Assessment of Cranial Nerves in The Child

Assessment of cranial nerves in the child. Obtained from Hadley (1994). S Sensory, M motor, EOM extraocular movement.

Cranial	Test for function
I Olfactory (S)
Olfactory nerve, mucous membrane of nasal passages and turbinates	With eyes closed child is asked to identify familiar odors such as peanut butter, orange, and peppermint. Test each nostril separately
II Optic (S)
Optic nerve, retinal rods and cones	Check visual acuity, peripheral vision, color vision, perception of light in infants, fundoscopic examination for normal optic disk
III Oculomotor (M)
Muscles of the eyes (superior rectus, inferior rectus, medial rectus, inferior oblique)	Have child follow an object or light with the eyes (EOM) while head remains stationary. Check symmetry of corneal light reflex. Check for nystagamus (direction elicited, vertical, horizontal, rotary). Check cover-uncover test.
Muscles of iris and ciliary body	Reaction of pupils so light, both direct and consensual, accommodation
Levator palpebral muscle	Check for symmetric movement of upper eyelids. Note ptosis
IV Trochlear (M)
Muscles of eye (superior oblique)	Check the range of motion of the eyes downward (EOM). Check for nystagmus
V Trigeminal (M, S)
Muscles of mastication (M)	Palpate the child’s jaws, jaw muscles, and temporal muscles for strength and symmetry. Ask child to move lower jaw from side to side against resistance of the examiner’s hand
Sensory innervation of face (S)	Test child for sensation using a wisp of cotton, warm and cold water in test tubes, and a sharp object on the forehead, cheeks, and jaw. Check corneal reflex by touching a wisp of cotton to each cornea. The normal response is blink
VI Abducens (M)
Muscles of eye (lateral rectus)	Have child look to each side (EOM)
VII Facial (M, S)
Muscles for facial expression	Have child make faces: look at the ceiling, frown, wrinkle forehead, blow out cheeks, smile. Check for strength, asymmetry, paralysis
Sense of taste on anterior two-thirds of tongue. Sensation of external ear canal, lachrymal, submaxillary, and sublingual glands	Have a child identify salt, sugar, bitter (flavoring extract), and sour substances by placing substance on anterior sides of tongue. Keep tongue out until substance is identified. Rinse mouth between substances
VIII Acoustic (S)
Equilibrium (vestibular nerve)	Note equilibrium or presence of vertigo (Romberg sign)
Auditory acuity (cochlear nerve)	Test hearing. Use a tuning fork for the Weber and Rinne tests. Test by whispering and use of a watch
IX Glossopharyngeal (M, S)
Pharynx, tongue (M)	Check elevation of palate with “ah” or crying. Check for movement and symmetry. Stimulate posterior pharynx for gag reflex
Sense of taste posterior third of the tongue	Test sense of taste on posterior portion of tongue
X Vagus (M, S)
Mucous membrane of pharynx, larynx, bronchi, lungs, heart, esophagus, stomach, and kidneys Posterior surface of external ear and external auditory meatus	Note same as for glossopharyngeal. Note any hoarseness or stridor. Check uvula for midline position and movement with phonation. Stimulate uvula on each side with tongue depressor – should rise and deviate to stimulated side. Check gag reflex. Observe ability to swallow
XI Accessory (M)
Sternocleidomastoid and upper trapezius muscles	Have child shrug shoulders against mild resistance. Have child turn head to one side against resistance of examiner’s hand. Repeat on the other side. Inspect and palpate muscle strength, symmetry for both maneuvers
XII Hypoglossal (M)
Muscle of tongue	Have child move the tongue in all directions, then stick out tongue as far as possible: check for tremors or deviations. Test strength by having child push tongue against inside cheek against resistance on outer cheek. Note strength, movement, symmetry

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Cranial Nerve - Brainstem Function

Cranial nerve assessment is basically an assessment of brainstem function because nuclei of 10 of the 12 cranial nerves are located in the brainstem. The proximity of these nuclei to the reticular activating system (arousal center) located in the midbrain is the anatomic rationale for assessing cranial nerves in conjunction with LOC. Important neurological functions and protective reflexes are mediated by the cranial nerves and many functions are dependent on more than one nerve. Some of the cranial nerves have both motor and sensory functions.

Diagram of the base of the brain showing entrance and exits of the cranial nerves

The two cranial nerves that do not arise in the brainstem are the olfactory nerve (CN I) and the optic nerve (CN II). CN I is located in the medial frontal lobe and is responsible for the sense of smell. This can be difficult to assess in the younger child, so is often omitted unless there is specific concern that there has been damage in that area. Taste may also be affected with injuries to CN I. CN II is assessed by determining a child’s visual acuity. This may be done more formally with visual screening or more generally by noting if the child’s vision appears normal in routine activities.
Pupil size and response to direct light are mediated by CN II and the oculomotor nerve (CN III) as well as the sympathetic nervous system. Many things can affect the pupillary response in a child, including damage to the eye or the cranial nerves, pressure on the upper brainstem, local and systemic effects of certain drugs, anoxia, and seizures. Pupillary size varies with age and is determined by the amount of sympathetic input, which dilates the pupil and is balanced by the parasympathetic input on CN III, which constricts the pupil. Pupillary response in the eye that is being checked with direct light as well as the other pupil (consensual response) are significant in that they can point to where damage to nerves exists and are an objective clinical sign that can be followed over time .

