OS 211 [A]: Integration, Coordination and Behavior

Neurologic Evaluation of Children with

Neurodevelopmental
Disorders
Name of Lecturer

I.
II.
III.
IV.

Introduction
Developmental Milestones
Key Principles: Reflexes
The Neurologic Examination
A. Sequence of Exam
B. Overview of the Stages of the Exam
C. Instruments and Tools
D. Components of the Exam
V. Important Reminders
VI. Summary
I.

Hello! This is based on Maam slides, lectures, Nelsons Pediatrics 19th ed,
Bates, and pictures from the internet. We hope this helps! Focus on
developmental milestones daw. :P
PS: Maam didnt give a copy of her powerpoint to us, so we couldnt write a
more detailed descriptions of the videos. We tried to add pictures instead.

OUTLINE AND OBJECTIVES:

Review the components of a neurologic examination

Review the emerging patterns of behavior from newborn to 5

years of age: focus on developmental milestones

Demonstrate an easy, rapid and complete neurologic examination

in small children
Emphasis on newborns and infants less than 2 years old.

March 1, 2016
Trans Number: 10

Dr. Lukban

OUTLINE

EXAM #2

I. INTRODUCTION
Modern technology DOES NOT and CANNOT substitute
for skilled history taking (and physical/neurologic
examination)
It is...
o Not a netting operation

Right now were used to casting out a net and

doing everything we like, hoping to find
something and synthesizing that data

But a neurological examination of children needs

to be dynamic in order to answer the questions
that we have
o Not data to be sorted later
o Data is: (Swaiman, 2006)

Dynamically synthesized when collected

Used to alter the direction and depth of the

questioning (and examination) process
It aims to answer the following questions (using the history
and neurologic examination):
o Is the nervous system involved?

Watch out for symptoms that hint at nervous

system involvement, such as weakness,
headaches, seizures, numbness, changes in
sensorium or consciousness.

At what age did the problem occur?

Did it occur during birth, infancy, childhood,

adolescence, or adulthood?

Different disorders manifest at different life

stages
o Is the process acute (ex. vascular), insidious (ex.
tumor), or chronic?
o Is the process progressive (ex. IEM) or static (ex.
Cerebral Palsy)?
o Is the problem familial or sporadic?
o Is the involvement diffuse or localized (focal or
generalized)?
In the physical and neurological examination, the goal of
the examiner is to get the child to be calm and cooperative
for the longest possible time.
o First key principle: Have a patient that will
cooperate with you.
o Least intrusive parts done first

Observe the child as he/she is playing and

interacting with the parents
o Allow parents to participate in calming the baby

Dont touch the patient right away!

o Do things in stages, including undressing (all of them
should be undressed as we need to look for
neurocutaneous lesions)
o PLAY!

II. DEVELOPMENTAL MILESTONES

Neurologic exam is performed in the context of
developmental milestones
Developmental milestones reflects the maturation of the
childs nervous system
What are we looking for?
o Delay in obtaining developmental milestones and
o Abnormal patterns of development are important
indicators of underlying neurological disease
Note: Memorize the developmental milestones

Table 1. Gross Motor Developmental Milestones

Age
2 wks
2 mos

2 years

3 years

3 mos

4 mos
6 mos
6.5 mos
12 mos
18 mos

4 years
5 years
6 years

Gross Motor
Moves head from side to side
Holds head steady while sitting
Follows past midline
Pulls to sit, with no head lag
Brings hands together in midline
Palmar grasp
Asymmetric tonic neck reflex gone
Sits without support
Rolls back to stomach
Walks alone
Stoops and stands
Runs
Kicks ball
Walks ups and down stairs one step at a
time
Throws overhand
Walks up and down steps with
alternating feet
Broad jump
Balances well on each foot
Hops on one foot
Skips
Heel-to-toe walks
Balances on each foot for 6 secs

Table 2. Fine Motor Developmental Milestones

Age
3.5 wks
4 mos
5.5 mos
8 mos
12 mos
13 mos
15 mos
18 mos
2 years
3 years
4 years
5 years
6 years

