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(BQ) Part 2 book “Illustrated textbook of pediatrics” has contents: Cardiac disorders, pediatric neurology, child abuse and child protection, infectious diseases, hemato-oncologic disorder, pediatric dermatology, joint and bone disorders, drug overdoses and poisoning,… and other contents.
12 HISTORY TAKING Obtaining satisfactory history often provides better clue than examination or investigation for diagnosis and management of a neurological disease History taking should be interactive Doctor should cross check, whether he understood, what the patient or care giver told Doctor should ask the patient or care giver, whether he (doctor) understood is the same as the patient told to doctor School-age children should be given an opportunity to speak to doctor alone History of Presenting Complaints Children may present with symptoms of following neurological conditions and disorders: • Paroxysmal episodes: Seizures, migraine • Pain: Headache (migraine) • Movement disorders: Ataxia, chorea • Altered consciousness: Intracranial infections (meningoencephalitis) • Developmental delay: Falling off from normal development [cerebral palsy (CP)] • Developmental regression: Loss of already achieved developmental skill (neurodegenerative disorders) However, the above neurological features should be obtained by taking history carefully Doctor should listen carefully what the patient said and try to rationalize the history in a broader way before jumping to describe the complaint as a specific pathological term For example, if the mother complains that her child falls frequently and the doctor term it as seizure disorder, dyspraxia or ataxia, then he has closed his thinking for wide range of simple nonorganic cause of balance problem including simple problem like fall due to generalized weakness On the contrary, some parents will use ill understood misleading medical term like telling doctor that their child has absence seizure, which should be gently discouraged For acute onset clinical problem, it is usually better to start at the beginning of the history like asking the parents when the child was reasonably well For very long-term problem, it may be more useful to start with present situation and fill in backward If a child of 5-year-old with CP presents with convulsion, listen the presenting problem and then go back how it started Currently, the child presented for the first time with convulsion However, the child was not normal before The problem started when he developed meningitis at year age, followed by developmental delay and he cannot stand at this age Later at year age he developed occasional seizure The time course over which the symptoms have evolved is particularly informative in relation to probable pathology Slowly progressive disorders like slow growing cerebral tumor usually progress over several years while cerebrovascular events have a sudden onset Pediatric Neurology Birth History Relevant to Neurological Condition Birth history is important and should be taken in detail Preterm, very extremely low-birth weight babies are more vulnerable to develop CP and developmental disorders Ask simple questions Was your baby born in due time (expected date of delivery) and what was his/her birth weight? If cannot remember, did he/she looked very small when he/she was born? Clinical events during birth are also important Ask the parents whether their baby cried immediately after birth, which is relevant to birth asphyxia, which may later lead to CP Take history whether the baby suffered from sepsis or meningitis Ask the parents whether their baby developed severe jaundice (hyperbilirubinemia) requiring phototherapy or exchange transfusion which may be relevant to kernicterus, etc which are relevant to later development of central nervous system (CNS) disorder Ask the parents simply whether their baby was discharged from hospital normally after birth, or did the baby require prolonged stay in the hospital particularly in neonatal intensive care unit requiring ventilatory care Prolonged ventilation care may cause pulmonary as well as CNS problem Developmental History It commonly is an underemphasized but useful part of neurological history taking Ask when the child was able to sit without support, and age of learning, age of crawling and walking Ask about speech development, including vocalizing, babbling and speaking meaningful words Inquire if there is any age-matched problem with language and communication (relevant to autism)? Can the baby respond to sound? Distinction between developmental delay (achieving developmental skills later) and developmental regression (loss of achieved skills) can be obtained by taking careful history Cognitive Development • Pointing at an object of his/her interest like dog or cat • and inviting others for shared attention to look at the same object Also vocalizes to bring the object to him/her Established by 18 months Symbolic toy test: Using representational toys (animals, dolls and cars) and function of use like showing toy aeroplane flying or kicking small football established by 18 months It also assesses early language development EXAMINATION OF CENTRAL NERVOUS SYSTEM Try to start examining the child with minimum touch, then more touch without disturbing the child and in the form of game Details of neurological examination of neonates and young infants are mentioned later, in this chapter and also in newborn examination (See Chapter 1) Illustrated Textbook of Pediatrics 442 Older children undergo the full adult neurological examination by making it a game Pay particular attention to gait, spine, head size and skin for neuromuscular stigmata EXAMINATION OF PERIPHERAL NERVOUS SYSTEM It comprises assessment of appearance, postures, gait, tone, power, reflexes, coordination and sensation Appearance and Posture Look for muscle balk, inspection of feet (equinus posture), neurocutaneous stigmata, (depigmented spot, cafe au lait spot, etc.) visible fasciculation and limb asymmetry Look for involuntary involvement (chorea, tic, etc ) Note whether stance is broad based (cerebellar problem) Spastic children take attitude of flexion or one sided of body is usually abnormal Any asymmetric abnormal movement and posture on motor or sensory test after or year is abnormal Symmetric deviant performance on motor (Fog’s test) or sensory test can occur above 4-year child with motor coordination disorder (clumsy child) but asymmetric performance occur in CP It helps clinical diagnosis of occult (apparently normal) hemiplegia Persistent and positive tests of more than one soft neurological signs or positive signs of one test performed in different ways of same test increases the sensitivity of positivity of the test For example persistent deviant performance on Fog’s test on walking on heal toe, inner and outer side of feet increases the sensitivity of positive Fog’s test How to Elicit Subtle Hemiparesis? This can be elicited by performing Pronator drift test and Fog’s test in the following ways: Gait Pronator Drift Gait can provide clue for diagnosis of neurological conditions without touching or disturbing the child Although, it is easily straightforward to recognize when a gait is normal but when the gait is abnormal, it can be challenging to find what is wrong Neurological diseases typically give one of several gestalt gait appearances that enable to recognize underlying neurological condition Remove the clothes as far as underwear, if the child is happy A useful technique to screen subtle hemiparesis is to ask a child to stand still for 20 seconds with arm outstretched or in pulled up position with palms outward and eyes closed Mild pyramidal weakness results in pronator drift, a downward drift and pronation of affected arm (Figs and 3) Neurological Gait: Gestalt Spastic hemiparesis: Equinus posture of the foot Tendency to catch a toe on the floor either resulting in leg swing laterally during swing phase (circumducting gait) or it is compensated by hip flexion Affected upper limb is flexed at elbow (Fig 1) Soft Neurological Signs A soft neurologic sign which include fog’s test and tandem test may be defined as particular form of deviant performance on a motor or sensory test Minimal choreoathetoid movements in the fingers of extended arm are normal up to years age However, gross abnormal movement and posture, particularly if such movement and posture are asymmetric Fig 2: A normal child showing no pronator drift Fig 1: Left-sided hemiplegia showing flexion of hip and elbow of affected side Fig 3: A left side hemiphagic child showing pronator drift Fog’s Test Flaccid foot drop: Ask the child to walk on heel It cannot perform due to weak dorsiflexion (tibialis anterior) Tendency to step “high” on the affected side flexing the hip to lift the foot clear of the floor Proximal weakness (e.g Duchenne dystrophy): Look for the muscle bulk (increase hypertrophied calf muscle) and for marked lumbar lordosis Exaggerated rotation and throwing of the hips to each side with each step results in waddling gait The ability to climb layers is limited Perform Gower maneuver (assessment of proximal muscle strength) which is positive in extreme proximal muscle weakness [Duchenne muscular dystrophy (DMD)] Dystonic gait: Can be extremely variable and extremely