Paeds · neurology-neurodisability-and-neuromuscular
Neurological examination across childhood
Also known as Paediatric neurology examination · Infant neurological assessment · Hammersmith Infant Neurological Examination · General Movements Assessment · Floppy infant examination · Paediatric tone and reflex assessment
A fellowship approach to the neurological examination from the newborn to the adolescent: hold a single constant framework — mental state, cranial nerves, motor, sensory, cerebellar and gait, and development — while adapting the technique to age and cooperation; read tone, reflexes, posture and movement through the lens of corticospinal maturation; use the Hammersmith Infant Neurological Examination and General Movements Assessment to detect cerebral palsy early; and separate the benign and transient from the red-flag findings that demand urgent imaging.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- A rapidly enlarging head that crosses centiles upward, a full or bulging fontanelle, or setting-sun eyes in an infant is raised intracranial pressure until proven otherwise — image and refer urgently
- Loss of previously acquired skills (developmental regression) is a neurodegenerative or structural process until proven otherwise, never simple delay
- An infant at corrected age three to five months with absent fidgety movements on General Movements Assessment, or a Hammersmith score below the optimality cut-off, is at high risk of cerebral palsy and must be referred for early assessment
- An acutely weak or floppy child with progressive bulbar or respiratory involvement may have a neuromuscular junction or spinal cord disorder that can decompensate in hours
- Asymmetric tone, reflexes or movements in an infant may signal a focal lesion such as a stroke, brachial plexus injury or hemiplegic cerebral palsy
Life stages
Care settings
Clinical exam formats
Board mappings
- Performing an age-appropriate neurological examination from newborn to adolescent
- Eliciting and interpreting primitive reflexes, tone and deep tendon reflexes
- Measuring and plotting head circumference and recognising crossing of centiles
- Using the Hammersmith Infant Neurological Examination and General Movements Assessment to detect early cerebral palsy
- Distinguishing spasticity, dystonia, rigidity and hypotonia using the Task Force on Childhood Motor Disorders definitions
- Assigning a Gross Motor Function Classification System level and relating it to the examination
- The newborn or infant with abnormal tone, posture or absent fidgety movements
- The floppy infant and the child with developmental delay or regression
- Red-flag neurological findings that mandate urgent imaging and referral
- Short case: systematic neurological examination of a school-age child
- Long case: an infant at high risk of cerebral palsy, discussing early detection
- Neurological and developmental assessment across the age range
- Recognition of abnormal tone, posture, reflexes and developmental trajectory
- Referral pathways for suspected cerebral palsy and neuromuscular disease
- Corticospinal tract maturation and the changing examination through infancy
- Classification of hypertonia and hypotonia
- Primitive reflex integration and deep tendon reflex grading
- Needle neurological examination in a short case
- Recognising the floppy infant and the child with cerebral palsy at the bedside
- The systematic, developmentally adapted neurological examination
- Interpretation of tone, reflexes and primitive reflexes by age
- Identification of neurological red flags requiring urgent evaluation
- Performing and documenting a complete paediatric neurological examination across age groups
- Early detection of cerebral palsy and neuromuscular disorders
- Recognition and initial management of raised intracranial pressure
- Age-stratified paediatric neurological examination
- Use of standardised infant tools (HINE, General Movements Assessment)
- Upper versus lower motor neuron signs and neurological localisation
The mark goes to the candidate who treats the examination as a developmental act, not a checklist applied once. The newborn brain is unfinished, and its examination reflects that: tone is flexor-biased, reflexes are mediated lower in the neuraxis, and signs we would call upper motor neuron in an adult are normal. Over the first two years the corticospinal tracts myelinate, voluntary control replaces reflex-driven movement, and the examination migrates toward the adult pattern. Reading a finding without this developmental lens is the commonest error in paediatric neurology — it labels the normal as abnormal, and far worse, can reassure when a finding has appeared that should alarm. [1] [2]
Overview & Definition
The paediatric neurological examination is a structured bedside assessment of a child's nervous system, performed to detect abnormality, to localise it within the neuraxis, and to track it over time. It is built on the same six-part framework used in adult neurology — mental state and higher function, the cranial nerves, motor system, sensory system, cerebellar and gait function, and development — but it is performed differently at every age, because the child's cooperation, their motor repertoire, and the maturity of their central nervous system all change month by month. [1]
What makes the paediatric examination distinctive is that the normal is a moving target. A term newborn lies flexed and tight, the hands clenched, the knees flexed, a brisk Moro snapping the arms open. Six months later that same child lies loose and open, reaches and rolls, and the primitive reflexes that dominated the newborn have integrated away. Two years on, the child walks and talks, and an upgoing plantar response — utterly normal in infancy — would now signal an upper motor neuron lesion. The clinician who can hold two questions at once — is this finding abnormal? and is it abnormal for this age? — has mastered the heart of the discipline. [2] [3]
The examination is also the single most reliable developmental surveillance tool in paediatrics, performed at every routine contact from the newborn check onward. Cerebral palsy affects roughly two per thousand live births, and the neurological examination — combined with the standardised infant tools — is how it is detected early enough for intervention to change the developing brain. A small, silent minority of findings are red flags: the head crossing centiles, the loss of a skill, the asymmetry that signals a focal lesion. The examination exists to catch these, and to distinguish them from the large benign majority. [8] [9]
References12ShowHide
- [1]Dubowitz L, Ricciw D, Mercuri E. The Dubowitz neurological examination of the full-term newborn Ment Retard Dev Disabil Res Rev, 2005.PMID 15856443
- [2]Guzzetta A, Haataja L, Cowan F, et al. Neurological examination in healthy term infants aged 3-10 weeks Biol Neonate, 2005.PMID 15627727
- [3]Ricci D, Cowan F, Pane M, et al. Neurological examination at 6 to 9 months in infants with cystic periventricular leukomalacia Neuropediatrics, 2006.PMID 17177152
- [4]Prechtl HF, Einspieler C, Cioni G, et al. An early marker for neurological deficits after perinatal brain lesions Lancet, 1997.PMID 9149699
- [5]Kuo TJ, Chen HC, Wang YH, et al. Hammersmith Infant Neurological Examination global scores for predicting neurodevelopmental outcomes after 2 years of age: a systematic review and meta-analysis Dev Med Child Neurol, 2026.PMID 42375103
- [6]Sanger TD, Delgado MR, Gaebler-Spira D, et al. Classification and definition of disorders causing hypertonia in childhood Pediatrics, 2003.PMID 12509602
- [7]Palisano R, Rosenbaum P, Walter S, et al. Development and reliability of a system to classify gross motor function in children with cerebral palsy Dev Med Child Neurol, 1997.PMID 9183258
- [8]Novak I, Morgan C, Adde L, et al. Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy: Advances in Diagnosis and Treatment JAMA Pediatr, 2017.PMID 28715518
- [9]Morgan C, Fetters L, Adde L, et al. Early Intervention for Children Aged 0 to 2 Years With or at High Risk of Cerebral Palsy: International Clinical Practice Guideline Based on Systematic Reviews JAMA Pediatr, 2021.PMID 33999106
- [10]Peredo DE, Hannibal MC. The floppy infant: evaluation of hypotonia Pediatr Rev, 2009.PMID 19726697
- [11]Prasad AN, Prasad C. Genetic evaluation of the floppy infant Semin Fetal Neonatal Med, 2011.PMID 21131247
- [12]Cicala G, Mercuri E. The floppy infant revisited: from bedside to genome Dev Med Child Neurol, 2026.PMID 41495003