Features of neurological examination of infants. The neurological status of the child is a mandatory characteristic of the development of life

When examining a child, the pediatrician evaluates the neurological status, and also makes a conclusion about his neuropsychic development (his age-appropriateness), which is recorded in the medical history or outpatient card. The study of the neurological status of the newborn and infant includes an assessment of:

Spontaneous position and motor activity of the child on the back and on the stomach;

Muscle tone during passive movements in the limbs, traction by the arms, suspension;

Unconditioned reflexes of newborns and tendon reflexes;

Visual and auditory reactions (gaze fixation, tracking, turn to sound);

Motor skills: holding the head, grasping, turning over, crawling, landing, standing up, walking;

Measurement of head circumference and size of fontanelles and sutures;

Identification of pathological eye signs (strabismus, anisocoria, asymmetry of the palpebral fissures, nystagmus, a symptom of the "setting sun");

Evaluation of emotional reactions and pre-speech development.

The newborn has an increased tone of the limb flexors (labyrinth reflex) - lying on the back, the arms are bent at the elbows, the legs are bent at the knees and brought to the stomach. Hypertonicity disappears by 1-2 months of life, first in the upper, then in the lower extremities. A newborn in the state of wakefulness is characterized by spontaneous choreic (athetosis-like) movements, which are bilateral, asymmetric, slow in nature with elements of “floating” movements, accompanied by tilting the head back and arching the body.

When assessing the neuropsychic development of a child older than 1 year, the following are also examined:

ü motor skills (walking, fine motor skills) and coordination of movements;

ü household skills and self-service (eating, dressing, hygiene skills);

ü communication and play activities;

ü speech ( vocabulary, articulation and grammar);

learning (reading, writing, arithmetic, school performance).

Reflexes of newborns

The study of reflexes is the most important component of assessing the neurological status of a newborn and a child of 1 year of age. From birth, there are lifelong automatisms: corneal, conjunctival, pharyngeal, swallowing, orbiculo-palpebral, superciliary and tendon reflexes. Specific reflexes of newborns and children infancy can be divided into two groups: the first - present at birth and subsequently lost (oral and spinal segmental automatisms, myelencephalic postural reflexes), the second - absent in the newborn and appearing at a certain age (mesencephalic adjusting automatisms). Reflexes of newborns can be characterized as normal, increased, spontaneous, exhaustible, reduced, symmetrical and asymmetric. Reflexes should be checked three times.

Table 1

Reflexes of newborns

static motor development

The main achievements of the static-motor development of the child are the ability to sit (sit down), stand with support, crawl, walk with support (support), stand and walk independently. Below are the average and deadlines for a child to master these skills.

Keep head - 3 months (2-4 months).

Directed hand movement (reaching for a toy) - 4 months (2.5-5.5 months).

Roll over from back to stomach - 5 months (3.5-6.5 months).

Sitting - 6 months (5-8 months).

Crawling - 7 months (5-9 months).

Purposeful grasping - 8 months (5.5-10 months).

Get up - 9 months (6-11 months).

Walk with support - 9.5 months (6.5-12.5 months).

Independent standing - 10.5 months (8-13 months).

Independent walking - 11.5 months (9-14 months).

These terms have a significant individual range, which is influenced by many endogenous and exogenous factors. Nutrition, care features and social conditions matter. To assess motor development, it is necessary to take into account the anamnesis, neurological and somatic condition. If the child does not sit at 6 months - this is a variant of the norm; if there is no landing at 7 months, this does not prove that he is lagging behind in development, but gives rise to a targeted examination of the child by a doctor; if the ability to sit down independently does not develop by 8 months, this is already a delay in motor development.

Psycho-speech development

At 1 year of life in the period of pre-speech development, a period of cooing (2-5 months) and babbling (5-9 months) is distinguished. Cooing is characterized by a melodious pronunciation of predominantly vowel sounds, spontaneous at first, then becoming more complex in structure, acquiring a variety of emotional coloring and appeal to an adult. Babbling is syllables that do not have a verbal formalized meaning, which are initially characterized by spontaneous repetition of sound combinations, then (from 7-8 months) by repeated repetition of sound combinations uttered by an adult. From 9 to 12 months, the first words appear on the basis of babbling. By the age of 1, a child usually actively uses up to 10 words (syllabic) and understands up to 20 words.

Allocate active speech(pronunciation of words) and passive(understanding of addressed speech).

Speech development has a wide individual range. We can talk about a delay in speech development at 2-3 years of age. In some children, due to individual features development in the 2nd and even 3rd year of life, active speech may be very limited or absent, while subsequently these children have normal development. Their passive speech is usually better developed. However, children who do not have active speech by the age of 3 require specialist advice, possibly corrective techniques.

According to WHO, up to 25% of 4-year-old children have serious speech development disorders. Speech development disorders can be combined with a general mental retardation, but in some cases, speech disorders in isolation and its correction can contribute to overall development. Violation of speech development may have a partial character and affect only articulation and pronunciation (dysarthria, dyslalia), grammatical structure (dyslexia), written speech (dysgraphia). These violations can significantly disrupt the learning and socialization of the child.

Comprehensive examination program for children with neurological disorders"Accurate diagnosis" is an effective method of examination and treatment of children with neurological pathology.

Based on the experience of working with more than 1000 children from 0 to 18 years old and observing a large number of cases of unproductive treatment due to inaccurate diagnosis, we have developed a program aimed primarily at establishing the correct diagnosis and as a consequence, effective treatment.

Program stages:

Electroencephalogram (EEG)

Conducted by a neurologist-neurophysiologist according to the protocols of the Institute of Neurosurgery named after Burdenko. A doctor specializing in the functional diagnosis of changes in the central nervous system.

EEG is a high-precision non-invasive research method that allows assessing the bioelectrical activity of the brain and identifying disorders in various parts of the cerebral cortex.

Initial examination by a neurologist

Initial examination of the child by a neurologist specializing in speech disorders and cognitive impairment in children.

During the examination, the neurologist first meets the child and the parents. The doctor receives information about the history of the disease, assesses the neurological status of the patient. Doctor compares clinical picture with changes detected on the EEG.

Neuropsychologist consultation

A neuropsychologist is a specialist who assesses the functional state of the child's brain, the maturity of the psycho-emotional sphere in accordance with age and identifies the prerequisites that led to the disease, determines the structure of the disorder.

The object of study of a neuropsychologist: the cortex, subcortex and brain stem, as well as the interaction of the cerebral hemispheres.

Consultation of a speech pathologist

A speech pathologist-defectologist conducts diagnostics of speech development, aimed at identifying the individual characteristics of the child, characterizing his communication capabilities, cognitive and emotional-volitional sphere.

Joint conclusion of speech pathologist-defectologist and neuropsychologist

At the final stage, a council of specialists collegially analyzes all the results of examinations and studies, and then draws up a single conclusion with the appointment and development of a correction route.

Repeated consultation with a neurologist (face-to-face/Skype-consultation)

At the final stage, the neurologist analyzes all the results of examinations and studies, and then draws up a single conclusion with the appointment drug therapy and corrective exercises.

The cost of the program "Diagnostics: Accurate Diagnosis": 14.200 rubles.

Very often, appeals to numerous doctors do not give the expected results. There is no improvement.

Why are there situations when treatment does not work?

In most cases, this is due to the fact that the cause of the violation was incorrectly identified.

Why the cause of the violation can be incorrectly established?

Because the violation can be complex, combined. That is, the basis of the violation may be not one reason, but several at once. And it is the combination of these reasons that leads to the problem.

Why is it so difficult to identify this complex of causes?
Because these reasons can relate to the area of ​​​​knowledge of several different specialists at once. And each doctor evaluates the violation from the point of view of his specialization.

Our program is based on the principle of not symptomatic treatment, but a morphological approach to making a diagnosis - all the main examinations are carried out in our center, our doctors have the opportunity to comprehensively identify the root cause of the disorder and collectively make a decision, which allows us to quickly restore the health of a small patient.

We are in an accessible language, explaining medical terms, openly explain to parents the causes of the violation and the prognosis of recovery. During the final consultation, doctors give comprehensive answers to all questions - what methods and in what time frame can achieve results. For those children who require further treatment, individual course programs are being developed.

Experience, professionalism, expert-class equipment and an interdisciplinary approach allow us to make the correct diagnosis with 100% certainty and prescribe the necessary course of corrective therapy.