bizarre Dystonic gaits are typically accompanied by sustained posturing of arms, trunk, head and neck Involvement of one foot or ankle, due to abnormal contraction caused by sustained contraction of agonists and antagonistic muscles Ataxic gait: Usually broad-based gait (Fig 6) Ask the child to walk in a straight line with hands folded and then quickly around A child with truncal ataxia cannot perform quickly (cerebellar dysfunction) This is also called Tandem test (Figs 7A and B) Sensory ataxia is similar to cerebellar ataxia but markedly worse with the eyes closed.fs TONE Fig 4: A normal child performing Fog's test by walking on tip toe showing no exaggerated upper limb movements Fig 5: A child with right-sided hemiplegia performing Fog's test by showing exaggerated movement and posture of right upper limb Next look for muscle tone Muscle tone is a state of tension or contraction found in the healthy muscles For clinical purposes, it may be defined as resistance felt when a joint is moved passively Younger children can find it hard to just relax which can cause misleading impression of increased tone Increased tone can be pyramidal (spastic) or extrapyramidal (dystonic) in nature The two may coexist, particularly in CP Spasticity is linked to sensation encountered when opening a clasp knife and is called “clasp knife” type of hypertonicity It is characterized by rapid buildup in resistance owing to the first few degree of passive movements and then as the movement continues there is sudden lessening of resistance It is a type of hypertonicity, when increased tone is produced by rapid stretching of muscle, Fig 6: A child with ataxic gait with broad-based walking and outstretched upper limb 443 Pediatric Neurology Elicit associated movements (soft neurological sign) in the upper limbs, when the child is asked to heel walk, toe walk on everted or inverted feet (Fig 4) In the 4-year-old child the upper limb normally mirror the pattern of the movement on the lower limb This becomes much less marked or has disappeared entirely by 9–10 years Asymmetries which are marked and reproducible point to hemisyndrome on the exaggerated side Therefore an 8-year-old child with subtle spastic rightsided hemiplegia not observed by gait and posture can show exaggerated-associated movements (increased flexion or extension, etc ) and excessive posturing of right upper limb (nondominant), when the child is asked to walk on inverted or everted feet (Fig 5) This will help to perform subsequent neurological examination like deep reflexes, when right side will show hyperreflexia in comparison to left Identification and elicitation of hyperreflexic deep reflexes of affected side in subtle hemiplegia, sometimes may pose difficulty without performing Fog’s test or pronator drift initially Excessive posturing, which is bilaterally exaggerated for the child’s age, points to an underlying developmental dyspraxia or clumsiness which is unlikely to be pathological Spastic paraparesis or diplegic gait: Legs are adducted across midline when viewed from in front (“Scissor gait”): Knees scraping together and bilateral toe walking and crouched stance due to bilateral flexion contracture Illustrated Textbook of Pediatrics 444 A B Phasic spasticity {10 = No increase in muscle tone = Slight increase in tone, with catch and release or minimal resistance at end range = Minimal resistance through range following catch, but body part is easily moved Tonic spasticity { = More marked increased tone throughout range = Considerable increase in tone, passive movement difficult = Affected part is rigid in flexion/ extension (Difficult to distinguish from dystonic hypertonicity) Phasic spasticity: Muscles are hypertonic on rapid stretch Its significance lies in the fact that, a child with upper motor (pyramidal) lesion occasionally look hypotonic (particularly if undernourished), but surprisingly with hyper-reflexic jerk (hypotonic are usually associated with hyporeflexia and vice versa) If muscles are not stretched rapidly, hypertonicity (phasic) may be missed out Tonic spasticity is characterized by hypertonicity with slow stretch Spasticity commonly and more easily detected in passive movements of the knee joint than it is in the upper limb Two maneuvers should be done Rapid passive movement and slow passive movement of knee or elbow joint, and to feel whether it is hypertonic on rapid (phasic spasticity) or slow stretch (tonic spasticity) Spasticity is associated with exaggerated tendon reflex Although spasticity is velocity dependent, but tone of spasticity unlike dystonic hypertonicity, does not change with change in posture, emotion or touch It usually