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Modified Glasgow Coma Scale For Infants And Children

Modified Glasgow Coma Scale for infants and children. Coma scoring system appropriate for pediatric patients.
Obtained from Marcoux (2005) [24]

Activity	Score	Infant/non-verbal child (<2 years)	Verbal child/adult (>2 years)
Eye Opening	4	Spontaneous	Spontaneous
	3	To Speech	To verbal stimuli
	2	To Pain Only	To Pain Only
	1	No Response	No Response
Motor Response	6	Normal/ spontaneous movement	Obeys commands
	5	Withdraws to touch	Localizes pain
	4	Withdraws to pain	Flexion withdrawal
	3	Abnormal flexion (decorticate)	Abnormal flexion
	2	Extension (decerebrate)	Extension (decerebrate)
	1	No response	No response
			2–5 years	> 5 years
Verbal Response	5	Cries appropriately, coos	Appropriate words	Oriented
	4	Irritable crying	Inappropriate words	Confused
	3	Inappropriate screaming / crying	Screams	Inappropriate
	2	Grunts	Grunts	Incomprehensible
	1	No Response	No Response	No Response

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Developmental Screening Tools Commonly Used To Assess Child Development

Developmental screening tools commonly used to assess child development. Data from references: Behrman et al. (2004) [4] and Wong et al. (2000) [35]

Tool name	Revised Denver developmental screening test (Denver II)	Prescreening developmental questionnaire R-PDQ)	Developmental profile II	Draw a person (DAP) test
Author	Frankenburg [13]	Frankenburg et al. [14]	Alpern et al. [1]	Goodenough [15]
Items scored	Gross motor Fine motor Language Personal-social	Parent answered prescreen of items on Denver II	Physical Self-help Social Academic Communication	Score for body parts
Age range	Birth–6 years	Birth–6 years	Birth–7 years	5–17 years
Interview	Parent/child	Parent only	Parent/child	Child only
Testing time	30–40 minutes	15–20 min	20–40 min	As needed
Training/certified	Yes	Self-instruction	Self-instruction	Self-instruction
Pros/cons	Range of items Identify child’s strengths/weakness Validity tested Cultural bias Teaching tool	Parent report Can rescreen If delays administer Denver II	Range of items Low rate of sensitivity	Nonverbal Nonthreatening Cultural unbias Few items to score Gives IQ score

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Age-appropriate Neuroassessment

Age-appropriate neuroassessment table. A brief guide to developmental milestones in children from infancy to age 12 years as a guide when performing a neurological assessment (Phoenix Children’s Hospital)

