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Editors
Cathy C. Cartwright Donna C. Wallace
Department of Neurosurgery Department of Neurosurgery
Children’s Mercy Hospital Children’s Mercy Hospital
Kansas City Kansas City
Missouri Missouri
USA USA

ISBN 978-3-642-32553-3 ISBN 978-3-642-32554-0 (eBook)

DOI 10.1007/978-3-642-32554-0
Springer Heidelberg New York Dordrecht London

Library of Congress Control Number: 2013931753

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Foreword

The Institute of Medicine (IOM) report (2011) The Future of Nursing:

Leading Change, Advancing Health is the first report from the prestigious
IOM to focus solely on the profession of nursing. It challenges nurses to
practice to the full extent of their knowledge and experience and to be full
partners with physicians and other health professionals to transform health
care to provide higher quality, safer, more affordable, and more accessible
care. Evidence-based practice and patient-centered care, which includes fam-
ily, are the expected standard of care. The report speaks to the profession of
nursing and all nurses to lead change. Such a responsibility and accountabil-
ity at the professional and individual level require well-educated nurses in
health care delivery and patient care.
The unprecedented knowledge explosion reflected in the development of
nursing science is framed against a background of national patient safety and
quality outcomes imperatives. The convergence of science and fundamental
changes in the health care delivery system are driving the science-based care
and practice in nursing and the rapid development in subspecialty profes-
sional practice. Nowhere is the phenomenal growth in specialty nursing prac-
tice more evident than in neuroscience nursing. New knowledge gained from
research and quality improvement is being translated into practice to support
evidence-based practice and care. In addition, recognition of the special
health problems and needs of neuroscience patients across the age continuum
from birth through aging is evident. Age-specific neurological assessment
along with comprehensive information of major neurological conditions,
treatment, and nursing care is needed as resources for nurses to provide high-
quality, safe care and achieve optimal patient outcomes. One area, pediatric
neuroscience care, has had a void until recently. Cathy C. Cartwright and
Donna Wallace, two expert pediatric neuroscience clinicians, have led the
way in addressing the need for a current and reliable resource with the Nursing
Care of the Pediatric Neurosurgery Patient, now in its second edition. Through
a comprehensive approach to the common neurosurgical problems, these two
experts share a wealth of knowledge in their text to guide nurses engaged in
the care of the pediatric neurosurgical patient. The neurological assessment
addressed includes assessment from infants to older children, which sets the
foundation for understanding the milestones of human development. A dis-
cussion of the common neurological problems and adaptation of care is pro-
vided along with detailed perioperative surgical management and care. A
particularly important chapter is transition care to adulthood. With improved

v
vi Foreword

treatment options, children with many neurological conditions are surviving

to be adults with chronic neurological conditions. The Nursing Care of the
Pediatric Neurosurgery Patient, 2nd edition, is an excellent resource for all
nurses engaged in pediatric neurological patient care.

Joanne V. Hickey, Ph.D., RN,

ACNP-BC, FAAN, FCCM
Preface

Our humble but ambitious idea to write a book that would serve as a reference
for nurses caring for children with neurosurgical conditions came to fruition
with the publication of the first edition in 2007. As the first book of its kind,
we wondered how it would be received by our colleagues. Would it be a valu-
able resource, something that both bedside nurses and advance practice nurses
would find helpful? We were gratified to find that not only was it well received
by nursing but that other health care disciplines also found it to be a valuable
resource. Child life specialists, medical students, resident physicians, and
even patients and families have used it as a reference.
Although novices in our first edition, we soon realized that we could
improve on the second edition. Our colleagues offered enthusiastic sugges-
tions and ideas which have been incorporated in this edition. Authors for each
chapter have done a tremendous job updating evidence-based practice, includ-
ing case studies, parent stories, and numerous illustrations to help explain the
pathophysiology, treatment, outcomes, and impact of neurosurgical disorders
on patients and families. The authors have again shared their experiences and
contributed their expertise to the chapters, and this book would not be possi-
ble without them. This edition includes two additional chapters, perioperative
care and transition care into adulthood. No neurosurgery book would be com-
plete without discussion of the nurse’s role preparing the patient and family
for surgery, caring for the patient in the operating room and in the post-anes-
thesia care unit. Because of the many advances in health care, children with
neurosurgical conditions are living into adulthood, and nurses need the tools
to help these children and their parents transition smoothly.
The editors would also like to thank Children’s Mercy Hospital for provid-
ing the atmosphere of learning and support that allows us to care for our
patients and families and share what we have learned from them.
Most of all, we are so grateful for the opportunity to be a part of the lives
of these children and their families. We learn so much from you. Not only do
you let us in when you are most vulnerable but you are willing to share your
journey with other families so they might be less anxious as they embark on
theirs. Thank you for sharing a part of your lives with us and helping us to
understand what it is like to live with a neurosurgical condition. May those
that read this book learn from the wisdom you impart.

