The neonatal intensive care unit and newborn nursery are often chaotic and noisy environments with a whirlwind of activity and a unique language of acronyms. The goal of this chapter is to provide a systematic, concise, and clinically usable approach to guide the bedside practitioner through this sea of chaos by first reviewing the normal neurological examination of the neonate with an emphasis on normal findings at different gestational ages and possible etiologies of abnormal findings. It will then cover in more detail several neurological abnormalities that are found in the neonatal period, including hypoxic-ischemic encephalopathy (HIE), intraventricular hemorrhage (IVH), and seizures in the newborn. Although there is overlap among these abnormalities, each will be covered individually, with a brief emphasis on the incidence, pathophysiology, pertinent clinical findings, the differential diagnosis, and a brief overview of clinical management.
This work was supported by NIH 5R21NS052583-02.
The neurological examination of the neonate presents the clinician with numerous challenges. First, it tests the examiner's powers of observation. Most of the neurological examination is carried out by observing the neonate's baseline state. The baseline state changes based on the gestational age of the neonate, level of arousal, and recent experiences (eg, postmedical procedures such as IV placement). Second, the patient is unable to respond to verbal commands. And, last, the examiner uses subjective methods of evaluating the neonate's response to various stimuli and cues. This necessitates a high level of experience and knowledge to obtain a thorough and accurate assessment of the neonate's neurological status. This section is designed to briefly review the complete neurological examination of the neonate. The rationale for each portion of the examination will be reviewed, as will the potential differential diagnosis for abnormal findings. The examination is laid out in a systematic manner beginning with simple observation and proceeding to active evaluation of tone and responses to various stimuli. The examination is performed in this manner to maximize the clinician's time at the bedside while thoroughly examining the neonate's neurological status (Figure 28-1).
The neonatal neurological examination. A summary of the neurological examination is illustrated using a flow chart. Step 1 involves a thorough review of the neonate's chart, including the maternal history, birth history, and hospital course. Step 2 involves observation of the neonate and addresses the neonate's mental and motor status. Normal and abnormal findings for both the mental and motor examination are found in the yellow grid square connected to the respective circle. The third step involves the physical examination, which includes visual inspection, examination of the cranial nerves, the motor examination, developmental reflexes, and deep tendon reflexes (DTRs). Normal and abnormal findings for both the cranial nerve and developmental reflex examinations are found in the blue grid square connected to their respective circle.