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Neurology Head Tower head or oxycephalic skull suggest premature closure of sutures (craniosynostosis) Broad forehead hydrocephalus Small

lus Small head microcephaly Square or box-shaped head suggest chronic subdural hematomas (enlargement of middle fossa) Observe venous pattern: increased ICP and thrombosis of superior sagittal sinus venous distention Cutis aplasia Abnormal hair whorls Two fontanels o Diamond shaped open anterior fontanel at junction of coronal and sagittal sutures, approximately 2 x 2 cm, average time of closure is 18 months but can close as early as 9 months; very small or absent anterior fontanel at birth premature fusion of sutures or microcephaly o Posterior fontanel at intersection of occipital and parietal bones, may be closed at birth or at most admit tip of finger; usually closed and nonpalpable by 1st 6 to 8 weeks of life; persistence suggests underlying hydrocephalus or the possibility of congenital hypothyroidism o Normally slightly depressed and pulsatile o Best evaluated when infant is upright while asleep or feeding o Bulging fontanel increased ICP; vigorous crying Palpation o Overriding of sutures for 1st several days, if longer underlying abnormality of brain o Craniotabes or softening of the parietal bone, often prematurity Auscultation o Cranial bruits over anterior fontanel, temporal region or the orbits o Soft symmetric bruits may be seen in normal children <4 years or in association with febrile illness o AV malformation of the middle cerebral artery or vein of Galen loud bruit o Murmurs from heart or great vessels may be transmitted to the cranium o Severe anemia may present with skull bruit that disappears with anemia o Increased ICP can cause bruit Head circumference o Midforehead extended circumferentially to include the most prominent portion of the occiput o Average head growth in a healthy premie is 0.5 cm in the 1st 2 wk, 0.75 during 3rd wk, and 1 cm in the 4th wk and thereafter until 40th wk o Term infant measures 34-35 cm, 44cm by 6 mo and 47 by 1 yr age

Smell can be reliably tested as early as the 32nd wk of gestation

Optic nerve Dilation of pupil to better visualize the retina: one drop of a combo: 1% cyclopentolate HCl, 2.5% phenylephrine HCL, and 1% tropicamide repeated 3 times at 15 min intervals effectively produces mydriasis Mydriatics should not be used if a patients pupil reaction is necessary to follow the level of consciousness or if a cataract is present Optic nerve is salmon pink in a child but is gray white in the newborn Papilledema, swelling of the optic disc due to ICP; rarely occurs in infancy because the skull sutures are capable of separating o Optic nerve becomes hyperaemic o Small capillaries that normally cross the optic nerve are no longer visualized (constricted) o Larger veins become dilated, arterioles constricted o Border of CNII becomes indistinct o Subhyaloid, flamed shaped haemorrhages appear in retina o Macular star develop in some due to retinal edema in the region of macula Papillitis is due to inflammation of the nerve (neuritis); there is visual loss unlike in papilledema but the blind spot is increased in both Retinal hem occur in 30-40% of a full term newborn infants; more common after vaginal delivery; not associated with birth injury or with neurologic complications; disappear spontaneously by 1-2 wk of age VISION o Normal 28 wk premie blink when a bright light is directed to the eyes and by 32 wk, maintain eye closure until the light source is removed o 37 wk normal premie turn the head and the eyes to a soft light and by term, visual fixation and follow brilliant target is present o Optokinetic nystagmus can be demonstrated in an alert newborn o VA in term infants ~20/150 and reaches 20/20 by about 6 mo of age o Children as young as 2.5-3 yrs with normal vision can identify the objects on the Allen chart at a distance of 15-20 ft o Pupil reacts to light by the 29th-32nd wk of gestation o Important to note presence of heterochromia or brushfield spots in the iris o Horner syndrome: miosis, ptosis, enophthalmos, and ipsilateral anhidrosis ; congenital or from a lesion involving the brainstem, cervical cord, sympathetic plexus in juxtaposition of carotid artery

Oculomotor , Trochlear, Abducens Nerve III superior, inferior, and medial rectus, inferior oblique, and levator palpebrae superioris muscles; complete paralysis causes ptosis, dilation of the pupil, displacement of the eye outward and downward, impairment of adduction and elevation IV superior oblique muscle; isolated paralysis causes the eye to deviate upward and outward, often with head tilt to compensate for vertical displacement of images VI- lateral rectus muscle; paralysis causes medial deviation of the eye with inability to abduct beyond the midline