Kansas City, MO 2012 Cathy C. Cartwright

Donna C. Wallace

vii
Acknowledgements

I wish to acknowledge Dr. Usiakimi Igbaseimokumo for his support and

encouragement and always reminding me to ask “why?” And to Zach, editor
extraordinaire and the real reason I am what I am.
C.C.
I wish to thank Dr. Harold Rekate and Dr. Usiakimi Igbaseimokumo for
their support and mentoring, in learning about caring for the pediatric neuro-
surgical patient.
Of course I must acknowledge my family and friends, who were always so
understanding when I needed to work on this book.
Like Cathy, I wish to point out that Zach was an ever-present force who
provided any kind of editorial help, whenever it was needed.
D.W.

ix
Contents

1 Neurological Assessment of the Neonate, Infant,

Child, and Adolescent ................................................................... 1
Jennifer A. Disabato and Dee A. Daniels

2 Hydrocephalus............................................................................... 37
Nadine Nielsen and Amanda Breedt

3 Craniosynostosis and Plagiocephaly ........................................... 85

Cathy C. Cartwright and Patricia D. Chibbaro

4 Neural Tube Defects ...................................................................... 119

Shona Swenson Lenss

5 Chiari Malformation and Syringomyelia ................................... 141

Susan McGee and Diane Baudendistel

6 Tumors of the Central Nervous System ...................................... 157

Tania Shiminski-Maher

7 Traumatic Brain Injury ................................................................ 193

Angela Hoersting and Jodi E. Mullen

8 Spine ....................................................................................... 249

Valorie Thomas and Anne Stuedemann

9 Neurovascular Disease .................................................................. 283

Theresa M. Gabay and Davonna Ledet

10 Surgical Management of Epilepsy ............................................... 333

Patti L. Batchelder

11 Surgical Management of Spasticity ............................................. 361

Herta Yu

12 Infections of the Central Nervous System................................... 375

Gina Weddle

xi
xii Contents

13 Perioperative Care ........................................................................ 389

Sarah M. Burr and Gail C. Dustman

14 Transition from Pediatric to Adult Care..................................... 413

Theresa M. Gabay, Jennifer A. Disabato, and Teresa Schultz

Index ..................................................................................................... 431

 Neurological Assessment of
the Neonate, Infant, Child, 1
and Adolescent

Jennifer A. Disabato and Dee A. Daniels

1.1 Introduction from a neurological disease or traumatic injury.

Potential complications include the inability to
1.1.1 Importance of Neurological protect the airway leading to aspiration, immo-
Assessment bility leading to venous stasis and thrombosis,
endocrine disorders related to central hormonal
Serial, consistent, and well-documented neuro- regulation, impaired communication, and behav-
logical assessments are the most important aspect ioral issues, among others (Hickey 2009).
of nursing care for the pediatric neurosurgical It is understood that children are not always
patient. A bedside nurse is often the first to note a under the care and custody of their parents. As
subtle change in a child’s level of responsiveness, used in this book, however, the term “parent(s)”
pattern of movement, or signs and symptoms of is intended to include family members who have
decline in neurological function. Both keen obser- custody of a child, foster parents, guardians, and
vation skills and knowledge of the patient’s base- other primary caregivers.
line neurological function are essential tools for
the pediatric neurosurgical nurse. Rapid response
and escalation of care in response to changes in 1.1.2 Nursing Approach to
assessment are necessary to prevent secondary Neurological Assessment
complications that can further impede recovery
Neurological assessment should be an integral
part of the entire physical assessment, and aspects
can be integrated into the general exam of patients
J.A. Disabato, DNP, CPNP-PC, AC (*) in both inpatient and outpatient settings. The
Perioperative Services, Children’s Hospital Colorado, approach to neurological assessment should be
Aurora, CO, USA
systematic and include pertinent health history;
University of Colorado College of Nursing, e.g., coexisting conditions, developmental status
Women, Children and Family Health,
of the child, the nature and extent of the injury or
13120 E. 19th Avenue, C288-11, Aurora,
CO 80045, USA surgery performed, and potential complications
e-mail: [email protected] (Amidei et al. 2010). Sources of this information
D.A. Daniels, MS, RN, CPNP are broad and include: the verbal report provided
Sie Center for Down Syndrome, in care transitions, the medical record, the parent
Department of Pediatrics, Children’s Hospital Colorado, caregiver, and nursing and medical colleagues,
University of Colorado School of Medicine,
13123 East 16th Ave, B-745, Aurora,
CO 80045, USA Karen W. Burkett was an author on the first edition but did
e-mail: [email protected] not contribute to the revision of this chapter

