2. Test coordination.

3. Sensory discrimination:

9. Usual grading of reflexes:

TABLE 1-1 Various Patterns of Respiration

Tachypnea	Increased rate
Bradypnea	Decreased rate
Dyspnea	Distress during breathing
Apnea	Cessation of breathing
Hyperpnea	Increased depth
Hypoventilation	Decreased depth (shallow) and irregular rhythm
Hyperventilation	Increased rate and depth
Kussmaul respiration	Deep and labored respiration, usually seen in respiratory acidosis (e.g., diabetic ketoacidosis)
Cheyne-Stokes respiration	Gradually increasing rate and depth with periods of apnea
Biot respiration	Periods of hyperpnea alternating with apnea (similar to Cheyne-Stokes except that the depth remains constant)
Seesaw (paradoxic) respiration	Chest falls on inspiration and rises on expiration
Agonal respiration	Last gasping breaths before death

TABLE 1-2 Assessment of Cranial Nerves

CRANIAL NERVE	DISTRIBUTION/FUNCTION	TEST
I—Olfactory (S)*	Olfactory mucosa of nasal cavity	With eyes closed, have child identify odors such as coffee, alcohol, or other smells from a swab; test each nostril separately.
II—Optic (S)	Rods and cones of retina, optic nerve	Check for perception of light, visual acuity, peripheral vision, color vision, and normal optic disc.
III—Oculomotor (M)*	Extraocular muscles (EOM) of eye: Superior rectus (SR)—Moves eyeball up and in Inferior rectus (IR)—Moves eyeball down and in Medial rectus (MR)—Moves eyeball nasally Inferior oblique (IO)—Moves eyeball up and out Pupil constriction and accommodation Eyelid closing

IV—Trochlear (M) Superior oblique (SO) muscle—Moves eye down and out Have child look down and in. V—Trigeminal (M,S) Muscles of mastication Have child bite down hard and open jaw; test symmetry and strength.   Sensory: Face, scalp, nasal and buccal mucosa VI—Abducens (M) Lateral rectus (LR) muscle—Moves eye temporally Have child look toward temporal side. VII—Facial (M,S) Muscles for facial expression Have child smile, make funny face, or show teeth to see symmetry of expression.   Anterior two thirds of tongue (sensory) Have child identify a sweet or salty solution; place each taste on anterior section and sides of protruding tongue; if child retracts tongue, solution will dissolve toward posterior part of tongue. VIII—Auditory, Acoustic, or Vestibulocochlear (S) Internal ear Hearing, balance Test hearing; note any loss of equilibrium or presence of vertigo (dizziness). IX— Glossopharyngeal (M,S) Pharynx, tongue Stimulate the posterior pharynx with a tongue blade; the child should gag.   Posterior one third of tongue (sensory) Test sense of sour or bitter taste on posterior segment of tongue. X—Vagus (M, S) Muscles of larynx, pharynx, some organs of gastrointestinal system, sensory fibers of root of tongue, heart, lung, and some organs of gastrointestinal system XI—Accessory (M) Sternocleidomastoid and trapezius muscles of shoulder Have child shrug shoulders while applying mild pressure; with the hands placed on shoulders, have child turn head against opposing pressure on either side; note symmetry and strength. XII—Hypoglossal (M) Muscles of tongue

^* S, Sensory; M, motor.