affects the flexor and adductor muscles, (as opposed to extensor muscles, affected by dystonia), giving rise to attitude of flexion and flexion deformity of joints Spasticity may complicate CP Consequences include: • Pain and discomfort • Loss of function, e.g mobility • Contracture • Difficulty with care, e.g in the groin area Spasticity is treated to ameliorate one or more of these, not for its own sake Realistic goals should be agreed prior to treatment and are the criteria against which success is assessed Dystonia or rigidity is the term used to describe resistance to passive movement, which is sustained throughout range of movement and unlike spasticity is velocity independent, and associated with fixed change in muscle, tendon and joints It is due to disease of basal ganglia This phenomenon gives rise to sensations reminiscent of those produced by bending a lead pipe, called lead pipe rigidity When tremor is superimposed on rigidity, the resistance to passive movement is jerky increased as if a ratchet were slipping over the teeth of a cog This is called cogwheel rigidity, and commonly felt in Parkinsonism Extrapyramidal (basal ganglia) and cogwheel rigidity are most easily detected at the wrist when relatively slow manipulation is employed Measurement scale of dystonia is not as well-established as spasticity The Barry-Albright dystonia scale was developed for children Five point-ordinal scale served for the following body parts—eyes, mouth, neck, trunk and each limb – Normal – Slight body part affected less than 10% of tone – Mild body part affected less than 50% tone, not interfering with function – Moderate body part affected more than 50% of tone and/or interference with function – Severe body part affected more than 50% of tone, prevents or severely limits function Unlike spasticity, dystonic hypertonicity is velocity independent, but changes with posture, emotion, tactile stimulation Tone may be increased in dystonic CP child, when the child sleeps on supine position but tone may be decreased on prone position which is important for postural management of dystonic CP A child with CP may throw himself into severe dystonic rigidity when he/she cries or emotionally upset A predominantly dystonic infant may show persistent primitive reflexes like exaggerated galant and perez reflex and overperformance of progression reflexes like stepping and walking reflexes, unlike spastic CP A child with dystonic hypertonicity usually takes the posture of extension, as opposed to flexion attitude of spastic child Tendon reflexes are also not increased in comparison to spastic child Persistent primitive reflexes like asymmetric tonic neck (ATN) reflex are also more associated with dystonic CP Spasticity Scale Difference between Spastic and Dystonic Hypertonicity Modified Ashworth Scale In CP there may be mixed pattern However, one may be more dominant than other (Table 1) Figs 7A and B: (A) Straight line walking test (Tandem test) for eliciting truncal ataxia in normal child (normal child); (B) Showing a child with truncal ataxia who is unable to walk on straight line with upper arm folded in front of chest by rapidly flexing and extending the muscle at joints Spasticity is therefore also called a form of hypertonicity, which is stretch sensitive Spasticity is velocity dependent with increase in resistance to passive muscle stretch Spasticity is divided roughly into two types: (1) Phasic spasticity; (2) Tonic spasticity A six point criteria is used to quantify degree of spasticity It is simple and widely used but not entirely reliable as speed of movement is not specified Hypotonia: This is harder to assess in younger children Posture may be more useful indicator of decrease tone in early infancy Table 1: Difference between spastic and dystonic hypertonicity Dystonicity Stretch sensitive and velocity dependent Velocity independent and not stretch sensitive Usually affects flexor and adductor muscles of joints Usually affects extensor muscles of joints Posture: presents attitude of Posture: attitude of extension flexion and adduction Tone: does not change with change of posture, emotion or tactile stimulation Tone: may change with change in posture, emotion and tactile stimulation Usually more hypertonic on supine position Reflexes: exaggerated tendon reflex Reflexes: no exaggerated tendon reflexes Knee flexion: flexor withdrawal of positive planter reflex Knee extension: extensor withdrawal of planter reflex They feel floppy, with poor head control, head leg and truncal instability Putting hands under armpit, it may slip under armpit while trying to lift the child (Fig 8) Hypotonia is often demonstrated by