C.C. Cartwright, D.C. Wallace (eds.), Nursing Care of the Pediatric Neurosurgery Patient, 1
DOI 10.1007/978-3-642-32554-0_1, © Springer-Verlag Berlin Heidelberg 2013
2 J.A. Disabato and D.A. Daniels

including the neurosurgeon, neurologist, and ing. However, the use of diagnostic testing in an
other health-care providers. era of health-care reform calls for all involved to
Knowledge of physical and developmental consider the costs associated with a test and query
disorders not directly associated with the neuro- whether the results will truly change the plan or
logical condition, such as renal, cardiac, or pul- outcome for the patient.
monary status is important to a comprehensive In general, radiographic or digital imaging
approach and enhancing the patient’s outcome. (such as MRI) are tools to evaluate the structure
Care planning should be a team approach that of the brain and spinal cord, while other diagnostic
involves the parents and the multidisciplinary tests like EEG, SPECT scanning, nuclear medicine
team to assure optimal communication of key scans, and Wada test (intracarotid sodium amobar-
information, and avoid unnecessary repetition of bital procedure to lateralize language and memory)
tests, or oversight of important clinical findings. are evaluating specific functions of the brain. PET
Factors that impact the nurses assessment of scans look at metabolic function and utilization of
the child will be the age and developmental stage glucose by the brain. Some tests serve both diag-
of the child, the nature of the child’s diagnosis nostic and therapeutic outcomes (Hedlund 2002).
(chronic, acute, static, progressive), the setting in Magnetoencephalography (MEG) or magnetic
which the assessment takes place (critical care source imaging (MSI) and functional MRIs (fMRI)
unit, general care are, outpatient clinic, school are methods of localizing areas of abnormality
nurse office), and the information available at the associated with ictal (seizure) onset (Knowlton
time of the assessment from other members of 2008). Newer technologies allow for evaluation
the multidisciplinary team. Family dynamics and of cerebral blood flow and brain perfusion. Three
social circumstances can also impact the nurses’ methods currently in use for monitoring cerebral
approach to the assessment. ischemia include Doppler ultrasound, near-infra-
red spectroscopy (NIRS) and amplitude-integrated
electroencephalogram (aEEG) (Greisen 2006; Iaia
1.1.3 Diagnostic Imaging and Testing and Barker 2008). Table 1.1 is a listing of the most
in Neurological Assessment common neurological diagnostic tests and imaging
modalities used in pediatrics.
Diagnostic imaging and other laboratory and elec-
trical testing of the nervous system play an impor-
tant role in understanding the nature of neurological
disorders. The brain, spinal cord, and peripheral 1.2 Developmental Assessment:
neurological system are organs of both intricate Growth and Developmental
structure and complex metabolic, vascular, and Tasks by Age
cellular function. Diagnostic tools are generally
focused on one aspect of the structure or function, Knowledge of human growth parameters and
but several tests incorporated with a neurological normal developmental landmarks is critical to the
assessment of the child are often the key to an assessment of each age group. The Individuals
accurate diagnosis and appropriate treatment. with Disabilities Education Act (IDEA) Amend-
Ongoing advances in medicine, technology, and ments of 1997 (U.S. Department of Education
pharmacology have contributed to safer outcomes Special Education and Rehabilitative Services
for children who may need sedation for diagnostic 2005) mandate the “early identification of,
imaging, and the speed of imaging has decreased and intervention for developmental disabilities
substantially in recent years. through the development of community-based
Advancements in imaging techniques make it systems”. This law requires physicians to refer
easier to consider repeat studies as treatment or children with suspect developmental delays to
recovery progresses, so that changes can be mon- appropriate intervention services in a timely
itored through comparisons to the baseline imag- manner. Early identification and intervention can
1 Neurological Assessment of the Neonate, Infant, Child, and Adolescent 3