In assessing the condition of a newborn or infant, a well-collected anamnesis, including the period of pregnancy and childbirth, is especially important. Most necessary. carefully find out how the mother's pregnancy proceeded, whether there were any complications (toxicosis, bleeding, etc.), what diseases she suffered during this period. It is important to establish at what time of pregnancy these complications or diseases were. Along the way, one should ask if there were any neurological diseases among close relatives, find out the living conditions of the family. You should find out in detail how the birth proceeded (normal, difficult, protracted, too fast). It is advisable, especially in cases of pathological childbirth, to get acquainted with an extract from the medical history of the relevant medical institution.

It should be found out whether the child was born at term, premature or overdue, whether surgical intervention during childbirth, whether he screamed immediately or there were signs of asphyxia, for how long resuscitation methods were used.

What is his birth weight? Were there convulsive conditions, bouts of cyanosis in the first hours of life? Did the newborn cry loudly? How long did neonatal jaundice last? Vigorously or sluggishly breastfeeding?

It is necessary to find out in detail how the further development of the child proceeded.

At what age did he begin to hold his head, roll over on his side, on his stomach, when he began to sit, stand up and walk on his own? Since when did he start laughing, watching the faces and objects around him? Did you grow up calm or, on the contrary, was too restless, how many hours a day did you sleep? Then you should clarify what the child was sick with. Pay attention to whether there were convulsive conditions with loss of consciousness? Were there rises in temperature, a period of great anxiety? Were there any injuries - falling from a bed, a chair, etc.?

When questioning, you should find out whether we are talking about residual phenomena that developed in the past - intrauterine damage, the result of a birth injury, previous meningoencephalitis, or whether there is a current process, a disease that is currently developing.

A neurological examination of newborns and infants is carried out according to the scheme that is used when examining older children:

1) research cranial nerves;

2) motor sphere;

3) reflex sphere;

4) sensitive area;

5) meningeal symptoms.

For a successful examination of the neurological status, certain conditions must be met: the child should be as calm as possible, the examination should be carried out in a room with sufficient high temperature air (25-27°C) to exclude reactions associated with the influence of the temperature factor. It is not advisable to watch the child immediately after feeding or before feeding, which may affect the state of the general and neurological status

The examination of the child begins with his position on his back. Active examination is preceded by observation; note the color of the child's skin, breathing, spontaneous movements - whether they are symmetrical, which movements prevail - flexion or extension. Extrapyramidal and athetoid movements are observed in newborns and are normal; if they are completely absent or elevated, this is already a sign of pathology. Weak trembling of the extremities can be regarded as a physiological phenomenon, strong trembling is a manifestation of a pathological condition. Observe the facial expression, his facial expressions. It is important to assess disembryological stigmas: incorrect structure and location auricles, hypertelorism (broad bridge of the nose), prognathism (retracted chin), low hair growth on the forehead. You need to pay attention to the shape of the head. The skull can be dolichocephalic - elongated in the anteroposterior direction, brachycephalic - elongated in the transverse direction, tower - elongated vertically; thus, a deformity of the head is possible, which is not associated with a change in the integumentary bones of the skull, but with the presence of a cephalohematoma or a birth tumor. It is necessary to take into account the size of the skull: normal, reduced - microcephaly, enlarged - macro- or hydrocephalus. Head circumference measurements in full-term newborns are 33-37.5 cm.

Average head circumference in children from birth to 1 year:

At birth - 35.3 cm

1 month - 37.2 cm

2 months - 39.3 cm

3 months - 40.4 cm

6 months - 43.4 cm

9 months - 45.3 cm

12 months - 46.8 cm

It is necessary to examine a large fontanel, its dimensions should not exceed 2.5 x 3 cm. When palpating the skull, the head baby they take it by the back of the head in such a way that with both thumbs it is possible to feel the large fontanel, coronary and sagittal sutures, and with the index and middle fingers - the lambdoid suture and its surroundings. By the time of birth, the coronal suture should be closed, the sagittal suture connecting the large and small fontanelles can be opened by no more than 0.5 cm. Then percussion is performed: the coronal and sagittal sutures, as well as the frontal, temporal and occipital regions. By the sound, one can judge the presence of hydrocephalus or the divergence of the sutures (“the sound of a cracked pot”). The following symptoms serve as signs of intracranial hypertension in children: anxiety, vomiting that occurs regardless of feeding, lack of interest in others, developmental delay. The size of the child's skull is enlarged: the skull may be asymmetrical, the large fontanel is protruding, tense, the bone sutures diverge, the saphenous veins of the head are dilated. Especially important symptom intracranial hypertension in children there is a pathological increase in the size of the head.

Symptoms that indicate the possibility of an increase intracranial pressure, also include a towering skull with a high forehead (“Socrates’ forehead”), a dolichocephalic skull with a sharply protruding occipital protuberance with a tendency to tilt the head back (the predominance of tone in the extensors of the neck).

Graefe's symptom - when standing still eyeballs with the opening of the upper eyelids, a strip of sclera remains above the iris. The symptom of the “setting sun” is that when the head is tilted forward, the eyeballs descend downward and a strip of sclera appears above the iris. The presence of this symptom indicates hypertension in the region of the third ventricle and the aqueduct of the brain.

After an external examination of the child, palpation and percussion of the skull, measurements of its circumference proceed to the study of the cranial nerves.

cranial nerves.

(olfactory nerve). To study the sense of smell in young children, substances with strong smell. At a sharp smell, the child wrinkles his nose, closes his eyelids, screams, sometimes sneezes.

(optic nerve). The preservation of visual function can be judged by the child's reaction to eye irritation with a bright light source - in response to irritation, the child closes his eyes.

(oculomotor, trochlear, abducens nerves). On examination, pay attention to the width of the palpebral fissures, the presence of ptosis.

The movement of the eyeballs in newborns - jerky is carried out separately, binocular vision is still absent. As the gaze is fixed, when the child begins to follow objects, the movements become smooth, friendly. Pronounced nystagmus, especially in combination with wide pupils and the absence of squinting to light, is characteristic of blind and visually impaired children.

By the end of the 1st month of normal life, children develop a concentration reaction in response to sound and visual stimuli with gaze fixation on an object.

From the moment of birth, there is a live reaction of the pupils to light, you should pay attention to the size and uniformity of the pupils, find out if there is strabismus and nystagmus. With postpartum traumatic plexitis, a symptom of Bernard-Horner is possible.

(trigeminal nerve). The motor portion is checked in newborns during the act of sucking. In case of paresis of the motor part trigeminal nerve the chin shifts to the affected side, the act of sucking becomes difficult, atrophy of the chewing muscles develops on the affected side. With the defeat of the first branch of the trigeminal nerve, there is no corneal reflex.

(facial nerve). Function facial nerve in a newborn, it is examined by monitoring the state of the mimic muscles during sucking, crying.

(auditory and vestibular nerve). With a sharp sound stimulation, the newborn responds with a start, fright, closing of the eyelids, turning the head, blinking, wrinkling the forehead, opening the mouth. Lack of response to loud sound is an indicator of hearing loss. By the 3rd month, the child begins to react to sounds, turn in the direction of the sound source.

The functions of the vestibular portion of the nerve are characterized by congenital Moro reflexes, tonic neck reflex, tonic labyrinth reflexes (see below).

(vagus and glossopharyngeal nerves). When these nerves are affected, swallowing is disturbed, the child takes the breast with difficulty, chokes, chokes, the sonority of the voice changes, crying becomes deaf, quiet, with a nasal tint. On the side of the lesion, the soft palate hangs down, its mobility is reduced compared to the opposite side.

(accessory nerve). With damage to the accessory nerve, torticollis is observed, the child cannot turn his head in the healthy direction, the shoulder on the side of the lesion is somewhat lowered.

(hyoid nerve). Normally, in a newborn, the tongue is in active movement all the time. With central paresis, the mobility of the tongue in the oral cavity is insufficient, the act of sucking is difficult. Peripheral paresis is accompanied by the development of atrophy and fibrillar twitching.

motor sphere. Determination of motor function in a child begins with an examination of the posture, facial expressions, activity of movements in the limbs. A healthy newborn for the first two months, lying on his back, makes constant chaotic movements with his limbs, the predominance of the flexor group attracts attention: the arms and legs are slightly bent, close to the body, the hands are clenched into fists, the feet are in moderate dorsiflexion. This position is called the fetal position. The head tends to tilt back due to increased tone in the extensors of the neck. Normally, muscle tone is increased up to 1 1/2-2 months in the extensors of the neck, in the flexors of the limbs, which gives them a flexor posture. And only the head tends to unbend.