hyperextensibility of joints Hyperextension of more than 9o at knee and more than 10o at elbow is significant hyperextension suggestive of hypotonia and lax joints (Fig 9) Similarly hyper-reflexion at wrist allows thumb to touch the dorsum of the forearm, which is normally not possible, is suggestive of significant hypotonia When thumb is closed in closed fist, it protruded beyond medial border of hand (Steinberg sign), a diagnostic test of Marfan syndrome, where hypotonicity and hyperextensibility coexist When child is asked to touch his or her nose with tongue, a child with hypotonia and hyperextensibility can it, which a normal child cannot perform If the child is hypotonic, look for visible fasciculation and wasting of muscle Fasciculation is produced by spontaneous contraction of large group of muscle fibers or a whole motor unit It suggests lower motor neuron lesion Grading of Muscle Power The evaluation of muscle power should be recorded quantitatively using the grading recommended by the Medical Research Council (MRC) – No active movement – Visible or palpable active contraction with active movement POWER Younger children often struggle to understand what is wanted of them in formal power test is done by requesting the child Fig 9: Figure showing hyperreflexion of wrist at thumb, allows thumb to touch dorsum of hands and hyperextension at right knee joint Fig 8: A floppy infant showing slipping through hands at armpit on vertical suspension Fig 10: Figure showing Gower’s maneuver with Gower sign positive 445 Pediatric Neurology Spasticity to pull the examiner towards the child, while the examiner resists such action to request, such as pull against me Testing of power of group of muscles can be done by asking the child to contract a group of muscles as powerfully as possible and thus move a joint and then maintain the deviated position of the joint while the examiner tries to restore the part to its original position Examine shoulder abduction on each side simultaneously then elbow flexion on each side before elbow extension Formal examination of power in legs is best performed in supine position Proximal weakness of shoulder and hip girdle (usually associated with complaints of difficulty in raising head from pillow, combing hair, raising arms above head and climbing stairs) usually implies muscle disease In severe proximal muscle weakness, Gower sign will be positive (Fig 10) Remember, the key feature that makes a Gower sign positive is not so much the “walking up legs” which may be absent if the proximal weakness is mild The child is required to turn from supine lying to prone position as a preclude to getting up The child will have difficulty rising from the floor (Gower’s maneuver) where the child climbs up his thigh with his hands to get up off the floor Proximal weakness of the body usually implies muscle disease while distal weakness as evidenced by difficulty in opening caps of bottles, turning keys, buttoning clothes usually occurs in neuropathic disease or in dyspraxic child Illustrated Textbook of Pediatrics 446 – – – Movement which is possible with gravity eliminated Movement which is possible against gravity Movement which is possible against gravity plus resistance but which is weaker than normal – Normal power Since this is a relatively crude scale, it is acceptable to subdivide grade-4 into +, and 4–, thus improving sensitivity In younger child, assessment of power may be difficult Try to assess power in the form of playing game with child and appreciating the child, while you observe, whether the child can lift (power level at least 3) his/her limbs and can kick or fist you against resistance (power level to 5) Knee Jerk (L3, 4): It can be elicited in various ways depending on age of the child In younger children adequate relaxation of quadriceps, muscles for elicitation of knee jerks can be assured with both child and examiner being seated and facing each other (Fig 14) Put the child’s feet either up on the front edge of your chair (Fig 15) or on your knees (Fig 14) In young infant it can be elicited in supine position (Fig 16) Feel the patellar tendon by thumb and placing thumb on tendon, strike your thumb with the hammer in young infant (Fig 16) In big child patellar tendon can be hit directly (Figs 14 and 15) Look jerks, by looking at brisk contractions of quadriceps and sudden extension of knee joints REFLEXES The successful elicitation of a deep tendon reflex requires the muscle belly to be relaxed yet moderately extended Attention to optimal limb position is thus helpful Young children may also be disconcerted by the idea of being hit! For both these reasons examination of reflexes