Table 1.1 Neurological diagnostic and imaging modalities

Diagnostic or imaging
modality Technology utilized Nursing and patient considerations
X-rays of the skull and X-rays to look at boney structures of the Patient should be immobilized in a collar for
vertebral column skull and spine, fractures, integrity of the transport if there is a question of spinal fracture.
spinal column, presence of calcium intra-
cranially.
Cranial ultrasound Doppler sound waves to image through soft No sedation or intravenous access needed. Used
tissue. In infants can only be used if fontanel to follow ventricle size/bleeding in neonates/
is open. infants.
Computerized tomography Differentiates tissues by density relative to Non-invasive unless contrast is used or sedation
with/without contrast water with computer averaging and needed. Complications include reaction to
mathematical reconstruction of absorption contrast material or extravasation at injection
coefficient measurements. site.
Computerized tomography Same as above with software capabilities to No changes in study for patient. Used for
– bone windows and/or subtract intracranial contents to look complex skull and vertebral anomalies to guide
three-dimensional specifically at bone and reconstruct the skull surgical decision-making.
reconstruction or vertebral column in a three-dimensional
model.
Cerebral angiography Intra-arterial injection of contrast medium to Done under deep sedation or anesthesia; local
visualize blood vessels; transfemoral reaction or hematoma may occur; systemic
approach most common; occasionally reactions to contrast or dysrhythmias; transient
brachial or direct carotid is used. ischemia or vasospasm; patient needs to lie flat
after and CMS checks of extremity where
injection was done are required.
MRI with or without Differentiates tissues by their response to No radiation exposure; screened prior to study
contrast (gadolinium) radio frequency pulses in a magnetic field; for indwelling metal, pacemakers, braces,
used to visualize structures near bone, electronic implants; sedation required for young
infarction, demyelination, and cortical children because of sounds and claustrophobia;
dysplasias. contrast risks include allergic reaction and
injection site extravasation.
MRA Same technology as above used to study In some cases can replace the need for cerebral
MRV flow in vessels; radiofrequency signals angiography; new technologies are making this
emitted by moving protons can be less invasive study more useful in children with
manipulated to create the image of vascular vascular abnormalities.
contrast.
Functional MRI Technique for imaging activity of the brain Used in patients who are potential candidates
using rapid scanning to detect changes in for epilepsy surgery to determine areas of
oxygen consumption of the brain; changes cortical abnormality and their relationship to
can reflect increased activity in certain cells. important cortex responsible for motor and
speech functions.
Physiologic imaging techniques – nuclear medicine imaging
SPECT Nuclear medicine study utilizing injection of Often used in epilepsy patients to diagnose areas
isotopes and imaging of brain to determine of cerebral uptake during a seizure (ictal
if there is increased activity in an area of SPECT) or between seizures (intraictal SPECT).
abnormality; three-dimensional measure-
ments of regional blood flow.
SISCOM Utilizing the technology of SPECT with No significant difference for patient; software as
MRI to look at areas of increased uptake in well as expertise of radiologist is used to
conjunction with MRI images of the cortex evaluate study.
and cortical surface.
PET Nuclear medicine study that assesses Patient should avoid chemicals that depress or
perfusion and level of metabolic activity of stimulate the CNS and alter glucose metabolism
both glucose and oxygen in the brain; (e.g., caffeine); patient may be asked to perform
radiopharmaceuticals are injected for the certain tasks during study.
study.
(continued)
4 J.A. Disabato and D.A. Daniels

Table 1.1 (continued)