To study active movements of the limbs, the following technique is used. Putting their palms under the back of the child, they raise it so that the head lies on one palm, and the torso on the other; paralyzed or hypotonic limbs will hang down. If a newborn child lying on his back is seated by pulling his hands, then his hands remain in a moderately bent position for some time, the child holds his head straight for several seconds. This is not observed in hypotonic children. When laying a child on his stomach, a healthy newborn turns his head, sometimes holds it for several seconds, tries to crawl. With increased tone and opisthotonus, the child can hold the head for a longer time. In case of hypotension, the child does not raise his head, lies helplessly sprawled. If a child lying on his stomach is lifted to a vertical position, supporting his chest with both hands, then a healthy newborn, overcoming gravity, holds his head, torso and, to a certain extent, limbs. In a hypotonic child, the head and limbs droop limply.

. Already in a newborn child, a knee jerk is evoked, but this is not always possible due to an increase in muscle tone characteristic of newborns. Achilles reflex in normal newborns and infants in 10-15% is not called. Abdominal reflexes in most cases can be induced as early as 2 months old. The first months they are sluggish, after 4 months they become alive. The cremasteric reflex is often caused already in newborn boys.

In a newborn, reflexes are evoked from the biceps and triceps muscles, from the styloid process.

Sensitivity testing in very young children is difficult. Newborns still show a reaction to thermal and cold stimuli in the form of changes in motor activity and crying.

Until the age of 3 months, the child has no voluntary coordinated movements; A 4-month-old healthy baby can already pick up his toys. The study of coordinating samples is possible only in older children. In young children, motor coordination can be explored during play.

The study in newborns and infants has a number of features. It should be borne in mind that due to the opening of the fontanelles and partially the sutures, tension of the meninges does not occur, there is no rigidity of the occipital muscles. Kernig's symptom and Brudzinsky's symptom are normal up to 4-6 months. A more effective indicator of irritation of the meninges in newborns and infants is the bulging, tension and pulsation of the large fontanel. At the same time, there is also general hyperesthesia, opisthotonus. Le Sage's symptom of "suspension" is manifested by tightening the legs.

An important indicator of the degree of maturation of the nervous system, the viability of the newborn are the unconditioned reflexes that he has.

Oral segmental automatisms- Kussmaul's search reflex consists in the fact that when stroking the corner of the mouth with a finger or nipple, the child turns the head in the direction of irritation, opens the mouth slightly.

Sucking reflex caused in a newborn with irritation of the oral cavity. The sucking reflex can be induced in a child up to a year old. Palmar-mouth reflex (Babkin reflex) occurs when pressing on the palmar surface of both hands in the thenar area. In response, the child should open his mouth and bend his head. The loss of this reflex is observed when the central nervous system is affected.

proboscis reflex caused by a quick light blow with a finger on the lips, in response there is a contraction, stretching the lips with a "proboscis".

Moro reflex(or grasping reflex) reflects the state vestibular system observed normally up to 3 months. The reflex is caused by the use of some sudden stimuli (sound, a blow to the pillow) and is considered positive if an extensor reaction and extension of the arms and legs occurs in the infant lying on its back, and then a flexion reaction and adduction, first of all, of the arms.

Strengthening the Moro reflex, its occurrence without causing irritation indicates increased convulsive readiness. The absence of the Moro reflex is usually associated with disorders of the vestibular system and motor disorders of a central or peripheral nature.

Magnus-Klein reflex indicates the functional maturity of the VIII-XI pairs of cranial nerves and their connections with propulsion systems. If you quickly turn the head of a child lying on his back in any direction, then the limbs of the same side are unbent, and the opposite side is bent. The child assumes the "swordsman" position. This reflex disappears by the end of the 1st year.

grasp reflex- with a slight irritation of the palm, the child's fingers reflexively compress and cover the doctor's fingers with such force that sometimes he can be lifted for a few seconds from a lying position. The compression force must be equal on both sides. Normally, this reflex disappears at 2-4 months of age.

plantar reflex- when you press a finger on the sole, a flexion movement of the sole appears and a tightening of the fingers. It is analogous to the grasping reflex. Normally, it disappears at 9-11 months of age, when the child begins to walk.

Support reflex and automatic gait in newborns. If you hold the child upright without support, then he bends his legs in all joints. The child, placed on a support with his feet, begins to step over his feet, making stepping movements Bauer's crawling reflex - when the newborn is laid on his stomach, he begins to make crawling movements. When the doctor's palm rests on the feet, the child reflexively pushes off with his feet and crawling intensifies.

Talent's spine reflex- with a slight irritation of the skin with a finger parallel to the spine, the torso unbends, the limbs on the side of irritation are drawn in. This reflex is normally called up to 3-4 months.

labyrinth reflexes appear at the age of 3 months. To study them, you need to cover the eyes of the child, lift him in a horizontal position and tilt him forward, backward and to the side. Despite the change in position, the baby will keep the head up and face forward.

It should be remembered that in the process of child development these reflexes disappear, giving way to voluntary movements. With the defeat of the nervous system, the disappearance of congenital reflexes is delayed. Their detection at a later age is a sign indicating the defeat of certain parts of the central nervous system.

The characteristics of the neurological status of a newborn child include the state of muscle tone and motor activity, assessment of unconditioned reflexes, the absence or presence of signs characteristic of damage to the cranial nerves, the ability to self-suck and elements of emotional tone at this stage of development.

Clinical examination data are supplemented by an obstetric anamnesis, the nature of labor and neurosonographic examination. The initial neurological evaluation may be changed later, the symptoms characterizing it may be short-lived and quickly disappear, or, conversely, appear later after a short or long latent period.

The standard of the norm is a healthy full-term baby, the neurological status of newborn premature babies is considered in accordance with their gestational age, which largely determines their neurological maturity.

Examination of the child when assessing the neurological status is performed on the changing table, under optimal temperature conditions. This applies to all weight categories, including children weighing 750-1000 g. We are not in favor of examining children directly in the incubator, as this limits the quality of the examination, but this does not apply to children who are on a ventilator.

The state of muscle tone determines the posture of the child. From the first days of life, a healthy full-term newborn is characterized by a flexor position of the limbs: the legs are bent at the hip and knee joints, the hips are laid to the sides, the arms are usually brought to the body and bent at the elbows. The extension of the limbs is difficult from moderate to more pronounced, which reflects their physiological hypertonicity.

Physiological hypertonicity of varying intensity is characteristic of all full-term newborns, it is already expressed at the birth of a child, at the age of 3-4 weeks it begins to gradually decrease and completely disappears by 2 months.

The absence of physiological hypertonicity in the first week of life indicates neurological abnormalities and requires clarification of the genesis of these disorders.

Pathological hypertonicity of the extremities in the neurological status of the newborn, as a result of hypoxic, traumatic or other type of brain damage, can also be expressed from the first days of life or appear later, at the age of 2-3 weeks, when it can still be confused with physiological hypertonicity. However, unlike the latter, it tends to progress and is combined with other neurological symptoms(crossing of the shins, tilting the head, decreased Moro reflex). In the anamnesis of these children, there are indications of a pathological course of pregnancy or trauma during childbirth.

Tone upper limbs determined by three positions: flexion, extension in elbow joints, abduction of hands to the sides, raising hands up. A lower tone is noted during flexion and extension of the arms, a higher one - when they are taken to the sides.

The tone of the hands is determined by fixing the child's forearm and "tossing" the hand up.

Tone lower extremities when evaluating the neurological status of a newborn, it is determined by flexion and extension of the legs at the knee, hip joints, and dilution of the hips. In addition, the position of the limbs is assessed, elongated legs in the absence of their lethargy indicate the predominance of extensors, and the location of the arm along the body indicates its hypotension.

Motor activity in small premature babies is determined by observing their behavior in the incubator, where they lie naked, and their activity (passivity) is clearly visible. It is advisable to evaluate the activity of the child in different positions: on the back and on the stomach.

Additionally, motor activity is judged during the assessment of the neurological status of the newborn, alternately spreading, abducting and straightening the arms and legs, and holding them in this position for about 5 s. Freezing in a pose indicates localized or general hypodynamia.

In general, even in children with a weight of 750-1000 g and a gestational age of more than 26-27 weeks without concomitant severe pathological conditions, motor activity is noted already in the first week of life.

Physical inactivity reflects not only the defeat of the central nervous system, but also accompanies severe somatic pathology.