Fine Motor
Grasps rattle
Reaches for objects
Palmar grasp gone
Transfers object hand to hand
Thumb-finger grasp
Turn pages of book
Scribbles
Builds tower of 2 blocks
Builds tower of 4 blocks
Builds tower of 6 blocks
Copies line
Builds tower of 8 blocks
Wiggles thumb
Copies circle
Draws person with 3 parts
Copies square
Copies triangle
Draw person with 6 parts

Table 3. Communication and Language Developmental Milestones

Age
2 wks
1.5 mos
2 mos

9-10 mos

12 mos
15 mos
18 mos

4 mos
6 mos
7 mos

Communication and Language

Alerts to bell (or voice)
Smiles in response to face, voice
Cooing
Searches for sounds with eyes
Laughs and squeals
Monosyllabic babble
Inhibits to no
Follows one-step command with gesture
Follows one-step command without
gesture
Says mama or dada
2-syllable sounds
Points to objects
Speaks first real word
Speaks 4-6 words
Speaks 10-15 words

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OS 211 [A]: Neurologic Evaluation of Children

2 years

3 years

4 years
5 years
6 years

Speaks 2-word sentences (ex: Mommy

shoe)
Points to pictures
Knows body parts
Names pictures
Speech understandable
Says 3-word sentences
Names colors
Understands adjectives
Counts
Understand opposites
Defines words

Table 4. Social/Cognitive Developmental Milestones

Age
2 wks
2 mos
4 mos
6 mos
8 mos

9 mos
12 mos

15 mos
17 mos

2 years

3 years
4 years

Social/Cognitive
Regards face
Smiles responsively
Lack of object permanence
Stares at own hand (self-discovery)
Cause and effect
Feeds self
Holds bottle
Bangs 2 cubes (active comparison of
objects)
Object permanence
Waves bye-bye
Plays patty cake
Begins symbolic thought
Egocentric symbolic play
Drinks from cup
Imitates others
Uses spoon and fork
Helps with housework
Able to link actions to solve problems
Symbolic thought
Pretend play
Washes and dries hands
Brushes teeth
Puts on clothes
Uses spoon well, spilling little
Puts on t-shirt
Brushes teeth without help
Dresses without help

III. KEY PRINCIPLES: REFLEXES

Development of motor control proceeds in a head to toe
fashion
o A child who has not learned to control his/her head
will not be able to sit and achieve truncal control. A
child who has not learned to sit, will not be able to
stand and walk.

In infants, absence or presence of primitive reflexes are

determined to evaluate the maturation stage of the
nervous system
On the other hand, the segmental reflexes of the muscle
stretch reflexes and the superficial reflexes are elicited to
determine the site of affection of the nervous system,
i.e. location of lesion.
Persistence of primitive reflexes (Moro, grasp) and the
lack of development of the postural reflexes (Landau,
parachute) are the hallmarks of an upper motor neuron
abnormality in the infant.
See Appendix for Primitive and Postural Reflexes

IV. THE NEUROLOGIC EXAMINATION

A. Sequence of Exam

Observation

Inspection

Palpation

Manipulation
B. Overview of the Stages of the Exam
Table 5. Stages of Neurologic Examination

Stage 1

Stage 2

Stage 3
Stage 4

Observation
Inspection
Child allowed to play around, baby carried by
mother in the lap
Palpation
Manipulation
Baby on examination table
Intrusive tests
Ex: Fundoscopy, head circumference
Special maneuvers to elicit function

*Sequence of examination is FLEXIBLE as compared to adults and

older children (but report like in Adult neuro exam)

C. Instruments and Tools

Neuro kit

Stethoscope

Toys
o Ex. rattle, plush toys, pretty/colorful toys

Children's books

Colorful pens, pencils, drawing materials

D. Components of the Exam
1. Physical Exam
Somatic Growth

Check for the following:

o Height
o Weight
o Head circumference

>+2 or >-2 Z-score is abnormal

o Check centiles.

