What is the approach to a comprehensive central nervous system (CNS) examination in pediatric patients?

CNS Examination in Pediatric Patients

The pediatric CNS examination must be systematically adapted to the child's developmental age, using age-specific assessment tools: the Cornell Assessment of Pediatric Delirium (CAPD) for children ≤12 years and the CARTOX-10 neurological assessment scale for patients ≥12 years with age-appropriate cognitive abilities. 1

Age-Specific Examination Framework

Infants and Young Children (≤12 years)

For children under 12 years, use the CAPD scoring system as your primary neurological screening tool, performing assessments at least twice daily in admitted patients. 1 A CAPD score >8 indicates delirium and warrants immediate escalation of care 1. The sensitivity and specificity of CAPD are highest in this younger age group 1.

Key examination components include:

• Level of consciousness and arousal: Assess for somnolence, confusion, or encephalopathy using developmentally appropriate anchor points 1
• Motor function: Evaluate for tremor, motor weakness, or incontinence 1
• Seizure activity: Document any brief partial seizures (without loss of consciousness) or generalized seizures 1
• Cognitive performance: Determine baseline developmental level, as early CNS changes can be subtle in children and require pediatric expertise to detect 1

Older Children and Adolescents (>12 years)

For patients over 12 years with age-appropriate cognitive performance, utilize the CARTOX-10 grading system for neurological assessment. 1 This 10-point scale provides standardized scoring:

• Score 7-9: Grade 1 neurological impairment 1
• Score 3-6: Grade 2 neurological impairment 1
• Score 0-2: Severe impairment requiring intensive monitoring 1

Assess for dysphasia, impaired attention, and changes in handwriting or language expression, as these are early indicators of CNS dysfunction in this age group 1.

Critical Examination Elements Across All Ages

Fundoscopic Examination

Perform fundoscopic examination to assess for papilledema in any child with suspected CNS pathology. 1 High-grade papilledema (stage 3-5) or signs of elevated intracranial pressure (CSF opening pressure ≥20 mmHg) indicate Grade 4 severity requiring immediate intervention 1.

Brainstem Reflexes and Cranial Nerve Assessment

In cases of severe CNS dysfunction or suspected brain death, systematically evaluate all brainstem reflexes. 1 The examination must include:

• Pupillary responses: Fixed, dilated pupils indicate brainstem dysfunction 1
• Corneal reflexes: Absence suggests pontine involvement 1
• Gag and cough reflexes: Test to assess medullary function 1
• Oculocephalic and oculovestibular reflexes: Evaluate in comatose patients 1

Motor and Sensory Examination

Evaluate motor function for focal deficits, weakness, and abnormal movements. 1 Document any postictal focal deficits, as these require emergent neuroimaging if they do not quickly resolve 2, 3.

Timing and Frequency of Assessments

Perform neurological assessments at least twice daily in hospitalized children, with the first assessment conducted at shift change between nursing providers. 1 Increase frequency if:

• Any change from prior scores occurs 1
• Caregivers raise concerns about the child's status 1
• The child has not returned to baseline within 5-10 minutes after a neurological event 3, 4

The trend in assessment scores within an individual patient is more important than isolated values; increasing scores indicate worsening CNS function. 1

Ancillary Testing Integration

Electroencephalography (EEG)

Obtain EEG when seizure activity is suspected or to evaluate for non-convulsive status epilepticus. 1 If no seizures are detected on EEG, continue prophylactic antiseizure treatment 1.

Neuroimaging

Order MRI of the brain with and without contrast for comprehensive CNS evaluation, including diagnostic lumbar puncture with opening pressure measurement. 1 Add spinal MRI if focal peripheral neurological deficits are observed 1. CT scan is acceptable if MRI is not feasible 1.

Brain Death Determination

For brain death evaluation in term newborns (37 weeks gestation to 30 days), perform two examinations 24 hours apart. 1 For children 31 days to 18 years, examinations should be 12 hours apart 1. Two different attending physicians must perform the examinations 1.

Common Pitfalls to Avoid

• Do not use adult CNS assessment tools in young children: CTCAE grading and adult CRES algorithms are not optimal for infants and younger children 1
• Do not delay assessment if baseline is unclear: The earliest signs of CNS dysfunction can be subtle in children, requiring pediatric expertise to establish baseline cognitive performance 1
• Do not perform single assessments: Serial examinations are essential, as CNS status can be labile and change rapidly 1
• Do not ignore caregiver concerns: Parents often detect subtle changes before objective scoring tools 1

Special Considerations for Specific Clinical Contexts

In children receiving CAR T-cell therapy or at risk for CNS toxicity, maintain heightened vigilance during the first 4 weeks post-treatment, as this is the high-risk period for CNS complications. 1 Avoid medications that cause CNS depression during this period 1.

For post-traumatic seizures, emergent CT head without contrast is the appropriate imaging modality to rapidly identify structural pathology such as intracranial hemorrhage. 2