An interview with the biological mother, or another familiar with the pregnancy, should include questions about any maternal illness, nutrition status, drug and/or alcohol use, chronic diseases, and any medications taken routinely, including prescription, over-the-counter, and herbal supplements. Important factors to know about the delivery include the administration of anesthesia or drugs and difficulties with the delivery like the need for forceps or vacuum devices.

Note the infant’s Apgar scores. A need for supplemental oxygen, intubation/ventilation, glucose, and abnormalities of bilirubin levels is also important. A history of post-birth infections, a need for medication/oxygen, feeding difficulties, and/or seizures may also indicate underlying problems.

The neonatal period is defined as the first 4 weeks of life. The neonate may be term or premature, and the physical characteristics of neonates vary with their gestational age. Inspection of the shape, symmetry, and mobility of the head of the neonate is critical for evaluating cranial abnormalities or soft tissue injuries. Head circumference at term will range from 34 to 36 cm within the 25–75% ranges. Neonates outside this range should be accurately plotted on the appropriate growth chart and serially measured (Nellhaus 1968). Further examination of the neonate’s head for a patent fontanel, tautness, and approximation of cranial sutures is vital. Fontanels are best palpated when the neonate is in the upright position and not crying. The cranial sutures should be well approximated, especially the coronal, squamosal, and lambdoid sutures, and should not admit a fingertip. The sagittal suture may be wider in normal newborns, especially if the baby is premature. A soft, flat, or sunken anterior and posterior fontanel should be palpated. The posterior fontanel may be palpated up to 4 weeks of age. More detailed information and illustrations regarding cranial sutures and related abnormalities can be found in Chapter 3.

Spine assessments include evaluation for abnormal midline lumps, dimples, tufts of hair on the spine, and palpation for vertebral anomalies. Skin markings such as petechiae, hemangiomas, and hypopigmented or hyperpigmented lesions may be present at birth and indicative of neurological congenital conditions. It is important to note the size, location, and number of hypo- or hyperpigmented lesions. In addition, congenital anomalies of the heart, lungs, and gastrointestinal tract may suggest abnormalities of brain development. However, optic or facial dysmorphisms more accurately predict a brain anomaly (American Academy of Pediatrics 1996). Some facial dysmorphisms to note include hyper- or hypotelorism, flat philtrum, thin upper lip, epicanthic folds, unequal size of the eyes, nystagmus, microphthalmia, hypoplastic face or facial droop, micrognathia, abnormal shape/size of the nose, asymmetry of smile, high-arched palate, congenital cataracts, small or simple ears, and preauricular skin tag/dimple and cleft lip/palate.

Neonatal function is primarily reflex activity and necessitates the assessment of infantile automatisms, i.e., those specific reflex movements which appear in normal newborns and disappear at specific periods of time in infancy. Table 1.3 outlines the primitive reflexes in more detail (Slota 1983a). Functional examination may begin by observation of the neonate in supine and prone positions, noting spontaneous activity in each position and the presence of primitive reflexes. The posture of the neonate is one of partial flexion with diminishing flexion of the legs as the neonate ages. Observe for hypotonia, which could indicate neurologic deficit or a genetic/metabolic disorder. Look for random movements of the extremities and attempt to distinguish single myoclonic twitches, which are normal, from repetitive movement seen with seizures. Observe for symmetry of movements. Care should be taken to observe for infantile spasms characterized by atonic head drops accompanied by the arms rising upward. Some neonates have an excessive response to arousal with “jitteriness” or tremulousness. This is a low-amplitude, rapid shaking of the limbs and jaw. It may appear spontaneously and look like a seizure. However, unlike seizures, jitteriness usually follows some stimulus, can be stopped by holding the limb or jaw, and does not have associated eye movements or respiratory change. When prominent, slow, and coarse, it may be related to central nervous system stress or metabolic abnormalities, but otherwise it is often a normal finding (Kramer et al. 1994; Shuper et al. 1991).