Use standard tables (See appendix)

o Compare with chest circumference and parents head
Fontanels and Sutures (From 2017 and 2018)
Table 6. Development of fontanels and sutures

Age
3mo
6mo
20mos
8 yrs
12 yrs

Figure 1. Primitive and Postural Reflexes. Primitive reflexes disappear at

about 6 months and postural reflexes appear. Additional reflexes develop over
time.

Primitive reflexes:
o Reflex actions originating in the central nervous
system that are exhibited by normal infants, but not
neurologically intact adults, in response to
particular stimuli
Postural reflexes:
o Automatic movements that control the equilibration
(balance, posture, and movement) we require once
upright and moving and having to combat the effects
of gravity

20 yrs
th
8
decade

Development
Posterior fontanel closed
Fibrous union of suture lines occurs & serrated
edges interlock
Anterior fontanel closed (others close at 18 mos.)
Ossification of craniobasal bones is complete
Sutures cannot be separated by raised intracranial
pressure more dangerous
Sutures still visible on radiographs
Solid bony union of all sutures is complete
* check for symmetry of the head

Closure:
o Anterior fontanel 18-20 mos
o Posterior fontanel 3 mos
Craniosynostosis microcephaly (complete closure of
all sutures)

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Example of Dysmorphic features

Crouzon's syndrome

Abdomen

Check for visceromegaly

o Storage diseases
Back and Spine

Scoliosis

Sacral abnormalities

Figure 2, 3, 4. Children with Crouzons syndrome. Usually present with

craniosyntosis and midface hypoplasia. May also present with
exophthalmos (bulging eyes due to shallow eye sockets after early fusion of
surrounding bones), hypertelorism (greater than normal distance between
the eyes), and psittichorhina (beak-like nose), external strabismus,
hypoplastic maxilla (insufficient growth of the midface) results in relative
mandibular prognathism (chin appears to protrude despite normal growth of
mandible) and gives the effect of the patient having a concave face.

Down syndrome
o Macroglossia and Mongolian slant of eyes

Figure 5, 6, 7. Children with Down syndrome. Usually present with a

small chin, macroglossia, Mongolian slanted eyes, flat nasal brigde, flat
and wide face, with a short neck.

Eye examination

The eye is the window to the brain

Check the fundus and retina.

o Congenital TORCH infection retinitis pigmentosa
Skin search

Look for stigmata of neurocutaneous syndromes

Table 7. Example of Neurocutaneous lesions.

Disorder
Tuberous
sclerosis
with infantile spasms

At least 3 spots

Often come in other

shapes, although
most are polygonal

Usually 0.5-2 cm in
diameter,
and
resemble
a
thumbprint

Watch
out
for
because might be
with seizures
Sturge Weber

Caused by vascular
anomaly

Watch
out
for
because might be
with seizures

Lesion
Ashleaf
patch

Figures 8, 9, 10

2. Stages
Stage 1: Mostly Observation

Starts during history taking

Children 2 to 5 years old - can participate in the history

taking, gives us an idea of his intellectual and language
skills, as well as behavior
o Ex. Extend your arm to a child as in Pinapamano mo
yung bata or ask the child How old are you? If child
does not respond or does not look directly at you
(examiner), screen for possible autism.

Two-step behavior, acknowledging examiner and

doing the action.

Child with autism will not acknowledge the hand.

Alternatively, can also ask them to look at the

light.

Through asking a child how he/she is, you can

also start to asses IQ.
o From 2018. Assess child for

Cooing- 6 mos, mama- 9 mos.

Mama is mama, papa is papa- 1 year/13 mos.