Age	Gross Motor	Fine Motor	Personal/social	Language
Newborn	Head down with ventral suspension Flexion Posture Knees under abdomen-pelvis high Head lag complete Head to one side prone	Hands closed Cortical Thumbing (CT)	With sounds, quiets if crying; cries if quiet; startles; blinks	Crying only monotone
4 weeks	Lifts chin briefly (prone) Rounded back sitting head up momentarily Almost complete head lag	Hands closed (CT)	Indefinite stare at surroundings Briefly regards toy only if brought in front of eyes and follows only to midline Bell sound decreases activity	Small, throaty noises
6 weeks	In ventral suspension head up momentarily in same plane as body Prone: pelvis high but knees no longer under abdomen	Hands open 25% of time	Smiles	Social smile (1st cortical input)
2 months	Ventral suspension; head in same plane as body Lifts head 45° (prone) on flexed forearms Sitting, back less rounded, head bobs forward Energetic arm movements	Hands open most of the time (75%) Active grasp of toy	Alert expression Smiles back Vocalizes when talked to Follows dangled toy beyond midline Follows moving person	Cooing Single vowel sounds (ah. eh, uh)
3 months	Ventral suspension; head in same plane as body Lifts head 45° (prone) on flexed forearms Sitting, back less rounded, head bobs forward Energetic arm movements	Hands open most of the time (75%) Active grasp of toy	Smiles spontaneously Hand regard Follows dangled toy 180° Promptly looks at object in midline Glances at toy put in hand	Chuckles “Talk back” if examiner nods head and talks Vocalizes with two different syllables (a-a. oo-oo)
4 months	Head to 90° on extended forearms Only slightly head lag at beginning of movement Bears weight some of time on extended legs if held standing Rolls prone to supine Downward parachute	Active play with rattles Crude extended reach and grasp Hands together Plays with fingers Toys to mouth when supine	Body activity increased at sight of toy Recognizes bottle and opens mouth For nipple (anticipates feeding with excitement)	Laughs out loud increasing inflection No tongue thrust
6 months	Bears full weight on legs if held standing Sits alone with minimal support Pivots in prone Rolls easily both ways Anterior proppers	Reaches for toy Palmar grasp of cube Lifts cup by handle Plays with toes	Displeasure at removal of toy Puts toy in mouth if sitting	Shy with strangers Imitates cough and protrusion of tongue Smiles at mirror image
7 months	Bears weight on one hand prone Held standing, bounces Sit on hard surface leaning on hands		Stretches arms to be taken Keeps mouth closed if offered more food than wants Smiles and pats at mirror	Murmurs “mom” especially if crying Babbles easily (M’s, D’s, B’s, L’s) Lateralizes sound
9 months	Sits steadily for 15 min on hard surface Reciprocally crawls Forward parachute	Picks up small objects with index finger and thumb (Pincer grasp)	Feeds cracker neatly Drinks from cup with help	Listens to conversation Shouts for attention Reacts to “strangers”
10 months	Pulls to stand Sits erect and steadily (indefinitely) Sitting to prone Standing: collapses and creeps on hands knees easily Prone to sitting easily Cruises – laterally Squats and stoops – does not recover to standing position	Pokes with index finger, prefers small to large objects	Nursery games (i.e., pat-a-cake), picks up dropped bottle, waves bye-bye	Will play peek-a-boo and pat-a-cake to verbal command Says Mama, Dada appropriately, finds the hidden toy (onset visual memory)
12 months	Sitting; pivots to pick up object Walks, hands at shoulder height Bears weight alone easily momentarily	Easy pinch grasp with arm off table Independent release (ex: cube into cup) Shows preference for one hand	Finds hidden toy under cup Cooperated with dressing Drinks from cup with two hands Marks with crayon on paper Insists on feeding self	One other word (noun) besides Mama, Dada (e.g., hi, bye, cookie)
13 months	Walks with one hand	Mouthing very little Explores objects with fingers Unwraps small cube Imitates pellet bottle	Helps with dressing Offers toy to mirror image Gives toy to examiner Holds cup to drink, tilting head Affectionate Points with index finger Plays with washcloth, bathing Finger-feeds well, but throws dishes on floor Appetite decreases	Three words besides Mama, Dada Larger receptive language than expressive
14 months	Few steps without support	Deliberately picks up two small blocks in one hand Peg out and in Opens small square box	Should be off bottle Puts toy in container if asked Throws and plays ball	Three to four words expressively minimum
15 months	Creeps up stairs Kneels without support Gets to standing without support Stoop and recover Cannot stop on round corners suddenly Collapses and catches self	Tower of two cubes “Helps” turn pages of book Scribbles in imitation Completes round peg board with urging	Feeds self fully leaving dishes on tray Uses spoon turning upside down, spills much Tilts cup to drink, spilling some Helps pull clothes off Pats at picture in book	Four to six words Jargoning Points consistently to indicate wants
18 months	Runs stiffly Rarely falls when walking Walks upstairs (one hand held-one step at a time) Climbs easily Walks, pulling toy or carrying doll Throws ball without falling Knee flexion seen in gait	Tower of three to four cubes Turns pages two to three at a time Scribbles spontaneously Completes round peg board easily	Uses spoon without rotation but still spills May indicate wet pants Mugs doll Likes to take off shoes and socks Knows one body part Very negative oppositions	One-step commands 10-15 words Knows “hello” and “thank you” More complex ‘jargon’ rag Attention span 1 min Points to one picture
21 months	Runs well, falling some tires Walks downstairs with one hand held, one step at a time Kicks large ball with demonstration Squats in play Walks upstairs alternating feet with rail held	Tower of five to six cubes Opens and closes small square box Completes square peg board	May briefly resist bathing Pulls person to show something Handles cup will Removes some clothing purposefully Asks for food and drink Communicates toilet needs helps wit h simple household tasks 3 body parts	Knows 15–20 words and combines 2–3 words Echoes 2 or more Knows own name Follows associate commands
24 months	Rarely falls when running Walks up and down stairs alone one-step-at-a time Kicks large ball without demonstration Claps hands Overthrow hand	Tower of six to seven cubes Turns book pages singly Turns door knob Unscrews lid Replaces all cubes in small box Holds glass securely with one hand	Uses spoon, spilling little Dry at night Puts on simple garment Parallel play Assists bathing Likes to wash 6 dry hands Plays with food + body parts Tower of 8. Helps put things away	Attention span 2 min Jargon discarded Sentences of two to three words Knows 50 words Can follow two-step commands (ain’t) Refers to self by name Understands and asks for “more” Asks for food by name Inappropriately uses personal pronouns (e.g., me want) Identifies three pictures
3–5 years	Pedals tricycle Walks up stairs alternating feet Tip toe Jump with both feet	Copies circles Uses overhand throw	Group play Can take turns	Uses three-word sentences
5–12 years	Activities of daily living	Printing and cursive writing	Group Sports	Reads and understands content Spells words

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