Neurological assessment

• Neurological exam in children can be difficult. Information can be gained through observing play, including fine motor skills, coordination and problem solving.
• Be flexible when assessing children. The initial examination is best completed with the parent or carer close by to reduce anxiety.
• Watch for age-appropriate milestones.
• Repeat the GCS.
• Check the pupil size, reactivity and equality.
• Assess arm and leg movements and strength, and document discrepancies.
• Observe posture and tone.
• If the patient is safe to mobilise observe gait, balance and coordination.
• Monitor vital signs.
• Neurological instability may present as:
• rapid or irregular respiratory rate
• hypertension
• temperature instability
• rise in pulse, followed by bradycardia if increased intracranial pressure
• blood sugar irregularities.

• Check fontanelles and neonatal reflexes in neonates and infants.
• Note the quality of the cry or vocalisation.

Intracranial pressure (ICP)

• Assess for an acute rise in intracranial pressure.
• Increased ICP may present as:
• severe headache
• persistent vomiting
• change in behaviour or altered mental state
• posturing (decerebrate and decorticate)
• Cushing's triad (a late sign), i.e. irregular respirations, widened pulse pressure and bradycardia.
• If concerned, elevate the head of the bed and escalate urgently as per local CERS protocol.

Cranial nerves

Cranial nerve examination is not always essential when initiating care. The following prompts can be used to complete the assessment, if concerned.

• Olfactory nerve (I):
• Ask the patient to smell something.
• Optic nerve (II). Use appropriate tool such as:
• Reaching for objects of interest or objects out of immediate reach.
• An appropriate Snellen chart with letters or shapes.
• Assess peripheral vision.
• Assess pupillary reflexes.
• Oculomotor, trochlear and abducens nerves (III, IV, VI):
• Look for ptosis.
• Assess extraocular eye movement, fix and follow.
• Look for facial symmetry. Comparing nasolabial folds may show subtle asymmetry.
• Assess the motor function of the facial muscles looking for asymmetry when crying or smiling.
• If age appropriate ask to copy your facial expressions or make facial expressions, e.g. blow out cheeks, show your teeth, screw up eyes or wrinkle forehead.
• Vestibulocochlear nerve (VIII). Use appropriate tool such as:
• Make a subtle sound next to their ear and watch for a response.
• Whisper several short sentences and ask them to repeat them.
• Assess balance, balance issues may include poor head control, ataxia, truncal unsteadiness, nausea and vomiting.
• Glossopharyngeal and vagus nerve (IX, X):
• IX, assess soft palate sensation and taste. Observe the uvula and ask the child to say "Ahh".
• Observe swallowing, drooling and coughing with feeds.
• X, assess cough, vocal cord control and voice.
• Accessory nerve (XI):
• Ask the patient to scrunch their shoulders up towards their ears.
• Ask patient to turn head against resistance.
• Hypoglossal nerve (XII):
• Look at the tongue when inside the mouth for fasciculations.
• Ask the child to stick out their tongue and assess for tongue deviation.
• Check whether the tongue can be equally protruded on both sides.