Complete sentence- 2 years old

Child less than 2 years old (usually in their mother's lap)

o Motor and verbal abilities in developmental history
o Observe & ask mother state of alertness, awareness
of surroundings, vocalization, behavior, facial and
ocular movements, symmetry of limb movements

Newborns and preterms

o Observe facial and motor movements during awake
and sleep states
o Inspect and palpate the head and the sutures

By observation:
o Detect abnormal involuntary movements
o Assess facial and eye movements
o Allow the child to play (should be appropriate for
his/her age) check for motor skills
Stage 1: Mental Status and Cranial Nerve Exam

Mental status: Alertness and responses to visual, tactile,

and auditory stimuli

Motor function: Muscle bulk, posture, limb position,

symmetry of movements, presence of abnormal and
involuntary movements

Cranial nerves
Table 8. Strategies to Assess Cranial Nerves in Newborns and Infants
from Bates Guide to Physical Examination and 2018 (in italics)

CN
Facial portwine stain

II
II and
III
III, IV,
VI
V
VII
VIII

Neurofibromatosis

Hyperpigmented

May be present at
birth or develop
within the first1-2
years of life.

At least 6 spots

Watch
out
for
tumors in the ears
and eyes

Caf au lait
spots

IX, X

XI
XII

V, VII,
IX, X,
XII

Strategy
Have baby regard your face and look for facial response and
tracking. Response to light while head is in midline.
Darken room, raise baby to sitting position to open eyes
Use light and test for optic blink reflex (blinking in response
to light). Use otoscope to assess papillary response.
Observe tracking as the baby regards your or mothers
smiling face move side-to-side.
Test rooting reflex. Test sucking reflex. Eye blinking as
response after visual threat.
Observe baby crying and smiling, note symmetry of face and
forehead.
Observe response to sound, turning of the head to the
source. Test acoustic blink reflex (blinking of both eyes in
response to noise).
Note the quality and strength of the cry. Observe
coordination during swallowing.
Observe symmetry of shoulders. Observe head and truncal
control
Observe coordination of swallowing, sucking, and tongue
thrusting. Pinch nostrils, and observe reflex opening of
mouth with tip of tongue midline.
Observe how the patient sucks and swallows milk

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Notes from the video
Normal Term Newborn Inspection

Baby is awake, alert

CN 2 function intact: Baby able to follow examiners face.

CN 3, 4, 6 function intact: Baby able to track.

CN 7: symmetrical

Symmetry in movement of both hands

Examiner is trying to test for sensation of the face

Cranial Nerves, motor function and moro reflex

Baby extends hands

Legs are symmetrical

Asymmetrical tonic head reflex

Abnormal Newborns Inspection
1. Normal
o No facial symmetry
o Arms are extended
o Abdominal breathing
o But legs are in a flexed position
2. Abnormal
o Baby with Down syndrome
o Hypotonic
4 months

Smiling

No facial asymmetry

Symmetrical movement of hands and legs

Should already be able to turn over and lift the chest with
hands when placed on a prone position

4 year old

Able to go up and down the stairs without assistance

Able to throw a ball in hyperbolic direction (in contrast to 2

yo who will just throw it downwards or release it)
Stage 2: Palpation and Manipulation Ventral position

Motor function: Posture, tone, motor strength and

abilities, fine motor skills and handedness, visuo-motor
coordination
o Note: When testing for motor function, make sure that
the head is midline or else you might get falsely
asymmetric results.

Developmental Reflexes and Deep Tendon Reflexes:

keyword is symmetry. Use fingers to elicit reflexes! Look
at Appendix for more reflexes!

Cranial Nerves refer to Table 8.

Cerebellar Function use a toy in finger-to-nose testing,

identifying his/her body parts.

Some notes:
o Preterm

Prone C-shaped spine, hypotonic

Upper and lower extremities extended

o 6 mos

Ventral suspension the examiner suspends

infant in prone position by supporting abdomen of
baby on his palm and assessing extension of
neck and flexion of extremities.
o 9 mos

Pull-to-sit maneuver normal response: infants

head will follow and arms will flex to help pull
itself up

In the video, there was head lag and extension of

arms.
o 18 mos

In the video, the 18 month-old was unable to

maintain a standing position with an inversion of
foot, which suggests a weakness in the
hamstrings.