TABLE 1-4 Motor Development During Infancy

AGE (MONTHS)	GROSS MOTOR	FINE MOTOR
1	Assumes flexed position with pelvis high but knees not under abdomen when prone (at birth, knees flexed under abdomen)* Can turn head from side to side when prone; lifts head momentarily from bed* Has marked head lag, especially when pulled from lying to sitting position Holds head momentarily parallel and in midline when suspended in prone position Assumes asymmetric tonic neck reflex position when supine When infant is held in standing position, body limp at knees and hips In sitting position back is uniformly rounded, head control is absent	Hands predominantly closed Grasp reflex strong Hand clenches on contact with rattle
2	Assumes less flexed position when prone—hips flat, legs extended, arms flexed, head to side* Less head lag when pulled to sitting position Can maintain head in same plane as rest of body when held in ventral suspension When infant is prone, can lift head almost 45° off table When infant is held in sitting position, head is held up but bobs forward Assumes asymmetric tonic neck reflex position intermittently	Hands frequently open Grasp reflex fading
3	Able to hold head more erect when sitting but still bobs forward Has only slight head lag when pulled to sitting position Assumes symmetric body positioning Able to raise head and shoulders from prone position to a 45° to 90° angle from table; bears weight on forearms When infant is held in standing position, able to bear slight fraction of weight on legs Regards own hand	Actively holds rattle but will not reach for it* Grasp reflex absent Hands kept loosely open Clutches own hand; pulls at blankets and clothes
4	Has almost no head lag when pulled to sitting position* Balances head well in sitting position* Back less rounded, curved only in lumbar area Able to sit erect if propped up Able to raise head and chest off surface to angle of 90° Assumes predominant symmetric position Rolls from back to side*	Inspects and plays with hands; pulls clothing or blanket over face in play* Tries to reach object with hand but over-shoots Grasps object with both hands Plays with rattle placed in hand, shakes it, but cannot pick it up if dropped Can carry objects to mouth
5	No head lag when pulled to sitting position When infant is sitting, able to hold head erect and steady Able to sit for longer periods when back is well supported Back straight When infant is prone, assumes symmetric positioning with arms extended Can turn over from abdomen to back* When infant is supine, puts feet to mouth	Able to grasp objects voluntarily* Uses palmar grasp, bidextrous approach Plays with toes Takes objects directly to mouth Holds one cube while regarding a second one
6	When infant is prone, can lift chest and upper abdomen off table, bearing weight on hands When infant is about to be pulled to a sitting position, lifts head Sits in highchair with back straight Rolls from back to abdomen When infant is held in standing position, bears almost all of weight Hand regard absent	Resecures a dropped object Drops one cube when another is given Grasps and manipulates small objects Holds bottle Grasps feet and pulls to mouth
7	When infant is supine, spontaneously lifts head off table Sits, leaning forward on hands* When infant is prone, bears weight on one hand Sits erect momentarily Bears full weight on feet When infant is held in standing position, bounces actively	Transfers objects from one hand to the other* Has unidextrous approach and grasp Holds two cubes more than momentarily Bangs cube on table Rakes at a small object
8	Sits steadily unsupported* Readily bears weight on legs when supported; may stand holding on to furniture Adjusts posture to reach an object	Has beginning pincer grasp using index, fourth, and fifth fingers against lower part of thumb Releases objects at will Rings bell purposely Retains two cubes while regarding third cube Secures an object by pulling on a string Reaches persistently for toys out of reach
9	Creeps on hands and knees Sits steadily on floor for prolonged time (10 minutes) Recovers balance when leans forward but cannot do so when leaning sideways Pulls self to standing position and stands holding on to furniture*	Uses thumb and index finger in crude pincer grasp* Preference for use of dominant hand now evident Grasps third cube Compares two cubes by bringing them together
10	Can change from prone to sitting position Stands while holding on to furniture, sits by falling down Recovers balance easily while sitting While child is standing, lifts one foot to take a step	Crude release of an object beginning Grasps bell by handle
11	When child is sitting, pivots to reach toward back to pick up an object Cruises or walks holding on to furniture or with both hands held*	Explores objects more thoroughly (e.g., clapper inside bell) Has neat pincer grasp Drops object deliberately for it to be picked up Puts one object after another into a container (sequential play) Able to manipulate an object to remove it from tight-fitting enclosure
12	Walks with one hand held* Cruises well May attempt to stand alone momentarily; may attempt first step alone* Can sit down from standing position without help	Releases cube in cup Attempts to build two-block tower but fails Tries to insert a pellet into a narrow-necked bottle but fails Can turn pages in a book, many at a time

^* Milestones that represent essential integrative aspects of development that lay the foundation for the achievement of more advanced skills

TABLE 1-5 Motor Development During Toddler Years

AGE (MONTHS)	GROSS MOTOR	FINE MOTOR
15	Walks without help (usually since age 13 months) Creeps up stairs Kneels without support Cannot walk around corners or stop suddenly without losing balance Assumes standing position without support Cannot throw ball without falling	Constantly casting objects to floor Builds tower of two cubes Holds two cubes in one hand Releases a pellet into a narrow-necked bottle Scribbles spontaneously Uses cup with lid well but rotates spoon
18	Runs clumsily, falls often Walks up stairs with one hand held Pulls and pushes toys Jumps in place with both feet Seats self on chair Throws ball overhand without falling	Builds tower of three or four cubes Release, prehension, and reach well developed Turns pages in a book two or three at a time In drawing, makes stroke imitatively Manages spoon without rotation
24	Goes up and down stairs alone with two feet on each step Runs fairly well, with wide stance Picks up object without falling Kicks ball forward without overbalancing	Builds tower of six or seven cubes Aligns two or more cubes like a train Turns pages of book one at a time In drawing, imitates vertical and circular strokes Turns doorknob, unscrews lid
30	Jumps with both feet Jumps from chair or step Stands on one foot momentarily Takes a few steps on tiptoe	Builds tower of eight cubes Adds chimney to train of cubes Good hand-finger coordination; holds crayon with fingers rather than fist Moves fingers independently In drawing, imitates vertical and horizontal strokes, makes two or more strokes for cross

Motor Development: Preschool Years
AGE (YEARS)	GROSS MOTOR	FINE MOTOR
3	Rides tricycle Jumps off bottom step Stands on one foot for a few seconds Goes up stairs using alternate feet, may still come down using both feet on step Broad jumps May try to dance, but balance may not be adequate	Builds tower of nine or 10 cubes Builds bridge with three cubes Adeptly places small pellets in narrow-necked bottle In drawing, copies a circle, imitates a cross, names what has been drawn, cannot draw stick figure but may make circle with facial features
4	Skips and hops on one foot Catches ball reliably Throws ball overhand Walks down stairs using alternate footing	Uses scissors successfully to cut out picture following outline Can lace shoes but may not be able to tie bow In drawing, copies a square, traces a cross and diamond, adds three parts to stick figure
5	Skips and hops on alternate feet Throws and catches ball well Jumps rope Skates with good balance Walks backward with heel to toe Balances on alternate feet with eyes closed	Ties shoelaces Uses scissors, simple tools, or pencil very well In drawing, copies a diamond and triangle; adds seven to nine parts to stick figure; prints a few letters, numbers, or words, such as first name

Grade 0	0	Absent
Grade 1	+	Diminished
Grade 2	++	Normal, average
Grade 3	+++	Brisker than normal
Grade 4	++++	Hyperactiave (clonus)