in the upper limb can be helped by your holding the arm, placing a finger or thumb over the tendon and striking your own finger or thumb With the child’s hands on his/her lap, press firmly with your thumb over the biceps (C5) tendon just above the elbow and strike your thumb (Fig 11) Elicited jerks are often as much felt (through your thumb) as seen Supinator reflexes (C5, 6) can be elicited by striking your finger placed just proximal to the wrist over the radial side of the partially supinated forearms as it rests in the child’s lap or for bigger children directly hitting on supinator tendon as shown in Figure 12 Triceps (C6, 7) may require a slightly different approach: hold the arm abducted at the shoulder to 90o and with the forearm hanging down passively, and strike the tendon directly as you won’t have a hand free (Fig 13) Fig 13: Eliciting triceps reflex (C6, 7) Fig 14: Eliciting knee jerk (L3, 4) in young child while both child and examiner being seated and facing each other Fig 11: Eliciting bicep reflex (C5) Fig 12: Eliciting supinator reflex (C5, 6) Fig 15: Eliciting knee jerk in young child in sitting position while legs are hanging from sitting position When tendon reflexes are pathologically exaggerated, they often spread beyond the muscles stimulated by nerve concerned and adjoining muscle of same side or even opposite limb may show brisk contraction (cross hyperreflexia) For examples in spastic CP, hyperreflexic knee joint in one side may be associated with brisk contraction of adductor muscle of opposite side (Cross adduction) (Fig 17) Hyperreflexia is usually associated with hypertonia Exaggerated hyperreflexic knee jerk not only can be elicited by striking patellar tendon, but also by striking hammer lower down the patellar tendon, e.g on shin of tibia Therefore if hyperreflexic knee jerk is expected, start striking gently on shin of lower tibia and gradually step up striking shin gently and finally strike patellar tendon (Fig 18) In hyperreflexic knee jerk, hyperreflexia may start well below down the patellar tendon due to extended afferent (usually seen in spastic CP) Observe at what level below patellar tendon, the quadriceps start contraction Also look for cross adduction in such case Similarly finger flexion often accompanied biceps and supinator jerks, when they are pathologically exaggerated Hoffman Sign It is another manifestation of hyperreflexia It is elicited by first flexing the distal interphalangeal joint of the patient’s middle Clonus When the tendon reflexes are exaggerated as a result of corticospinal lesion, there may be clonus To test for ankle clonus, bend the patient’s knee slightly and support it with one hand, grasp the fore part of the foot with the other hand and suddenly dorsiflex the foot The sudden stretch causes brief reflex contraction of the calf muscles, which then becomes relaxed, continued steady stretch causes a regular oscillation of contraction and relaxation which is called clonus There may be clonus with minimal or no stretch, called spontaneous clonus Sustained clonus or spontaneous clonus is abnormal and is evidence of an upper motor neuron lesion (Fig 19) Grading the Reflexes The tendon reflexes are graded as follows: – Absent – Present – Brisk – Very brisk with extended afferent and cross hyperreflexia – Clonus Ankle Jerk (S1, S2) In supine posture, place the lower limb on the bed so that it lies everted and slightly flexed Then with one hand slightly dorsiflex the foot so as to stretch the Achilles tendon and with hammer on other hand, strike your hand which dorsiflexed the child’s foot or if the child is big (> years) strike the tendon directly on its posterior surface of tendoachilles A quick contraction of calf muscle results (Fig 20) Planter Response (S1) Planter responses are elicited in usual manner A firm but gentle striking stimulus to the outer edge of the sole of the foot evokes initial dorsiflexion (extension) of large toe and fanning of the other toes, which is positive Babinski sign, characteristic of pyramidal lesion; but it is normal below 18 months of age For positive Babinski sign, always look for initial upward movement of hallux, as it may undergo flexion following brief dorsiflexion, and falsely interpreted as negative Babinski sign (Fig 21) Fig 17: Exaggerated knee jerk with hitting the left patellar tendon and showing contraction of adductor muscle of hip of opposite side (right) due to cross adduction (see arrow) Fig 18: Eliciting knee jerk in upper motor neuron lesion with hyperreflexia with suspected extended afferent Picture shows striking hammer on shin of lower tibia and gradually stepping up in order to identify