Figure 11. Sample picture of baby in prone position. (Not from video)

9 months (abnormal)

Hands are extended

Legs are in a frog-leg position, very weak

Unable to do pull-to-sit maneuver (head lag, arm just

extend unable to flex to help achieve sitting position)

Presence of head lag when trying

Unable to follow things (normal)

Figure 12. Sample picture of baby with frog-leg position. (Not from
video)

Figure 13. Sample picture of baby with head lag during the pull-to-sit
maneuver. (Not from video)

18 months

Just crying

Reaching out hands

Poor head control, muscles look thin

Asked to take tape measure, but did not perform

Some inversion of foot

Unable to run, just sitting with assistance

Figure 14. Sample picture of baby with in ventral position (Not from
video)

Figure 15. Sample picture of baby with normal pull-to-sit maneuver

response. (Not from video)

Stage 3: Intrusive Tests

Head circumference measurement

o Perform twice
o Glabella and most prominent part of occiput

Fundoscopic examination and pupillary light reflex

Examination of the ears, mouth, throat, and teeth.

Examination of the anal sphincter reflex

Palpation of abdomen for hepatosplenomegaly

Stage 4: Maneuvers (Observation and Manipulation)

Motor function
o Gait and balance abnormalities walk on toes,
walk on heels, stand on one feet, tandem gait,
Romberg's test
o Motor strength traction or pull to sit maneuver,
parachute
response,
wheelbarrow
maneuver,
crawling
o Fine motor skills test hand function (give child
crayon, observe how he grasps it while scribbling)

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Figure 16. Parachute reflex. This occurs in slightly older infants when the
child is held upright and the baby's body is rotated quickly to face forward
(as in falling). The baby will extend his arms forward as if to break a fall,
even though this reflex appears long before the baby walks

3. Notes from Bates

Neurologic Examination of Newborns and Infants

neurologic screening examination of all newborns should

include assessment of:
o Mental status
o Gross and fine motor function
o Tone

First by carefully watching their position at rest

and testing their resistance to passive
movement.

Move each major joint through its range of

motion, noting any spasticity or flaccidity.
o Cry
o Deep tendon reflexes and primitive reflexes

If you suspect any abnormalities from the history or

screening, a more detailed examination is indicated.
o Cranial nerve function
o Sensory function
o Less common primitive reflexes

Figure 17. Palmar, Intermediate, and Pincer Grasps.

Sensory function

Notes from video

Rett Syndrome

Loss of ability to use hands

A genetic disorder of neurodevelopmental arrest rather

than a progressive process

Physical findings vary according to the clinical stage of

disorder. Common findings include:
o Stage 1: Gross motor delay, loss of eye contact
o Stage 2: Autistic-like behavior
o Stage 3: Hand stereotypies, rigidity
o Stage 4: Dystonia, muscle wasting, quadriparesis
Teenager with Nystagmus

Has horizontal and lateral nystagmus

Tandem walk abnormal

Diagnosis: Cerebellar Tumor

Viral encephalitis

Mask-like facies

Dystonic gait when walking

Basal ganglia lesion

From 2017

The plantar response is plantar flexor in direction in all

children with normal CNS function. According to Paine and
Oppe, a bilateral Babinski sign is seen normally in the
majority of 1 year old children and in many up to 2 12
years of age but if asymmetrical, there is a problem

How to elicit: stroke the lateral border of the sole forward

crossing over the distal end of metatarsals toward the
base of the great toe. You may use your thumb and apply
firm pressure (Nelsons) (Maam mentioned on using a
broken tongue depressor for this).

Normal (negative) response: plantar flexion

Positive Babinski reflex: Dorsiflexion of the big toe and

fanning of the other toes. (Maam said if big toe
dorsiflexion was only observed, its considered positive)

Absence of Babinski in neonates is normal.