Increased motor activity, short-term or longer with excessive movement of the limbs and movement around the incubator is not uncommon and can be observed in children weighing 900-1500 g, indicating hypoxic or hemorrhagic damage to the central nervous system.

With increased motor activity, attention should be paid to their nature. Movements that resemble the picture of riding a bicycle, in the form of pedaling, rowing or swimming, are equivalent to seizures.

Mild tremor and single shudders in the first 2-3 days of life can be considered as a variant of the norm of the neurological status of the newborn.

Page 51 of 51

Chapter 10
FEATURES OF NEUROLOGICAL EXAMINATION OF INFANTS
Study of the nervous system in children early age has specific features associated with the age physiology of this period of development. Intensive formation of the nervous system in the first years of life leads to a significant complication of the child's behavior, so the neurological examination of children in this group should be dynamic and based on the evolution of basic functions.
A neurological examination of a newborn begins with an examination. Examination of a young child is carried out in a calm environment, excluding, if possible, distractions.
Examination of newborns is carried out 1 - 2 hours after feeding at a temperature of 25 - 27 ° C. The light should be bright, but not irritating, and the surface on which the child is examined should be soft, but not sagging.
A neurological examination of a newborn begins with observing his behavior during feeding, wakefulness and sleep, the position of the head, trunk, limbs, and spontaneous movements. As a result of physiological hypertension of the muscles of the flexor group, which prevails in a child of the first months of life, the limbs of the newborn are bent at all joints, the arms are pressed to the body, and the legs are slightly abducted at the hips. Muscle tone is symmetrical, the head is in the midline or slightly tilted back due to increased tone in the extensors of the head and neck. The newborn also makes extensor movements, but the flexion posture predominates, especially in the upper limbs (embryonic posture).
With damage to the nervous system in newborns, various pathological postures can be observed. With opisthotonus, the child lies on its side, the head is sharply thrown back, the limbs are unbent and tense. The opisthotonic posture is maintained by enhanced tonic reflexes (abnormal postural activity). The “frog” pose is noted with general muscular hypotension. The posture of the "legged dog" (thrown back head, arched torso, retracted stomach, arms pressed to the chest, legs pulled up to the stomach) can be observed with inflammation of the meninges.
With obstetric paresis of the hands, an asymmetric arrangement of the upper limbs is determined. On the side of the lesion, the arm is extended, lies along the body, rotated inward in the shoulder, pronated in the forearm, the hand is in palmar flexion. An asymmetric arrangement of the limbs is possible with hemiparesis.
; It is necessary to describe the position of the head, the shape of the skull, its dimensions, the condition of the cranial sutures and fontanelles (retraction, bulging, pulsation), displacement, defects of the cranial bones, note the presence of a birth tumor, cephalohematoma. Knowing the size of the skull at birth and monitoring its further growth dynamics are important for diagnosing hydrocephalus and microcephaly in the first weeks of a child's life.
In children with severe lesions of the nervous system, with severe motor disorders, mental retardation, often from the first months of life, slow growth of the skull, rapid closure of the cranial sutures, and premature closure of the large fontanel can be noted. Progressive excessive increase in the size of the skull is observed in congenital and acquired hydrocephalus.
In some cases, the expression on the face of the child matters. A gloomy, painful expression on the face of a newborn is one of the signs of damage to the nervous system. It is important to determine if there are congenital craniofacial asymmetries or other specific facial features. For example, grotesque facial features with prominent frontal tubercles and a saddle-shaped skull are characteristic of some mucopolysaccharidoses and mucolipidoses, "Mongoloid" facial features are observed in Down's disease, and a "doll" face is a symptom of early forms of glycogenosis.
Attention should be paid to the general physique of the child, the proportionality of the trunk and limbs. Thus, a violation of the proportion of the trunk and limbs is characteristic of chromosomal syndromes, connective tissue diseases, congenital ectomesodermal dysplasia.
Of great importance is the statement of minor developmental anomalies (dysembryogenetic stigmas), which are the result of various unfavorable factors in embryogenesis.
The study of the functions of the cranial nerves in newborns is a difficult task. It is necessary to take into account the age evolution of functions, the immaturity of many brain structures.
pair. - olfactory nerve. Newborns react to pungent odors with displeasure, close their eyelids, wrinkle their faces, become restless, and scream.
pair - optic nerve. In newborns, all parts of the eyeball necessary for vision are formed, with the exception of the fovea centralis, which is less developed in them than the rest of the retina. Incomplete development of the fovea centralis and imperfectly operating accommodation reduce the possibility of a clear vision of objects (physiological farsightedness). An artificial light source causes a reflex closing of the eyelids and a slight throwing of the head back in the newborn.
The blinking reflex, which occurs when an object approaches the eyes, is absent in a newborn; it appears only on the 2nd month of life.
Vision in a newborn may be impaired as a result of retinal hemorrhage during difficult childbirth. Usually hemorrhages resolve on the 7th - 10th day of life; in severe cases, repeated hemorrhages are possible, which further cause varying degrees amblyopia. In addition, in newborns, various developmental anomalies can be detected (atrophy optic nerves coloboma, cataract, microphthalmia). For early diagnosis of the pathology of the retina and transparent media of the eye, it is necessary to examine newborns by an ophthalmologist in maternity hospitals.
Ill, IV and VI. pairs: oculomotor, trochlear, abducens nerves. The newborn has pupils of the same size, with lively direct and friendly reactions to light. The movements of the eyeballs are carried out separately: there is no binocular vision yet. Combined eye movements are inconsistent, occur randomly. The eyeballs often spontaneously converge to the midline, and therefore convergent strabismus is periodically observed. It should not be permanent, otherwise it indicates damage to the central nervous system. The movements of the eyeballs in newborns are jerky. Gradually, as the gaze is fixed, when the child begins to follow objects, the movements become smooth, friendly.
When researching oculomotor nerves in newborns, it is important to pay attention to the size of the palpebral fissures. With obstetric paresis of the hand, Bernard-Horner syndrome sometimes occurs on the side of the paresis. Ptosis occurs with congenital aplasia of the macrocellular nucleus of the III pair, as well as with masticatory-blinking synkinesis of Marcus - Gunn.
In the first days in newborns, more often in premature babies, one can observe the symptom of the "setting sun": a child in a horizontal position is quickly transferred to a vertical position, the eyeballs turn down and inward, in a wide palpebral fissure a strip of sclera becomes visible; after a few seconds, the eyeballs return to their original position. The presence of this symptom after 4 weeks of age, in combination with other symptoms, indicates damage to the nervous system, increased intracranial pressure.
Fixation of gaze on an object can sometimes be noted already in 5-8-day-old children, but it becomes more constant from the 4th to 6th week of life. At 9-10 days of age, newborns make their first attempts to follow moving bright objects, while only the eyeballs move, the head remains motionless. After 4 weeks, a combined turn of the head and eyeballs gradually appears. The development of gaze fixation on an object is connected to a certain extent with the degree of mental development. The timely appearance of gaze fixation is a favorable symptom, indicating normal mental development. If the child is detained mental development, gaze fixation appears late, it is unstable, the child quickly loses the object from the field of view and becomes indifferent to it.
With damage to the oculomotor nerves, there may be convergent and less often divergent strabismus. Ptosis in young children may be due to underdevelopment of the levator levator muscle. upper eyelid, aplasia of the nucleus of the oculomotor nerve and non-separation in embryogenesis of the functions of the muscles of the pterygoid and levator upper eyelids (chewing-blinking synkinesis).
