What to expect in a neurological exam

Your child was referred to a pediatric neurologist for a neurological exam, also called a neuro exam, part of a complete neurological evaluation. You know your pediatrician and generally what to expect during those visits. What happens in a neurological exam, and what can you expect?

Why would my child need a neurological exam?

Your pediatrician may suggest a complete evaluation of your child’s nervous system if the doctor suspects your child might have an underlying issue. The nervous system includes the brain, spinal cord and the nerves in these areas, including the muscles, also called the neuromuscular system. Some reasons why you may be referred for a complete neurological exam include:

  • Your pediatrician noticed something during a routine physical.
  • Your pediatrician noticed something during a newborn physical.
  • More information is needed about a diagnosis.
  • The neuro exam is needed to assess any congenital conditions of the head or spine.
  • Your child experiences:
    • Abnormal movements like tics
    • An injury to the head, neck or back
    • Blurry vision
    • Changes in behavior, balance or coordination
    • Chronic fatigue
    • Decreased movement in the arms or legs
    • Fever with unknown cause
    • Headaches
    • Missed milestones, such as holding the head up, rolling over, or learning to walk or feed themselves
    • Numbness or tingling in the arms or legs
    • Passing out spells
    • Seizures
    • Slurred speech
    • Staring spells
    • Tremor
    • Weakness

What happens during a neurological exam?

Depending on your child’s age, the tests may be slightly different. However, this is a good overview of areas and functions that may be evaluated during a neurological exam, including:

  • Mental status: The neurologist will examine your child’s level of awareness and interaction with their environment. This is done by watching the child interact with you (if your child is younger) or by talking with an older child, asking them questions and asking them to follow directions for small steps. Older children will be monitored to make sure that their speech is clear and makes sense. This may be done by the neurologist interacting with you and your child during the appointment.
  • Cranial nerve exam: The 12 main cranial nerves of the brain are evaluated to help determine different functions of the brain, including:
    • Olfactory nerve: Your child will be asked to identify different types of smells with his or her eyes closed.
    • Optic nerve: Your child’s vision, including your child’s pupils (the black part of the eye), will be assessed by a visual test and an eye exam with a special light.
    • Oculomotor nerve, trochlear nerve, abducens nerve: The testing for these nerves checks eye movement. The test will include asking your child to use their eyes to follow a light or a finger in various directions.
    • Trigeminal nerve: This nerve allows you to feel your face and inside the mouth, and move jaw muscles. The neurologist may touch your child’s face at various spots and have your child “bite down” as if chewing.
    • Facial nerve: This nerve helps with showing emotion and taste on the tongue. Your child may be asked to identify different kinds of taste (bitter, sweet, sour), and move parts of their face –– smile, blink, show their teeth, move their cheeks and forehead.
    • Vestibular cochlear nerve: This nerve helps with hearing and balance. Testing this nerve can include a hearing test and additional testing for vestibular (balance) function.
    • Glossopharyngeal nerve and vagus nerve: These nerves help with taste, gag reflex, swallowing and some speech skills. Your child may be asked to identify tastes on the back of the tongue and to swallow. The doctor also may prompt the gag reflex by using a tongue depressor on your child.
    • Accessory nerve: This nerve involves movement in shoulders and neck. Your child will be asked to turn their head from side to side, with mild resistance being applied. The child may be asked to shrug their shoulders as well.
    • Hypoglossal nerve: This nerve helps with moving the tongue. Your child will be asked to stick their tongue out and to speak.
  • Motor function: A neurologist will check motor function by asking a child to push and pull the doctor’s hands by using their hands and legs. A child also may be asked to squeeze a doctor’s fingers or to jump, skip or hop.
  • Sensory exam: This test will check a child’s ability to feel. Different tools may be used, including dull needles, alcohol swabs, tuning forks or other instruments. The neurologist may touch your child’s legs, arms or other parts of the body and ask them to identify the feeling (dull, sharp, hot, cold, etc.).
  • Muscle stretch reflexes (deep tendon reflexes): This tests the peripheral nerves and spinal cord. It is done by the neurologist using a reflex hammer on the knee or elbow, testing the reflex arc between the nerves that cause muscles to contract. If there is an issue with the nerves, there may be little or no response. If the child is experiencing a spinal injury of some kind, there may be an amplified response. Decreased or amplified/brisk reflexes can be physiological/normal in some patients.
  • Infantile reflexes: Newborns and infants will be checked for the primitive reflexes, or infantile reflexes. These reflexes exist early on in a child’s life and may stop as a child ages. The primitive reflexes include:

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    • Blinking: This is checked by shining a light in the child’s eyes to get them to blink
    • Plantar reflex (Babinski reflex): When the sole of an infant’s foot is stimulated, most often the toes go up. This is called the Babinski’s sign. After the age of 1 1/2 to 2,  if the toes go up it is often a sign of a central nervous system disorder.
    • Crawling: A child is placed on their stomach to see if they will make a crawling motion.
    • Moro reflex (startle reflex): A reflex that usually disappears after 6 months of age, this is when any sudden movement change causes the child to throw their arms out, with hands open, and push their head back.
    • Palmar and plantar grasp: An infant will grasp around a finger placed near their fingers and toes
    • Tonic neck reflex: This reflex usually disappears after 6 months of age. To test it, a child will lie down, face up. If the head lies to one side, the arm on that side extends, with the other arm flexing at the elbow and shoulder.
  • Balance and coordination. A child’s balance can be checked by monitoring how a child walks or stands. Additionally, older children may be asked to stand with their eyes closed while the doctor gently pushes the child from side to side.

The neurological examination is always interpreted and acted upon in light of the complete neurological picture.


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