Diagnostic or imaging
modality Technology utilized Nursing and patient considerations
Electrical studies
EEG Records gross electrical activity across Success of study dependent on placement and
Routine surface of brain; ambulatory EEG used may stability of electrodes and ability to keep them
Ambulatory be used for 24–48 h with data downloaded on in children; routine studies often miss actual
after study; video combines EEG recording seizures but background activity can be useful
Video
with simultaneous videotaping. information.
Evoked responses Measure electrical activity in specific Results can vary depending on body size, age,
SSER sensory pathways in response to external and characteristics of stimuli; sensation for each
VER stimuli; signal average produces waveforms test will be different for patient – auditory clicks
that have anatomic correlates according to (BAER), strobe light (VER) or electrical current
BAER
the latency of wave peaks. on skin – somatosensory (SSER).
MEG (magneto- Non-invasive functional brain imaging that Patients will need to remove all metal prior to
encephalography) uses electrodes on the scalp to measure tiny entry into room. Pacemakers or vagus nerve
mapping changes in magnetic fields between groups stimulators (VNS) will cause artifact. VNS
of neurons and projects them onto MRI should be turned off prior to the study and any
brain imaging for correlation. Used to assist magnetic field can affect the function of the
in localization of seizure foci in evaluation VNS.
of patients for epilepsy surgery, and to
determine the language dominant
hemisphere.
MSI (magnetic source Using a weak magnetic field, images normal
imaging) and abnormal electrical activity and
produces clear images. Messages are sent to
the brain via small stimulators on lips and
fingers of the patient, and measured and
recorded as electrical activity.
aEEG (amplitude Filtered and compressed EEG data used to Used primarily in neonates to predict neurologi-
integrated EEG) evaluate long-term trends in background cal outcome following perinatal asphyxia.
patterns.
Cerebral perfusion studies
Near infrared spectroscopy Using light, monitors changes in cerebral
(NIRS) tissue oxygenation through functional
measurements of differential absorption of
hemoglobin at multiple wave lengths.
Transcranial Doppler A non-invasive method of monitoring Results indicating low flow velocities after head
(TCD) ultrasound cerebral circulation (flow velocity) over the injury are consistent with low cerebral blood
middle, anterior and posterior cerebral, flow, high ICP levels, and a poor prognosis.
ophthalmic, and carotid arteries.
Adapted from Disabato and Wulf (1994), and expanded using Iaia and Barker (2008)
MRI magnetic resonance imaging, MRA magnetic resonance angiography, MRV magnetic resonance venography,
SPECT single photon emission computerized tomography, SISCOM subtracted ictal spectroscopy coregistered with
MRI, PET positron emission tomography, EEG electroencephalogram, SSER somatosensory evoked potentials, VEP
visual evoked potentials, BAER brainstem auditory evoked potentials, CNS central nervous system

have significant impact on later developmental cate slight or early impairment of development
outcomes (Hamilton 2006). and an abnormal neurological assessment. An
Development is the essential distinguishing abnormality in development from birth suggests
feature of pediatric nursing. Normal development an intrauterine or perinatal cause. Slowing of the
is a function of the integrity and maturation of the rate of acquisition of skills later in infancy or
nervous system. Only with a working knowledge childhood may imply an acquired abnormality of
of age-related developmental standards can the the nervous system or metabolic disease. A loss
examiner be sensitive to the deviations that indi- of skills (regression) over time strongly suggests
1 Neurological Assessment of the Neonate, Infant, Child, and Adolescent 5