Gaze paresis in newborns is more often congenital. Their cause is the underdevelopment of the brain stem.
V pair - trigeminal nerve. In newborns, the function of the motor portion is checked by observing the act of sucking. When the motor portion of the trigeminal nerve is affected, the lower jaw sags, it shifts to the diseased side, difficulty in sucking, and atrophy of the masticatory muscles on the affected side are observed. When the I branch of the trigeminal nerve is damaged, the corneal reflex is absent, mito is reduced.
para - facial nerve. It is possible to study the function of the facial nerve in a newborn by observing the state of the mimic muscles during sucking, crying, crying of the newborn, as well as by causing a number of reflexes that require the participation of mimic muscles for their implementation (corneal, corneal, orbiculopalpebral, search, proboscis, sucking) .
Peripheral paresis of the facial muscles occurs in newborns extracted with abdominal forceps when the terminal branches of the facialis are injured. Observing newborns, one can note the expansion of the palpebral fissure on the side of the lesion; when crying, the corner of the mouth is drawn to the healthy side. Rough damage to the facial nerve makes sucking difficult: the child cannot tightly grasp the nipple, sometimes milk flows out of the corner of the mouth. The search reflex is depressed on the affected side. Stroking in the area of ​​the corner of the mouth causes a reflex turn of the head towards the stimulus, and lowering the corner of the mouth is difficult. Central paresis of the facial muscles is more difficult to diagnose - the asymmetry of the nasolabial folds in newborns is mild and is not always associated with damage to the VII pair of nerve.
pair - auditory and vestibular nerves. The newborn responds to a sharp sound stimulus by closing the eyelids (acoustic-palpebral reflex), a fright reaction, a change in the respiratory rhythm, motor restlessness, and turning the head. In the first days of life, the reaction is caused with difficulty, quickly depleted after repeated stimulation, but later it is observed normally in all newborns. In response to a sound stimulus, twitching of the eyeballs, blinking, wrinkling of the forehead, opening of the mouth, extension of the arm, spreading or squeezing the fingers of the hand, cessation of screaming, sucking movements, etc. also occur. There is evidence that even before birth the fetus responds to sudden movement to a sound stimulus that occurs outside the mother's body. As the child grows and develops, at first it begins to respond to the mother's voice, but does not yet localize other sounds, by the 3rd month it begins to respond to sounds, to localize them. In a newborn with damage to the nervous system, the reaction to a sound stimulus is significantly delayed. Along with this, the neuropsychic development of a child in the first year of life is closely related to the normal development of the auditory analyzer.
The vestibular analyzer begins to function even in the prenatal period. The movement of the fetus in the uterus leads to the excitation of the receptors of the vestibular nerve, which send impulses to the nuclei of the oculomotor nerves, the motor cells of the cerebellum, the brain stem and spinal cord. The vestibular apparatus has great importance for the normal development of the child. Violation of its function can have a negative impact on the formation of motor functions.
When the fetus moves along the birth canal, the vestibular apparatus is excited, as a result of which in newborns in the first days of life one can observe spontaneous, small-scale horizontal nystagmus, which becomes clearer after weak head movements. Normally, nystagmus is unstable. Persistent nystagmus in newborns indicates damage to the nervous system. With severe intrauterine damage to the nervous system, intracranial hemorrhages in newborns, horizontal, vertical, and rotatory nystagmus can be seen early. Retinal hemorrhages, bilateral cataracts, and atrophy of the optic nerve nipples can also cause nystagmus.
IX, X pairs - glossopharyngeal and vagus nerves. In newborns, it is possible to investigate the function of the IX, X cranial nerves by observing the synchronism of the acts of sucking, swallowing and breathing. When the IX, X pairs of nerves are damaged, swallowing is disturbed: the child holds milk in his mouth, does not swallow for a long time, takes the breast with difficulty, screams during feeding, chokes, chokes. The cry is monotonous, slightly modulated. Early diagnosis of the boulevard syndrome is very important, since the ingestion of food - in Airways often leads to aspiration pneumonia.
XI pair - accessory nerve. When the XI nerve is damaged in newborns, there is no turning of the head in the opposite direction, there is a tilting of the head back, and limitation of raising the arm above the horizontal level. Irritation of the accessory nerve is accompanied by spasmodic torticollis and twitching of the head in the opposite direction. In newborns, torticollis is most often the result of a mechanical injury to the sternocleidomastoid muscle. With breech presentation, when the head is removed using various obstetric manipulations, sometimes a muscle is torn, followed by its shortening due to the growth of connective tissue. In 50 - 60% of cases, damage to the accessory nerve is combined with damage to the brachial plexus during childbirth. With hemiatrophy, underdevelopment of the sternocleidomastoid muscle is noted and, as a result, torticollis.
In children with severe cerebral palsy, with severe pathological postural activity that occurs with elements of torsion dystonia, the head is constantly turned to one side, which leads to the development of spastic torticollis, which in turn maintains the pathological distribution of muscle tone. Therefore, when examining newborns, it is necessary to differentiate these conditions.
XII pair - hypoglossal nerve. The position of the tongue in the mouth, its mobility, participation in the act of sucking give an idea of ​​the state of the hypoglossal nerve. In young children with cerebral palsy with bilateral lesions of the corticonuclear pathways, the functions of the tongue are impaired (pseudobulbar syndrome). Atrophy of the muscles of the tongue is not detected. With malformations, macroglossia can be observed - an increase in the size of the tongue. Sometimes marked congenital underdevelopment language (coffin syndrome).
Motor area. The study of motor function is the basis for assessing the neurological status of a young child. With intrauterine, intranatal and postnatal lesions of the nervous system, the development of motor skills is primarily affected, therefore, it is necessary to carefully analyze motor activity, the volume of active and passive movements in various positions - on the back, stomach, in an upright position.
In the development of a child's motor skills, two interrelated trends can be outlined: the complication of motor functions and the extinction, reduction of a number of innate unconditioned reflexes. The reduction of these reflexes does not mean their complete disappearance, but, on the contrary, indicates the inclusion of complex motor acts in the system. At the same time, the delay in reduction, the late extinction of these reflexes indicate a lag in the development of the child. Prolonged examination of the child depletes his responses and makes examination difficult. Therefore, it is necessary to determine the group of the most important reflexes for the diagnosis, which are important in assessing the neurological status. The excitability of the child is associated with age, fatigue, mood, drowsiness, food saturation. In the study of unconditioned reflexes, optimal conditions must be observed. Reflexes will be distinct if they are evoked in a calm environment, when the child does not experience discomfort, and the irritations applied do not cause him pain. If the child is restless or drowsy, the study is inappropriate. To obtain more reliable data, the newborn should be examined again within a few days. When studying the unconditional reflex activity of a newborn, it is necessary to take into account not only the presence of one or another reflex, but also the time of its appearance from the moment the irritation was applied, its completeness, strength and speed of extinction.
The main unconditioned reflexes of an infant can be divided into two groups: segmental motor automatisms, provided by segments of the brain stem (oral automatisms) and spinal cord (spinal automatisms), and suprasegmental postural automatisms, providing regulation of muscle tone depending on the position of the body and head (regulated by centers medulla oblongata and midbrain).

