Children who present with neurological problems or developmental abnormalities on general physical examination should undergo a complete neurological assessment.1,2 Initially, as much information as possible from the parents or caregivers should be obtained during the first visit. During the initial clinical encounter, the examiner should formulate an opinion regarding possible causes (Table 1-1). A diagnostic hypothesis can then be confirmed, supported, or rejected by the neurological and physical examinations, laboratory tests, and other tests. A clear chief complaint is probably one of the most important first steps, and is best elicited from the child, parents, or caretakers. It is common that school-age children may often provide their own chief complaint. The chief complaint should represent the exact words or expression of the child or parent and not a reinterpretation of the symptoms by the physician. Ideally, the child or parent should be allowed to freely tell the story without interruption or distractions. However, brief directed questions can help focus the interview, especially if the history begins to wander. It is important to note that one should be certain that interrupting will not result in suppression or skewing of important information and the parent’s concerns.

Information related to the timing of the onset of symptoms (acute, progressive, and chronic) should be obtained. It is also important to develop optimal rapport with both the parents and child. An environment that is both child friendly, free of distractions, and age appropriate will help to facilitate an ambience of ease for both child and parent. Parents are quick to pick up on a hurried care-provider, so allowing at least 1 hour or more for a new consultation and at least 30 minutes for follow-up visits is important to keep in mind. Additional questions such as precipitating factors or triggers, past or concurrent illnesses, toxic exposures, sick contacts, travel history, and changes in mood or appetite are just some of the other pertinent items that should be obtained. In most cases at this point, the examiner should be able to attempt to develop an initial interpretation of the most likely diagnoses before proceeding to gather more details.

A complete birth history is probably the most important item in the past medical history. Information about the length of pregnancy, complications, use of medication or drugs, and details about the immediate and first days and weeks following birth should be obtained. Prenatal and perinatal events—including duration of labor, route and means of delivery, and Apgar scores—should be obtained. Obtaining developmental milestones is an important reflection of the maturation of the child’s nervous system, and assessing development is an essential part of the pediatric neurological assessment. In assessing the child’s developmental level, the examiner must know the age when key social, motor, and language skills are normally acquired. There are several screening tools that can be useful for this, such as the Denver Developmental Screening Test II. Delay in obtaining developmental milestones and abnormal patterns of development are important indicators of underlying neurological disease.

When taking a developmental history, key principles of neurodevelopment should be kept in mind. The development of motor control proceeds in a head-to-toe fashion. Head control develops first, then trunk control (sitting), and finally control of the lower extremities (walking). Primitive reflexes (such as the Moro, grasp, and Galant reflexes) are normally present in the term infant and diminish over the next 4 to 6 months of life. The postural reflexes (such as the positive support, Landau, lateral propping, and parachute reflexes) emerge at 3 to 8 months of age. Persistence of primitive reflexes and the lack of development of the postural reflexes are the hallmark of an upper motor neuron abnormality in the infant and should be further investigated.

During the general physical examination (Table 1-2), certain characteristics of the general examination are particularly important to note:

• Somatic growth. Measure height and weight, and compare percentiles with head circumference.
  
• Skin. A careful complete skin search is important. Look for the stigmata of the neurocutaneous syndromes such as café au lait or ash leaf lesions, hypopigmentation, or port wine stains.
  
• Dysmorphic features. Carefully make note of the face especially the midface, ears, eye separation, head shape, neck, and extremities.
  
• Eye examination. This part of the exam is often left for last, as children are often uncooperative and it is difficult to clearly observe eye grounds when the child is moving or fails to focus on a distant object.
  
• Abdomen. Palpate for organomegaly, which can indicate the presence of one of the storage diseases or neuroblastoma, for example.
  
• Spine. Look for scoliosis, any sacral anomalies, clefts, dimples, or tufts of hair.