an underlying degenerative disease of the central behavioral, social, and functional capabilities.
nervous system (Volpe 2009). The younger the child, the more developmental
Serial measurements can indicate the normal or history is needed from the parents. Accurate
abnormal dynamics of the child’s growth. One key identification of the child’s mastery of cognitive
growth measurement important to the neurological and emotional developmental milestones, as it
assessment of the child is the head circumference. relates to chronological age, is necessary for a
The measurement is taken around the most promi- comprehensive neurological assessment. It is
nent frontal and occipital bones, that which offers imperative to note if the child is making steady
the maximal circumference. How rapidly the head developmental progress or has experienced
circumference accelerates or decelerates away from regression. If regression is noted, then it is impor-
the percentile curve can determine if the underlying tant to note the onset of regression. Documenting
cause of the growth change is more benign or seri- examples of regression and the temporal relation-
ous. An example of a benign finding is the presence ship to current symptoms gives further context
of extra-axial fluid collections of infancy, which that may influence the evaluation, diagnosis, and
often present with an accelerating head circum- subsequent treatment plan. If the child had
ference. Generally, the infant with this finding is significant regression in speech at 18 months of
observed over time, but no intervention is warranted. age followed by seizure onset at 3 years of age,
On the other hand, an accelerating head circumfer- this knowledge may lead to further consideration
ence can also be a sign of increasing intracranial of autism spectrum disorder rather than simply a
pressure in uncompensated hydrocephalus, which seizure disorder. This history is imperative in
would require immediate evaluation and treatment. planning a comprehensive evaluation and future
A child with a large head in the setting of normal treatment plan that would span many health-care
development and normal neurologic exam could be disciplines.
explained by measuring the parents’ head circum-
ference, as large heads can be familial.
Voluntary motor skills generally develop in a 1.2.1 Neonate
cephalocaudal and proximodistal progression, as
it parallels the process of myelinization. Myelin is Aside from head shape and size and assessment of
a phospholipid layer that surrounds the axons of fontanels, there are other aspects unique to the
many neurons, which regulate the speed of trans- neurological exam of the neonate and/or infant.
mission. First the head, then the trunk, arms, These are important to understanding the integrity
hands, pelvis, legs, bowel, and bladder are brought of the nervous system early in life and are detailed
under voluntary control. Early in life motor activ- in this section. The proportional changes in head
ity is largely reflexive, and generalized move- and body growth from fetal life to adulthood are
ments predominate. Patterns emerge from the depicted in Fig. 1.1 (Santrock JW 1998).
general to the specific; for example, a newborn’s
total-body response to a stimulus is contrasted 1.2.1.1 Maternal and Pregnancy/Labor
with the older child, who responds through sim- and Delivery History
ply a smile or words. So as the neuromuscular An interview with the biological mother, or
system matures, movement gradually becomes another familiar with the pregnancy, should
more purposeful and coordinated (Schultz and include questions about any maternal illness,
Hockenberry 2011). The sequence of develop- nutrition status, drug and/or alcohol use, chronic
ment is the same for all children, but the rate of diseases, and any medications taken routinely,
development varies from child to child. including prescription, over-the-counter, and
Finally, as important to a complete neurologi- herbal supplements. Important factors to know
cal exam is an assessment of the child’s cognitive about the delivery include the administration of
and emotional development. These abilities anesthesia or drugs and difficulties with the deliv-
impact directly on expectations of the child’s ery like the need for forceps or vacuum devices.
6 J.A. Disabato and D.A. Daniels

2 months (fetal) 5 months Newborn 2 years 6 years 12 years 25 years

Fig. 1.1 Changes in Proportions of the Human Body During Growth (Santrock JW 1998)

Note the infant’s Apgar scores. A need for mal newborns, especially if the baby is prema-
supplemental oxygen, intubation/ventilation, glu- ture. A soft, flat, or sunken anterior and posterior
cose, and abnormalities of bilirubin levels is also fontanel should be palpated. The posterior fonta-
important. A history of post-birth infections, a nel may be palpated up to 4 weeks of age. More
need for medication/oxygen, feeding difficulties, detailed information and illustrations regarding
and/or seizures may also indicate underlying cranial sutures and related abnormalities can be
problems. found in Chap. 3.
Spine assessments include evaluation for
1.2.1.2 Physical Appearance abnormal midline lumps, dimples, tufts of hair
The neonatal period is defined as the first 4 weeks on the spine, and palpation for vertebral anoma-
of life. The neonate may be term or premature, lies. Skin markings such as petechiae, heman-
and the physical characteristics of neonates vary giomas, and hypopigmented or hyperpigmented
with their gestational age. Inspection of the shape, lesions may be present at birth and indicative of
symmetry, and mobility of the head of the neo- neurological congenital conditions. It is impor-
nate is critical for evaluating cranial abnormali- tant to note the size, location, and number of
ties or soft tissue injuries. Head circumference at hypo- or hyperpigmented lesions. In addition,
term will range from 34 to 36 cm within the congenital anomalies of the heart, lungs, and
25–75 % ranges. Neonates outside this range gastrointestinal tract may suggest abnormalities
should be accurately plotted on the appropriate of brain development. However, optic or facial
growth chart and serially measured (Nellhaus dysmorphisms more accurately predict a brain
1968). Further examination of the neonate’s head anomaly (American Academy of Pediatrics
for a patent fontanel, tautness, and approximation 1996). Some facial dysmorphisms to note
of cranial sutures is vital. Fontanels are best pal- include hyper- or hypotelorism, flat philtrum,
pated when the neonate is in the upright position thin upper lip, epicanthal folds, unequal size of
and not crying. The cranial sutures should be well eyes, nystagmus, microphthalmia, hypoplastic
approximated, especially the coronal, squamosal, face or facial droop, micrognathia, abnormal
and lambdoidal sutures, and should not admit a shape/size of nose, asymmetry of smile, high-
fingertip. The sagittal suture may be wider in nor- arched palate, congenital cataracts, small or
1 Neurological Assessment of the Neonate, Infant, Child, and Adolescent 7