Rice. 76. Reflexes of newborns and infants.
search; 3 - proboscis; 4 - sucking.
B. Spinal motor automatisms in newborns; 5 - protective; 6 - crawling reflex
(Bauer): 7 - support reflex and automatic gait; 8 - grasping reflex

Rice. 76. Continued.
D Labyrinth reflexes: 14 - labyrinth installation reflex (Landau); 15 a, b

Oral segmental automatisms Are of great importance for the newborn, as they determine the possibility of sucking. They are detected in a full-term newborn from the first day of life (Fig. 76).
Palmar-mouth reflex (Babkin reflex) - pressure on the palm area causes the mouth to open and the head to bend. The reflex is normal in all newborns, it is more pronounced before feeding. Sluggishness of the reflex is observed when the central nervous system is affected. The rapid formation of the reflex is a prognostically favorable sign in children who have undergone birth trauma. The palmar-mouth reflex may be absent with peripheral paresis of the hand on the side of the lesion.
The hand-mouth reflex is phylogenetically very ancient; various hand-mouth reactions are formed on its basis. In the first 2 months life, the reflex is pronounced, and then begins to weaken, and at the age of 3 months. only some of its components can be noted. With damage to the central nervous system in a child older than 2 months. the reflex does not tend to fade, but on the contrary, it intensifies and occurs even with light touching of the palms, passive movements of the hands.
Proboscis reflex - a quick light blow with a finger on the lips causes a contraction of m. orbicularis oris, proboscis lip extension. This reflex is a constant component of sucking movements. Normally, the reflex is determined up to 2-3 months, its extinction is delayed in children with damage to the nervous system.
Search (search) Kussmaul reflex - stroking with a finger in the corner of the mouth (without touching the lips) causes the corner of the mouth to lower and the head to turn towards the stimulus. Pressing on the middle of the lower lip causes the mouth to open, the lower jaw to drop, and the head to bend. The reflex should be called carefully, without causing pain to the newborn. With pain irritation, only the head turns in the opposite direction. The search reflex is well expressed before feeding. It is important to pay attention to the symmetry of the reflex on both sides. The asymmetry of the reflex is observed when the facial nerve is damaged. In the study of the search reflex, it should also be noted what is the intensity of the turn of the head, whether there are grasping movements of the lips. The search reflex is observed in all children up to 3-4 months of age, and then a reaction to a visual stimulus appears, the child revives at the sight of a bottle of milk, when the mother prepares the breast for feeding.
The search reflex is the basis for the formation of many mimic (expressive) movements: shaking the head, smiling. Observing the feeding of the child, it can be noted that, before grasping the nipple, he makes a series of rocking movements with his head until he firmly grasps the nipple.
The sucking reflex occurs in a newborn in response to irritation of the oral cavity. For example, when inserting a nipple into the mouth, rhythmic sucking movements appear. The reflex persists during the first year of life.
Spinal motor automatisms. Protective reflex of the newborn. If the newborn is placed on the stomach, then a reflex turn of the head to the side occurs. This reflex is expressed from the first hours of life. In children with central nervous system involvement, the protective reflex may be absent, and if the child's head is not passively turned to the side, the child may suffocate. In children with cerebral palsy, with an increase in extensor tone, a prolonged rise of the head and even tipping it back is observed.
Support reflex and automatic gait in newborns. The newborn does not have the readiness to stand, but he is capable of a support reaction. If you hold the child vertically in weight, then he bends his legs in all joints. The child placed on a support straightens the body and stands on half-bent legs on full foot. The positive support reaction of the lower extremities is a preparation for stepping movements. If the newborn is slightly tilted forward, then he makes stepping movements (automatic gait of newborns). Sometimes when walking, newborns cross their legs at the level lower third shins and feet. This is caused by a stronger contraction of the adductors, which is physiological for this age and outwardly resembles the gait in cerebral palsy.
The support reaction and automatic gait are physiological up to 1-1-4 months, then they are inhibited and physiological astasia-abasia develops. Only by the end of the 1st year of life does the ability to stand and walk independently appear, which is considered as a conditioned reflex and requires the normal function of the cerebral cortex for its implementation. In newborns with intracranial injury, born in asphyxia, in the first weeks of life, the support reaction and automatic gait are often depressed or absent. In hereditary neuromuscular diseases, the support reaction and automatic gait are absent due to severe muscle hypotension. In children with lesions of the central nervous system, automatic gait is delayed for a long time.
Crawling reflex (Bauer) and spontaneous crawling. The newborn is placed on the stomach (head in the midline). In this position, he makes crawling movements - spontaneous crawling. If a palm is placed on the soles, then the child reflexively pushes away from it with his feet and crawling intensifies. In the position on the side and on the back, these movements do not occur. Coordination of movements of arms and legs is not observed. Crawling movements in newborns - become pronounced on the 3rd - 4th day of life. The reflex is physiological up to 4 months. life, then it fades away. Independent crawling is a precursor to future locomotor acts. The reflex is depressed or absent in children born in asphyxia, as well as in intracranial hemorrhages, spinal cord injuries. Pay attention to the asymmetry of the reflex. In diseases of the central nervous system, crawling movements persist for up to 6-12 months, like other unconditioned reflexes.
A grasping reflex appears in a newborn when pressure is applied to his palms. Sometimes a newborn wraps his fingers so tightly that he can be lifted up (Robinson's reflex). This reflex is phylogenetically ancient. Newborn monkeys hold onto the mother's hairline by grasping the brushes. With paresis of the hands, the reflex is weakened or absent. In inhibited children, the reaction is also weakened, in excitable children, on the contrary, it is strengthened. The reflex is physiological up to 3-4 months, later, on the basis of the grasping reflex, voluntary grasping of the object is gradually formed. The presence of a reflex after 4 - 5 months. indicates damage to the nervous system.
The same grasping reflex can also be evoked from the lower extremities. Pressing the ball of the foot with the thumb causes plantar flexion of the toes. If you apply a dashed irritation to the sole of the foot with your finger, then there is a dorsiflexion of the foot and a fan-shaped divergence of the fingers (the physiological reflex of Babinsky).
Reflex Galant. When the skin of the back is irritated paravertebral along the spine, the newborn bends the back, an arc is formed that is open towards the stimulus. The leg on the respective side often extends at the hip and knee joints. This reflex is well evoked from the 5th - 6th day of life. In children with damage to the nervous system, it may be weakened or completely absent during the 1st month of life. When the spinal cord is damaged, the reflex is absent for a long time. The reflex is physiological until the 3rd 4th month of life. With damage to the nervous system, this reaction can be observed in the second half of the year and later.
Perez reflex. If you run your fingers, slightly pressing, along the spinous processes of the spine from the coccyx to the neck, the child screams, raises his head, unbends the torso, bends the upper and lower limbs. This reflex causes a negative emotional reaction in the newborn. The reflex is physiological until the 3-4th month of life. Inhibition of the reflex during the neonatal period and a delay in its reverse development is observed in children with lesions of the central nervous system.
Moro reflex. It is caused by various methods: a blow to the surface on which the child lies, at a distance of 15 cm from his head, raising the extended legs and pelvis above the bed, sudden passive extension of the lower extremities. The newborn takes his hands to the sides and opens his fists - I phase of the Moro reflex. After a few seconds, the hands return to their original position - phase II of the Moro reflex. The reflex is expressed immediately after birth, it can be observed during the manipulations of the obstetrician. In children with intracranial trauma, the reflex may be absent in the first days of life. With hemiparesis, as well as with obstetric paresis of the hand, an asymmetry of the Moro reflex is observed.
With pronounced hypertension, there is an incomplete Moro reflex: the newborn only slightly abducts his hands. In each case, the threshold of the Moro reflex should be determined - low or high. In infants with lesions of the central nervous system, the Moro reflex is delayed for a long time, has low threshold, often occurs spontaneously with anxiety, various manipulations. In healthy children, the reflex is well expressed until the 4th - 5th month, then it begins to fade; after the 5th month, only a few of its components can be observed.
Suprasegmental postural automatisms. The most important stages of a child's motor development - the ability to raise his head, sit, stand, walk - are closely related to the improvement of the regulation of muscle tone, its adequate redistribution depending on the position of the body in space. The centers of the medulla oblongata (myelencephalic), and later the centers of the midbrain (mesencephalic) take an active part in this regulation. Untimely reduction of myelencephalic postural reflexes leads to the formation of pathological tonic activity, which prevents the mastery of the most important motor functions.
Myelencephalic postural automatisms include asymmetric cervical tonic reflex, symmetrical cervical tonic reflex, tonic labyrinth reflex. Their centers are located in the medulla oblongata.
Asymmetric cervical tonic reflex. If you turn the head of a newborn lying on his back so that the lower jaw is at shoulder level, then the extension of the limbs to which the face is turned and the flexion of the opposite ones occur. More constant is the response of the upper extremities.
Symmetrical tonic neck reflex. Flexion of the head causes an increase in flexor tone in the arms and extensor tone in the legs.
Tonic labyrinth reflex - in the supine position maximum increase tone in the extensor muscle groups, in the position on the stomach - in the flexion.
Labyrinth and tonic neck reflexes are constantly observed during the neonatal period, but are not as pronounced as all other reflexes.
Myelencephalic postural reflexes are physiological up to 2 months. (in term babies). In case of prematurity, these reflexes persist for a longer time (up to 3-4 months). In children with lesions of the nervous system, occurring with spastic phenomena, tonic labyrinth and neck reflexes do not fade away. The dependence of muscle tone on the position of the head in space and on the position of the head in relation to the body becomes pronounced. This hinders consistent motor and mental development.
In parallel with the reduction of myelencephalic postural automatisms, mesencephalic adjusting reflexes (chain symmetrical reflexes) are gradually formed, which ensure the straightening of the body. Initially, in the 2nd month of life, these reflexes are rudimentary and manifest as head straightening (labyrinth straightening head reflex).
This reflex stimulates the development of chain symmetrical reflexes aimed at adapting the body to a vertical position. Chain symmetrical reflexes provide the installation of the neck, torso, arms, pelvis and legs of the child. These include:
Cervical rectifying reaction - the rotation of the head to the side, made actively or passively, is followed by the rotation of the torso in the same direction. As a result of this reflex, by the 4th month, the child can turn from a position on his back to his side. If the reflex is pronounced, then turning the head leads to a sharp turn of the body in the direction of rotation of the head (turning in a block). This reflex is already expressed at birth, when the baby's torso follows the turning head. The absence or inhibition of the reflex can be the cause of prolonged labor and fetal hypoxia.
Trunk rectifying reaction (rectifying reflex from the trunk to the head). When the child's feet come into contact with the support, the head straightens. It is observed distinctly from the end of the first month of life.
Straightening reflex of the trunk, acting on the trunk. This reflex becomes pronounced by the 6th - 8th month of life and modifies the primitive cervical rectifying reaction, introducing rotation of the body between the shoulders and the pelvis. In the second half of the year, turns are already carried out with torsion. The child usually turns the head first, then the shoulder girdle, and finally the pelvis around the axis of the body. Rotation within the axis of the body allows the child to turn from back to stomach, from stomach to back, sit down, get on all fours and take a vertical pose.
Straightening reflexes are aimed at adapting the head and torso to a vertical position. They develop from the end of the 1st month of life, reach consistency at the age of 10-15 months, then they change and improve.
Another group of reflexes observed in young children does not belong to the true rectifying reflexes, but at certain stages contributes to the development of motor reactions. These include the protective reaction of the hands, the Landau reflex.
The defensive reaction of the arms is to spread them apart, stretch them forward, pull them back in response to a sudden movement of the body. This reaction creates the prerequisites for keeping the body in an upright position.
The Landau reflex is part of the rectifying reflexes. If the child is held freely in the air face down, then at first he raises his head so that the face is in a vertical position, then comes the tonic extension of the back and legs; sometimes the baby arches. The Landau reflex appears at the age of 4-5 months, and some of its elements even earlier.