the point where hyper-reflexia begins below patellar tendon (dots and arrow marks) for extended afferent Fig 19: Testing for ankle clonus 447 Pediatric Neurology Fig 16: Eliciting knee jerk in young infant Relax quadriceps by flexing the knee with one hand and placing the thumb on the patellar tendon Strike your thumb with the hammer in your free hand Look for quadriceps contraction or feel the contraction with the hand on the infant finger and then flicking it down further so that it springs back to normal When tendon reflexes are hyperactive the thumb quickly flexes in response to this maneuver Tendon reflexes are exaggerated in upper motor neuron disease (pyramidal) Children with spastic CP are usually associated with hyperreflexic tendon reflexes Illustrated Textbook of Pediatrics 448 Fig 22: Reinforcement in eliciting the knee jerk Fig 20: Eliciting ankle jerk in a small infant, with one hand dorsiflexing in the foot while with hammer on the other hand striking the hand of the examiner which dorsiflexed the child’s foot point discrimination Loss of spinothalamic and preservation of dorsal column (touch and proprioception) is an important sign of Syringomyelia Joint position sense may be assessed at a single joint in the older child in the usual manner, but it is more useful to screen for compared proprioception by performing the Romberg test (looking for increased body sway in standing with eye closed) COORDINATION OR ATAXIA Fig 21: Eliciting the planter reflex (S1) showing extensor response Diminished or absent tendon reflexes: Diminished or absent tendon reflexes: Usually associated with hypotonia, associated with lower motor neuron disease [Guillain-Barré syndrome (GBS), spinal muscular atrophy (SMA), etc ] The significance of depressed tendon reflexes needs to be interpreted by comparison between the responses obtained on two sides and between the amplitude of the jerks in the arms and those in the legs If normally brisk contractions are seen in the arm and the very poor responses are evoked at knee and ankles, then it is possible that the later findings are pathological Reinforcement: In bigger child if no response is obtained after routine tendon tap, the absence of reflexes should be confirmed by reinforcing the jerk Tendon reflexes are increased in amplitude (i.e potentiated or reinforced) by forcible contraction of muscles remote from those being tested To reinforce the knee and ankle jerks, the patient may be asked forcibly to close the hands An alternative procedure requires the patient to hook the fingers of the hand together and then forcibly attempt to pull one away from the other without disengaging the fingers (Fig 22) Abdominal reflexes are elicited by scratching the skin along a dermatome toward the midline They may be absent in 15% of the normal population and may be normally asymmetrical They can help localize thoracic spinal cord lesion, though they are less reliable than sensory level to pin prick SENSATION If indicated assess sensation by asking them to close their eyes and say “yes” every time they feel your touch Pain and temperature sensation (testing spinothalamic tract) may be difficult in children, but if possible should be carried out by two Truncal Coordination: Measure of Cerebellar Function Ask the child to walk on a straight line, with heel of one foot just in front of toe of other foot (heel-toe walking) keeping upper arms folded in front of chest, so that the child cannot compensate possible balance problem by freed upper arms Child with truncal coordination (cerebellar vermis lesion) problem cannot perform It may be found in a child with motor coordination disorder This is called Tandem test (Figs 7A and B) Peripheral in-coordination (Finger-nose test): Ask the child to move his index finger from tip of his nose to the tip of your index finger, and back to the tip of his nose Ask to it repeatedly Emphasize the accuracy not the speed, whether finger lands precisely on tip of the nose If this movement is performed naturally and smoothly and without random errors, coordination (peripheral) is normal If finger cannot touch tip of nose, rather goes past nose (past pointing dysmetria), then incoordination (cerebellar hemisphere) is present Intention tremor: It is characteristic of damage of posterior lobe of the cerebellum The patient’s hand is steady at rest but develops a tremor as it approaches its target, e.g as it approaches tip of his nose or tip of examiner’s index finger CRANIAL NERVES Olfactory Nerve (I) Rarely tested in children, may be tested in condition associated with anosmia (Kallmann syndrome) Optic Nerve (II) Visual Acuity Test If the child is small (