Notes from videos

Childhood cerebral palsy
o Spastic Hemiplegic

Asymmetric legs

Learn to walk on tiptoes as compensation

Spasticity due to tightening of Achilles tendon

o Spastic Quadriplegic

Tightness of adductors

Scissoring

V. IMPORTANT REMINDERS
Throughout the Examination, testing for mental abilities:
o Degree of alertness and interest in surroundings
o Verbal and nonverbal language function
o Intelligence ability to learn and follow instruction,
picture and object identification, memory and
calculation

Things NOT to do with Children

o Do not test the CORNEAL reflex for CN 5.
o Do not GAG to test CN 9 and 10.
o Do not inflict pain in sensory exam.
o All of these are done only on a stuporous or a
comatose child.
From 2018

Behavior
Cranial nerves
Resting posture
UE tone
Arm traction
Arm recoil
Scarf sign
Hand position
LE tone
Leg traction
Leg recoil
Popliteal angle
Heel to ear
Neck tone

Term Newborn
Head lag
Head control
Prone
Vertical and ventral suspension
Deep tendon reflex
Plantar reflex
Sucking and rooting reflex
Moro reflex
Stepping reflex
Grasping reflex
Head shape and sutures
Head circumference (last)

Six-month old infant

Behavior
Cranial nerves
Motor sitting, hand, tone
Position prone
Reflexes deep tendon, plantar
Primitive reflexes should be absent
Postural reflexes (refer to Appendix)
Head appendix
2 to 4 years old
Behavior
Motor tone
Fine motor coordination
Reflexes
Motor

VI. SUMMARY
Neurologic exam should always be a part of the
developmental and routine evaluation of a child
The success in obtaining a good result is dependent on
the cooperation of the child
A significant part is made thru observation
Neurologic exam is NOT DIFFICULT to do!!

END OF TRANSCRIPTION
Hi! Lets watch Mediscene! :D #detox
From Maam: http://library.med.utah.edu/pedineurologicexam

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VII. APPENDIX
Appendix A: Cheers
1.

2.

3.

4.

5.

6.

7.

Which of the following motor developmental milestones are expected to be performed by a 24-monthold child?
A. Walks up and down stairs one step at a time
B. Walks up and down stairs with alternating feet
C. Stands on one foot
D. Imitates circular strokes
Which of the following motor developmental milestones IS NOT expected to be performed by a 36- month old child?
A. Walks up and down stairs with alternating feet
B. Rides tricycle
C. Hops on one foot
D. Imitates circular strokes
What is the EARLIEST developmental age of a child who is able to do the following movements: stands with assistance and cruises around
holding on to furniture, waves bye-bye, holds toys and transfers objects from one hand to the other?
A. 6-8 months
B. 9-11 months
C. 12-15 months
D. 15-18 months
Which of the following primitive reflexes normally persists at 7 months of age
A. Moro reflex
B. Palmar grasp reflex
C. Plantar grasp reflex
D. Asymmetric tonic neck reflex
Which of the following reflexes is NOT expected in a normal newborn term baby?
A. Positive supporting action
B. Placing reaction
C. Cross extensor reflex
D. Neck righting reflex
The following cranial nerves can be assessed by observing the patients ability to suck and swallow?
A. Cranial nerves II, V, VII, IX, X
B. Cranial nerves V, VII, IX, X, XII
C. Cranial nerves V, VII, IX, X, XI
D. Cranial nerves VII, IX, X, XI, XII
The following postural reflexes can be normally performed by a 6 month old child EXCEPT?
A. Positive supportive
B. Landau
C. Lateral propping
D. Parachute

Answers: A, C, B, C, D, C, D

Appendix B: Examining Newborns (Bates)

Appendix C: Developmental Milestones During Infancy

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Appendix D: Primitive Reflexes That Should Be Part of Routine Neurologic Examination of Infants (Bates)
Primitive
Reflex

Figure

Maneuver
Place your fingers into the babys hands and
press against the palmar surfaces.

Palmar
Grasp
Reflex

The baby will flex all fingers to grasp your

fingers.