Rice. 77. Terms of detection of the main unconditioned reflexes in full-term children.

The balance reaction is a group of reflex reactions that ensure balance while sitting, standing, walking. The mechanism of these reactions is complex, carried out with the participation of the cerebellum, basal ganglia, and the cerebral cortex. Equilibrium reactions appear and grow during the period when the rectification reactions have already been fully established. The equilibrium reaction completes its formation in general terms from 18 months. up to 2 years. Their improvement continues up to 5 - 6 years.
The extension and balance reactions together represent a normal postural reflex mechanism that forms the necessary basis for the performance of any motor skills.
The terms for identifying the main unconditioned reflexes and postural automatisms are presented in Table. 7 and in fig. 77.
The study of the motor functions of an infant includes an assessment of the overall muscle development, volume and strength of active and passive movements, the state of muscle tone and coordination.

Table 7. Terms of detection of the main unconditioned reflexes in full-term children

General muscle development is determined by inspection, palpation, measurement of symmetrical areas with a centimeter tape. Muscle atrophy in in young children may be the result of their underdevelopment (for example, with congenital hemiaplasia) or impaired innervation with paresis and paralysis of traumatic and infectious genesis.
Muscle hypertrophy in infancy is rare, mainly with myotonia. Thomsen.
In the analysis of the motor functions of an infant, an important place is occupied by the study of muscle tone. It is necessary to examine muscle tone when the child is calm. This should be done, avoiding sudden movements, muscle strain, without causing painful irritation to the child. With gross manipulations, resistance to passive movements arises and the assessment of muscle tone may be incorrect.
With damage to the nervous system, resistance to passive movements can be increased symmetrically or asymmetrically. Muscular hypertension in newborns is observed with severe intrauterine damage to the nervous system, prolonged antenatal and intranatal asphyxia, and intracranial hemorrhages. Muscular hypotension can also be a symptom of cerebral pathology. It must be differentiated from congenital, hereditary diseases that occur with muscular hypotension (phenylketonuria, Down's disease, etc.).

The volume of spontaneous movements, their symmetry, excessive movements, in particular athetoid ones, tremors matter. If the muscle tone is disturbed, the movements of the newborn may be slow or too strong, such as throwing. It is necessary to evaluate the strength of active movements and resistance to passive movements in each joint separately.
When examining muscle tone, it must be remembered that in a newborn and children in the first months of life, the state of muscle tone is affected by the position of the head in space and the position of the head in relation to the body (tonic labyrinth and neck reflexes). Asymmetry of muscle tone is observed in hemiparesis, in obstetric paresis of the hands.
In healthy newborns, there are separate athetoid movements in the fingers and forearm with extension at the elbow and rotation of the hand. In the first weeks of life in premature babies, they are more pronounced, then disappear. Hyperkinesias caused by damage to the nervous system are clinically manifested by the end of the 1st year of life, and in the first half of the year they are not pronounced. However, with kernicterus as a consequence hemolytic disease newborn hyperkinesis appear already in the first half of the year. This form of damage is characterized by muscular dystonia with a predominance of hypotension. Hyperkinesis often occurs against the background of reduced muscle tone.
In the first days of life in newborns, it is normal to observe trembling of the limbs during screaming, motor restlessness. In this period, the jitter is characterized by high frequency, low amplitude, inconsistency and quickly fades away. When the nervous system is damaged, trembling of low frequency and high amplitude occurs spontaneously at rest, and increases with a cry. In the neonatal period, trembling often precedes clonic convulsions and is a kind of sign of a high "convulsive readiness" of the child.
Of the tendon reflexes in newborns, knee reflexes, reflexes from the tendons of the biceps and triceps muscles, are most constantly evoked. During the neonatal period, dorsiflexion of the foot predominates, so Achilles reflexes are difficult to elicit, they are unstable. As the child develops (by the 4th month), when plantar flexion begins to predominate, the Achilles reflexes become more distinct.
Inhibition of tendon reflexes, and sometimes their absence is observed in the acute period of intracranial injury, with congenital neuromuscular diseases. Hyperreflexia, expansion of reflexogenic zones are noted in excitable children, with an increase in intracranial pressure. With a sharp increase in muscle tone, tendon reflexes are difficult to elicit. Abdominal reflexes in newborns are inconsistent and become more distinct in the second half of the year, when the child begins to sit up.
Some special diagnostic techniques also contribute to the identification of motor disorders.

Traction test.

In the position of the child on the back, they take his hands By the wrists and slowly pull him towards himself to a sitting position. Normally, there is moderate resistance to extension of the arms at the elbows. In children with severe hypotension, resistance is absent or weakened. With pronounced hypertension, excessive resistance is observed. This test can also reveal the asymmetry of muscle tone.
Withdrawal reflex. In the position of the newborn on his back, when his lower limbs are relaxed, a needle prick is alternately applied to each sole. There is a simultaneous flexion of the hips, shins and feet. It is necessary to pay attention to the symmetry and strength of the response. The reflex can be weakened in children born in the breech presentation, with spinal cord injury, with hereditary and congenital neuromuscular diseases, myelodysplasia.
cross reflex extensors. In the position of the child on the back, one lower limb is passively unbent and a needle is injected into the sole of the fixed leg. Extension and slight adduction of the other leg occur. Normally, in the first days of life, the reflex is weakened, and then it is observed in all newborns. The reflex is weakened or absent in lesions of the spinal cord and peripheral nerves.

Lower limb abduction test.

In the position of the child on the back, the unbent lower limbs are quickly moved to the sides. Normally, there is a moderate resistance, which is weakened or absent with muscle hypotension. In newborns with increased muscle tone, resistance to abduction of the hips is pronounced, while the legs cross. Difficulty in hip abduction is also observed in congenital dislocations and dysplasia. hip joints. An increase in tone in the adductors of the thighs can be with normal tone in the flexors. At early. detection of an increase in adductor tone and its correction, the crossing of the lower extremities in children with cerebral palsy is prevented.
Sensitivity testing is of lesser importance in determining the neurological status of an infant. The newborn has developed only superficial sensitivity. Deep sensitivity develops by the age of 2, which is associated with the maturation of afferent systems in the spinal cord and brain. The child immediately after birth reacts to temperature stimuli, especially to cold ones. In this case, most often there is a general motor reaction. The newborn has developed tactile sensitivity: in response to touching the skin or mucous membrane, general anxiety or a reflex protective reaction appears. In response to pain stimulation, a general motor reaction most often occurs. Child at an early age childhood cannot accurately localize pain, tactile, temperature stimuli. This is due to the fact that he still has insufficiently developed differentiation of stimuli, their higher analysis at the level of the cerebral cortex of the cerebral hemispheres.
In the study, you can only get a general idea of ​​\u200b\u200ba sensitivity disorder. It is almost impossible to define clear boundaries and type of sensitive disorders.
For some pathological conditions(meningitis, hypertensive-hydrocephalic syndrome) there may be an increase in sensitivity skin- hyperesthesia. Even a light touch on the skin causes a painful reaction, a cry, and restlessness.
Lack of response to pain and temperature stimuli is most often the result of malformations and injuries of the spinal cord. Congenital insensitivity to pain due to underdevelopment of sensory pathways has been described.
The vegetative-trophic functions of the newborn are imperfect. This is due to the incompleteness of the morphological and functional organization of the autonomic nervous system. In newborns, vegetative disorders can be manifested by bouts of cyanosis, blanching, redness, marbling of the skin, a disorder in the rhythm and frequency of breathing and cardiac activity, "pupil play", hiccups, yawning, frequent regurgitation, vomiting, unstable stools, sleep disturbance. Some of these reactions may be further fixed in the form of a conditioned reflex, as is observed in children with early childhood nervousness. In addition to the disorders described above, the pathology of the autonomic nervous system can be manifested by trophic skin disorders, subcutaneous tissue, bones. Such disorders are observed in congenital Parry-Romberg hemiatrophy. The defeat of the diencephalic region can lead to the development of malnutrition, and sometimes to early obesity. The defeat of the limbic system causes disturbances in the emotional sphere - children are sharply excitable, scream a lot, sleep poorly.