Strength is assessed by observing the newborn’s spontaneous and evoked movements and by eliciting specific newborn reflexes. Neonates with neuromuscular conditions may manifest with abnormally low muscle tone (hypotonia), paradoxical breathing, hip dislocation, or contractures. The neonate is capable of reacting to moving persons or objects within sight or grasp, both for large and small objects. Neonates can visually fixate on a face or light in their line of vision (American Academy of Pediatrics 1996). The quality of the cry can suggest neurological involvement. A term newborn’s cry is usually loud and vigorous. A weak or sedated neonate will cry only briefly and softly or may just whimper. A high-pitched cry is often associated with a neurological abnormality or increased intracranial pressure (Freedman et al. 2009). Functional capabilities of the preterm infant will vary by gestational age. Premature infants demonstrate less strength and decreased muscle tone compared to a term infant. Table 1.3 provides some of the key changes and the approximate time when selected milestones appear in most premature infants (McGee and Burkett 2000).

The most critical need of both the term and premature neonate is for the establishment of adequate respiratory activity with appropriate oxygenation. Respiratory immaturity added to the neurological insults from seizures, congenital conditions such as spina bifida and genetically linked syndromes, as well as intraventricular hemorrhage and hydrocephalus all have the capability to severely limit the neonates’ ability to buffer these conditions. Infections, an immature immune system, and gastrointestinal deficiencies also can severely compromise the neonate’s ability to dampen the physiological effects of neurological conditions. For the preterm neonate with a neurological disorder, dampening the effects becomes even more crucial and makes the preterm infant vulnerable to multisystem failures. Developmental care teams can be mobilized to augment the neonate’s capacity for optimal growth and interaction with his or her environment.

In the United States, all 50 states have laws that require car seats for infants and toddlers. Since the implementation of such passenger safety laws, hospitals and health-care providers have played an important role in providing awareness, education, and access to equipment (Elliott et al. 2013; Knoeker et al. 2015). Despite this, motor vehicle accidents continue to be one of the leading causes of death for children and youth. These statistics emphasize the need to provide appropriate car safety education to caregivers during the assessment.

Observation of the neonate at rest is the first step in a comprehensive approach to neurological assessment of the neonate. Usually, the head can be inspected and palpated before awakening the neonate and measuring the head circumference. Most neonates arouse as they are unwrapped, and responses to stimuli are best assessed when the neonate is quietly awake. As the neonate arouses further, the strength of his spontaneous and active movement can be observed and cranial nerves assessed. Stimulation of selected reflexes, like the Moro reflex, and eye exam are reserved for last, since they usually elicit vigorous crying. The typical cry of an infant is usually loud and angry. Abnormal cries can be weak, shrill, high pitched, or catlike. Crying usually peaks at 6 weeks of age, when healthy infants cry up to 3 h/day, and then decreases to 1 h or less by 3 months (Freedman et al. 2009). The ability to console, including the sucking response, can be evaluated whenever the neonate is agitated. The sequence of the examination can always be altered in accordance with the newborn’s state or situation. Excessive stimulation or cooling may cause apnea or bradycardia in the preterm neonate, and components of the exam may need to be postponed until the neonate is stabilized.

Infancy is defined as 30 days to 12 months of age. An infant’s head grows at an average rate of 1 cm per month over the first year. Palpation of the head should reveal soft and sunken fontanels when quiet and in the upright position. A bulging fontanel in a quiet infant can be a reliable indicator of increased intracranial pressure. However, vigorous crying of an infant can cause transient bulging of the fontanel. The posterior fontanels will close by 1–2 months of age with wider variability in the anterior fontanel, often closing between 6 and 18 months of age. If the sutures close prematurely and skull shape becomes abnormal, evaluate for craniosynostosis. Delayed closure of the sutures may indicate increased intracranial pressure or hydrocephalus, warranting further evaluation. Inspection of the scalp should include observation of the venous pattern, because increased ICP and thrombosis of the superior sagittal sinus can produce marked venous distention (Dlamini et al. 2010).

Observation of the spine should include an examination for lumps, bumps, dimples, midline hemangiomas, and tufts of the hair. Examination of rectal tone for an anal wink should be performed, especially when suspicion is present for an occult spinal dysraphism. The absence of an anal wink is noted when the anal sphincter does not contract when stimulated or there is a lack of contraction of the anal sphincter during the rectal examination. Identification of a sensory level of function in an infant with a spinal abnormality can be very difficult. If decreased movement of extremities is noted, observe the lower extremities for differences in color, temperature, or perspiration, with the area below the level of spinal abnormality usually noted to be cooler to touch and without perspiration (McGee and Burkett 2000).

Assessment of the infant’s function requires knowledge of normal developmental landmarks. Refer to Table 1.4.