Plantar
Grasp
Reflex

Touch the sole at the base of the toes.

The toes curl.

Hold the baby supine, supporting the head,

back, and legs. Abruptly lower the entire body
about 2 feet.

Moro Reflex

Age

Notes
Persistence beyond 4 mos
suggests cerebral dysfunction.

Birth to
34 mos

Birth to
68 mos

Birth to
46 mos

The arms abduct and extend, hands open, and

legs flex. Baby may cry.

Persistence of clenched hand

beyond 2 mos suggests central
nervous system damage.

Persistence beyond 8 mos

suggests cerebral dysfunction.

Persistence beyond 4 mos

suggests neurologic disease;
beyond 6 mos strongly suggests
it.
Asymmetric response suggests
fracture of clavicle or humerus or
brachial plexus injury.

With baby supine, turn head to one side, holding

jaw over shoulder.
Asymmetric
Tonic Reflex

The arms/legs on side to which head is turned

extend while the opposite arm/leg flex.

Birth to
2 mos

Persistence beyond 2 mos

suggests neurologic disease.

Repeat on other side.

Hold the baby around the trunk and lower until

the feet touch a flat surface.

Positive
support
reflex

The hips, knees, and ankles extend, the baby

stands up, partially bearing weight, sags after
2030 seconds.

Birth or
2 mos
until
6 mos

Lack of reflex suggests hypotonia

or flaccidity.
Fixed extension and adduction of
legs
(scissoring)
suggests
spasticity due to neurologic
disease.

Appendix E: Additional Primitive Reflexes That Should Be Tested If Neurologic Abnormality is Suspected (Bates)
Primitive
Reflex

Rooting
Reflex

Galants
Reflex
(Trunk
Incurvation)

Figure

Maneuver
Stroke the perioral skin at the corners of the
mouth.
The mouth will open and baby will turn
the head toward the stimulated side and suck.

Support the baby prone with one hand, and

stroke one side of the back 1 cm from midline,
from shoulder to buttocks.

The hip and knee of that foot will flex and the
other foot will step forward.
Alternate stepping will occur.

Landau
Reflex

Notes

Birth to
34 mos

Absence of rooting indicates

severe generalized or central
nervous system disease.

Birth to
2 mos

The spine will curve toward the stimulated side.

Hold baby upright from behind as in positive

support reflex. Have one sole touch the tabletop.
Placing and
Stepping
Reflexes

Age

To test for the reflex, the doctor will hold the

infant face down horizontally. The baby's head
will raise up, while her trunk will be straight and
her legs extended. When the doctor pushes the
baby's head downward, her legs should drop as
well. When the doctor releases the baby's head,
both her head and legs should return to their
original positions.

Birth (best
after 4
days).
Variable
age to
disappear

Birth to
6 mos

Absence suggests a transverse

spinal cord lesion or injury.
Persistence may indicate delayed
development.

Absence of placing may indicate

paralysis.
Babies born by breech delivery
may not have placing reflex.

Persistence beyond 2 mos

suggests neurologic disease.

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Parachute
Reflex

Suspend the baby prone and slowly lower the

head toward a surface.
The arms and legs will extend in a protective
fashion.

46 mos
and does
not
disappear

Delay in appearance may predict

future delays in voluntary motor
development

Appendix F: Postural Reflexes

Appendix G: Ballard Score For Neuromuscular Maturity

The Ballard Maturational Assessment, Ballard Score, or Ballard Scale is a commonly used technique of gestational age assessment. It assigns a score to
various criteria, the sum of all of which is then extrapolated to the gestational age of the baby. These criteria are divided into Physical and Neurological criteria.
This scoring allows for the estimation of age in the range of 26 weeks-44 weeks.
Each of the above criteria is scored from -1 through 5. The scores were then ranged from -10 to 50, with the corresponding gestational ages being 20 weeks and
44 weeks. An increase in the score by 5 increases the age by 2 weeks.

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Appendix H: Growth Charts

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[JOV, KEESH, JESSA]

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