Table 8. Dynamics of development of the main analyzers in young children

In comparison of repeated studies. If pathological signs are observed repeatedly, then they become reliable and indicate damage to the nervous system.
In conclusion, a summary diagram of the neuropsychic development of a child during the first year of life is given.
Month 1st. The position of the child depends on the predominance of flexor hypertension in the extremities. The arms are bent at all joints, the fingers are clenched into a fist and brought to the body, the legs are bent and slightly abducted at the hips. In the position on the stomach, the child turns his head to the sides, more often to the light source, reacts to the stimulus with general motor activity, does not coordinate movements. In the position on the stomach, the child raises his head for a few seconds and sets it in the midline (labyrinthic installation reflex on the head). By the end of the 1st month of life (and sometimes even earlier), visual concentration on an object and tracking of a moving object with one's eyes appear without the participation of the head. Visual reactions during this period have a number of features: they are unstable, do not affect the general movements of the child, and their duration is insignificant. The eyes follow the object with a great delay, as if catching up with it, the movements of the eyeballs are jerky. Sound stimuli do not differentiate. The child makes guttural sounds. All unconditioned reflexes are pronounced.
Month 2nd. The influence of flexor tone on the position of the trunk and limbs decreases, the tone in the extensors increases, and the volume of active movements increases. The child often takes his hands to the sides, raises them above the horizontal level, opens his fist, turns his head to the side. The effect of extensor tone on head position is reduced. On the stomach, the child holds his head along the midline for a longer time, begins to hold his head in an upright position, but still inconsistently (head dangling), fixes his gaze on a stationary object. The movements of the eyeballs become smooth, coordinated; reactions of gaze fixation, tracking and convergence begin to occur in a variety of positions. So, visual fixation of the object is observed not only in the position of the child on the back, but also on the stomach, in a vertical position. Being in an upright position, the child first fixes objects located at a great distance, and only gradually does he develop the ability to fix close objects. Head movements begin to be included in the system of optical-adaptive reactions. Convergence is still imperfect, which makes it difficult for visual reactions to variously located objects to occur. The child smiles in response to affectionate treatment of him, hums; positive emotional reactions predominate. Congenital reflex reactions are still well expressed, with the exception of the support reaction and automatic gait of newborns. The latter gradually fade away, and physiological astasia-abasia develops. Straightening reflexes of the body begin to develop, position reflexes are developed. Thus, in the 2nd month of life, chain symmetrical reflexes are fixed, which, developing and improving, will contribute to the vertical position of the body.
Month 3rd. Increased range of motion in the limbs, especially in shoulder joints. The child often raises his hands above the horizontal level, holds the toy put into the hand, pulls it into his mouth; in the position on the stomach raises the head and rests on the forearms at an acute angle, holds the head well in a vertical position, turns from the back to the side. During this period, the dorsal flexion of the foot weakens. In this regard, plantar flexion encounters less resistance. The child bends his head when trying to lift him by the hands from a supine position. There is a combined turn of the head and eyes to the side. Visual reactions are longer. The child responds more differentiatedly to various stimuli, turns his head to the mother's voice, looks intently at the pizza, makes an attempt to examine the toy put into his hand, traces the object not only while lying on his back, in an upright position, but also on his stomach; smiles, sometimes laughs; positive emotional reactions are pronounced and persist for a long time. A smile is accompanied by motor activity, a general revival. If the child is healthy, then during the entire time of wakefulness he is in a joyful state. Intense movements that occur with emotions of joy help to reduce the physiological flexor hypertension of the child's muscles and stimulate the development of reciprocity. The child hums, pulls vowel sounds longer.
At this age, the child has specific reflex reactions. In connection with the increasing role of the cerebral cortex and the development of voluntary activity at the 3rd month of life, inhibition of congenital reflexes continues, labyrinth neck tonic reflexes weaken, the activity of analyzers expands, and the importance of motor and auditory analyzers increases compared to tactile. If in the first months of life a search reflex occurs in response to a tactile stimulus, then at the end of the 3rd month, at the sight of the mother’s breast or a bottle of milk, the child revives and prepares itself for the act of sucking. At the age of 2 months. the child grasps an object that has come into contact with the palmar surface. At the end of the 3rd and the beginning of the 4th month, the grasping reflex weakens and voluntary grasping of the object develops. The child sees the toy, reaches for it and grabs it.
Month 4th. The child holds his head well, turns in the direction of the sound, reaches for the toy, grabs it, feels objects with his hands, pulls them into his mouth, turns on his side, sits down when pulling his hands, sits with support; lying on the stomach, leans on the forearms at a right angle, raises the upper body. By this age, physiological flexor hypertension disappears. The child closely follows a moving object, gradually developing hand-eye coordination. He distinguishes the voices of loved ones, often smiles, laughs, makes loud lingering sounds, pronounces vowel sounds more clearly. .Unconditioned reflexes continue to fade into the background. On the basis of the grasping reflex, arbitrary grasping of objects is formed. In the prone position, the child can raise his head and torso against gravity.
Months 5 and 6. The child sits with the support of one hand, and sometimes on his own, but when sitting, kyphosis of the spine is still pronounced; turns from back to side and stomach, leans on his stomach on his outstretched arms, raises his upper body, leaning on his palms, begins to grasp objects that he touched not only with the palmar, but also with the back or side of the hand. The labyrinthine reaction to the head becomes more distinct. The cervical rectifying reaction is modified. Rotation between chest and the pelvis creates the opportunity to turn from the back to the stomach, and a little later from the stomach to the back. Lying on his stomach, the child stretches out one hand, supporting himself with the other, moves the body from one hand to the other. The child develops a protective extension of the arms forward and backward. Lying on his back, he plays with his feet; turns his head in the direction of the sound, distinguishes familiar faces, follows the fallen toy, picks it up. Emotional manifestations are more diverse. The child pronounces consonant sounds, he has the first attempts to pronounce the syllables “ba”, “pa”, “ma”, “dya”.
Months 7 and 8. The child sits steadily on his own, maintains balance, gets on all fours, turns from his stomach to his back, makes attempts to sit up on his own from a position on his back, stands up with support, and can stand for some time with support. The balance reaction is expressed in the position on the back, on the stomach, sitting. Protective extension of the arms forward and to the side allows the child to sit with balance and prevent falling. With the help of hands, the baby sits down from a position on the back and on the stomach, examines the toy, shifts from one hand to the other, the movements are more purposeful. The child stretches out his hands to his mother and acquaintances, claps his hands, repeats the syllables "ma-ma", "ba-ba", tries to attract the attention of adults, recognizes strangers, knows his parents well, looks for the object he needs, expresses surprise or interest when meeting new subjects.
Months 9 and 10. The child kneels, holding on to the barrier, moves, holding on to a support, stands with support, makes attempts to stand on his own, crawls. The movements are relatively coordinated. The child imitates the movements of adults, takes small objects with two fingers, collects scattered toys, takes toys out of the box, monitors the fall of thrown objects; watches adults, waves to them, eats with a spoon with the help of adults, knows the meaning of frequently used words, the name of favorite toys, finds them among others, says separate words: “dad”, “mother”, “woman”, “uncle”, etc. .d. Fulfills simple requirements of adults, understands prohibitions.
Months 11 and 12. The child walks supported by one hand, takes separate steps on his own, but the gait is still unstable, the baby often falls, the child has a well-defined defensive extension of the arms back. The combination of defensive extension of the arms forward, to the sides and back gives him the opportunity to push off with one hand to sit down from a supine position. The child sits down with less rotation of the torso around the axis of the body, freely manipulates objects, squats to pick up a fallen toy, knows the name of many objects, localizes painful irritations, indicates parts of the body, helps with dressing, eats independently with a spoon, follows a large number of instructions, loves children , knows everyone in the family, pronounces individual words.