopharyngeus, nervus Nervus glossopharyngeus, nervus vagus and nervus hypoglossusvagus and nervus hypoglossus. Damage . Damage of these nerves cause bulbar palsy, of these nerves cause bulbar palsy, which can be revealed by difficulties of which can be revealed by difficulties of swallowing. swallowing.

Damage of nervus accesorius causes Damage of nervus accesorius causes lower position of arm and signs of lower position of arm and signs of muscle atrophy. muscle atrophy.

Laboratory approaches of Laboratory approaches of investigation of nervous system.investigation of nervous system.

Analysis of blood sample on Analysis of blood sample on bacterias and viruses.bacterias and viruses.

Analysis of blood on metabolic Analysis of blood on metabolic processes.processes.

Biochemical analysis of urine.Biochemical analysis of urine. Genetic investigationGenetic investigation Bacterial-viral analysis of CSF.Bacterial-viral analysis of CSF. Biopsy of neural tissue. Biopsy of neural tissue.

Instrumental approaches of Instrumental approaches of investigation of nervous systeminvestigation of nervous system

OphtalmologicalOphtalmological AudiometryAudiometry NeurosonoscopyNeurosonoscopy EchoscopyEchoscopy EEGEEG X-RayX-Ray EMGEMG Angiography, myelographyAngiography, myelography CTCT MRIMRI

Ophtalmological Approaches Ophtalmological Approaches In newborns the mostly used method is In newborns the mostly used method is

investigation of eye fundus. investigation of eye fundus.

As a result neuroophtalmologist can see As a result neuroophtalmologist can see haemmorages, neuritis of disc of haemmorages, neuritis of disc of ophtalmical nerve, intracranial ophtalmical nerve, intracranial hypertension, revealing by oedema of hypertension, revealing by oedema of disc, widening of venous system, nerve disc, widening of venous system, nerve atrophy ( color loss of disc, reducing of atrophy ( color loss of disc, reducing of size).size).

Otoneurologic investigation- Otoneurologic investigation- assessing of assessing of hearing in newborn by means of hearing in newborn by means of audiometry.audiometry.

Neurosonoscopy-Neurosonoscopy-is method by is method by which radiologist conducts which radiologist conducts scanning of brain’s structure, scanning of brain’s structure, sizes of ventricles, echogenity of sizes of ventricles, echogenity of CSF, also it helps to detect CSF, also it helps to detect hypoxy, hemmorage, leikomalacy, hypoxy, hemmorage, leikomalacy, inflammation, development inflammation, development defect, hypertension, calcification defect, hypertension, calcification of brain. of brain.

Ultrasound Dopplerography- Ultrasound Dopplerography- helps helps to investigate vessels of the to investigate vessels of the brain. brain.

Electroencephalography ( EEG)- Electroencephalography ( EEG)- is an is an extremely valuable method to identify extremely valuable method to identify epileptic seizures and mental epileptic seizures and mental retardation signs as well. In recent retardation signs as well. In recent years the researchers started to use it years the researchers started to use it for evaluation of brain death in order for evaluation of brain death in order to stop artificial respiration and to stop artificial respiration and emergency help in terminal stage emergency help in terminal stage patients. patients.

Craniography- Craniography- serves to detect serves to detect congenital and acquired defects of congenital and acquired defects of skull: micro,- and macrocephaly, skull: micro,- and macrocephaly, craniostenosis, intracranial craniostenosis, intracranial hypertension.hypertension.

CT – CT – is high sensitive method. It is high sensitive method. It shows brain slices in various shows brain slices in various projections. It is very valuable in projections. It is very valuable in different neurological diseases different neurological diseases such as ischemic brain lesions, such as ischemic brain lesions, hemmorages, abscesses, hemmorages, abscesses, atrophy, edema, tumors. atrophy, edema, tumors.

MRI- MRI- is more sensitive method is more sensitive method than CT, which helps to detect than CT, which helps to detect different cerebral and spinal different cerebral and spinal diseases. diseases.

Analysis of CSFAnalysis of CSF

Is extremely informative in certain Is extremely informative in certain neurological diseases. The neurological diseases. The important characters are important characters are transparency, color, pressure, transparency, color, pressure, inclusion and number of cells, inclusion and number of cells, proteins, glucose, chlorides.proteins, glucose, chlorides.

Sometimes neurologist needs to Sometimes neurologist needs to identify bacteries and viruses in identify bacteries and viruses in CSF. CSF.

After using all these methods and After using all these methods and assessing approaches experienced assessing approaches experienced neurologist can make precise neurologist can make precise diagnosis and plan of effective diagnosis and plan of effective treatment.treatment.

If newborn’s condition requires If newborn’s condition requires additional assessing of different additional assessing of different profile doctors he/she has to inform profile doctors he/she has to inform parents or other caregivers or in the parents or other caregivers or in the case if neurologist exclude case if neurologist exclude neurological disturbance, it is neurological disturbance, it is obligatory to identify which profile obligatory to identify which profile doctor is needed.doctor is needed.