Cranial Nerves Olfactory nerve Anosmia commonly associated with URTI; fracture or the base of the skull and cribriform plate as well as a frontal lobe tumor; rarely congenital

In older children, RED GLASS TEST is used to assess extraocular palsies Internuclear ophthalmoplegia due to lesion in the medial longitudinal fasciculatus of the brainstem and consists of paralysis of medial rectus function of the adducting eye and nystagmus confined to the abducting eye Internal ophthalmoplegia refers to a dilated pupil that is unreactive to light and accommodation but has normal extraocular functions External ophthalmoplegia: ptosis and paralysis of all eye muscles with preservation of the papillary response Nystagmus is an involuntary rapid movement of the eye that may be horizontal, vertical, rotator, pendular, or mixed Jerk nystagmus describe a fast and slow phase and is usually normal when only present at end point of lateral gaze Horizontal nystagmus occur with an abnormality of the peripheral labyrinth or with a lesion of the vestibular system in the brainstem or cerebellum (or drugs like phenytoin) Vertical nystagmus is indicative of brainstem dysfunction or structural. Complete ocular movement: 25 week of gestation using the dolls eye maneuver (vertical and horizontal eye movements) Opsoclonus or chaotic jerky oscillations of the eyes often associated with neuroblastoma or viral infections Ocular bobbing associated with pontine lesions Premies have slightly disconjugate eyes at rest, with one eye horizontally displaced from the other by 1 or 2 mm Skew deviation of the eye (vertical displacement) is always abnormal

Congenital anomalies of head and neck Bacterial meningitis Congenital infections due to rubella, toxoplasmosis, herpes, and cytomegalovirus Vestibular function may be evaluated by the caloric test: normal subjects, ice water produces nystagmus with the quick component in the opposite direction to the stimulated labyrinth; no response implies severe dysfunction of the brainstem and medial longitudinal fasciculus (dont perform in ruptured TM syempre)

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Glossopharyngeal Nerve Innervates stylopharyngeus muscle Isolated lesion is rare Observe gag response Taste for posterior 1/3

Vagus Nerve Unilateral injury produces weakness and asymmetry of the ipsilateral soft palate and a hoarse voice due to paralysis of a vocal cord Bilateral lesion: respiratory distress as a result of vocal cord paralysis; nasal regurgitation of fluids; pooling of secretions, and an immobile, low-lying soft palate Isolated lesions: after thoracotomy due to separation of recurrent laryngeal nerve; common in type II chiari malformation To test for cough in a neonate/infant, the examiner applies gentle pressure to the trachea at the suprasternal notch

Trigeminal Nerve Ophthalmic, maxillary, mandibular Tested by light touch and pinprick Corneal reflex Function in premies is best documented by facial grimacing from a pinprick or by stimulating the nostril with a cotton tip Absent reflex may be due to sensory defect (trigeminal) or motor defect (facial) Motor function may be tested by examination of the masseters, pterygoid, and temporalis muscles during mastication as well as by evaluation of the jaw jerk

Accessory Nerve Paralysis and atrophy of the sternocleidomastoid and trapz SCM is tested by forceful rotation of the head and neck against the examiners hand Motor neuron dss, myotonic dystrophy, and myasthenia gravis

Hypoglossal Nerve Innervates the tongue Wasting, weakness and fasciculations If injury is bilateral: no tongue protrusion, dysphagia may be present Werdnig-Hoffmann disease and congenital anomalies in the region of foramen magnun

Facial Nerve Upper motor neuron or supranuclear corticospinal lesion : decreased voluntary movement of lower face with flattening of nasolabial angle on ipsilateral side Lower motor neuron tends to involve the upper and lower facial muscles equally Test for anterior 2/3 of the tongue

Auditory Nerve Neurologically, abnormal infants do not habituate By 3 months, normal infants turn toward source of sound Risk factors for testing with Audiometry or brainstem evoked potential testing: o Family history of deafness o Prematurity o Severe asphyxia o Use of ototoxic drugs in the newborn period o Hyperbilirubinemia

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