simple ears, preauricular skin tag/dimple, and Pediatrics 1996). The quality of the cry can sug-
cleft lip/palate. gest neurological involvement. A term newborn’s
cry is usually loud and vigorous. A weak or
1.2.1.3 Functional Capabilities sedated neonate will cry only briefly and softly,
Neonatal function is primarily reflex activity and or may just whimper. A high-pitched cry is often
necessitates the assessment of infantile automa- associated with a neurological abnormality or
tisms, i.e., those specific reflex movements which increased intracranial pressure (Freedman et al.
appear in normal newborns and disappear at 2009). Functional capabilities of the preterm
specific periods of time in infancy. Table 1.2 out- infant will vary by gestational age. Premature
lines the primitive reflexes in more detail (Slota infants demonstrate less strength and decreased
1983a). Functional examination may begin by muscle tone compared to a term infant. Table 1.3
observation of the neonate in supine and prone provides some of the key changes and the approx-
positions, noting spontaneous activity in each imate time when selected milestones appear in
position and presence of primitive reflexes. The most premature infants (Yang 2004).
posture of the neonate is one of partial flexion
with diminishing flexion of the legs as the neo- 1.2.1.4 Vulnerabilities
nate ages. Observe for hypotonia, which could The most critical need of both the term and pre-
indicate neurologic deficit or a genetic/metabolic mature neonate is for the establishment of ade-
disorder. Look for random movements of the quate respiratory activity with appropriate
extremities and attempt to distinguish single oxygenation. Respiratory immaturity added to
myoclonic twitches, which are normal, from the neurological insults from seizures, congenital
repetitive movement seen with seizures. Observe conditions, such as spina bifida and genetically
for symmetry of movements. Care should be linked syndromes as well as intraventricular
taken to observe for infantile spasms character- hemorrhage, and hydrocephalus all have the
ized by atonic head drops accompanied by arms capability to severely limit the neonates’ ability
rising upward. Some neonates have an excessive to buffer these conditions. Infections, an imma-
response to arousal with “jitteriness” or tremu- ture immune system, and gastrointestinal
lousness. This is a low- amplitude, rapid shaking deficiencies also can severely compromise the
of the limbs and jaw. It may appear spontane- neonate’s ability to dampen the physiological
ously and look like a seizure. However, unlike effects of neurological conditions. For the pre-
seizures, jitteriness usually follows some stimu- term neonate with a neurological disorder, damp-
lus, can be stopped by holding the limb or jaw, ening the effects becomes even more crucial and
and does not have associated eye movements or makes the preterm infant vulnerable to multisys-
respiratory change. When prominent, slow, and tem failures. Developmental care teams can be
coarse, it may be related to central nervous sys- mobilized to augment the neonate’s capacity for
tem stress or metabolic abnormalities, but other- optimal growth and interaction with their
wise it is often a normal finding (Kramer et al. environment.
1994; Shuper et al. 1991). Strength is assessed by
observing the newborn’s spontaneous and evoked 1.2.1.5 Tips in Approach to Child/Family
movements and by eliciting specific newborn Observation of the neonate at rest is the first step
reflexes. Neonates with neuromuscular condi- in a comprehensive approach to neurological
tions may manifest with abnormally low muscle assessment of the neonate. Usually, the head can
tone (hypotonia), paradoxical breathing, hip dis- be inspected and palpated before awakening the
location, or contractures. The neonate is capable neonate and measuring the head circumference.
of reacting to moving persons or objects within Most neonates arouse as they are unwrapped, and
sight or grasp, both for large and small objects. responses to stimulus are best assessed when the
Neonates can visually fixate on a face or light in neonate is quietly awake. As the neonate arouses
their line of vision (American Academy of further, the strength of his spontaneous and active