Pediatric CNS, pg 1 of 12
The key points!
• Understand pediatric differences - Assessment
• Nursing care with ALOC – Overarching themes
• Increased ICP
• Seizures
• DI/SIADH
• Structural abnormalities
• Hydrocephalus
• Spina Bifida
• Infections of the Neurological system
• Cerebral Palsy
Pediatric Differences: Neonatal
• Dr. Tobar says to keep in mind that the brain and spinal cord are formed very early in embryonic development. Any
insult early in gestation is likely to cause congenital malformations.
• 1/3 of congenital malformation in live births = CNS malformations
• 90% are neural tube defects...MOST COMMON!
• Account for 40% deaths in first year of life
Pediatric Differences: Structure
• Head proportionately large/ thin bones/ unfused sutures/ fontanels. The head is also heavier in relation to the
child’s body than in an adults...so if there’s a car accident or a fall the head is what makes impact first. Unfused
sutures allow for some expansion, meaning there is a little bit of wiggle room.
• Immature muscles/ligaments: The neck is pretty weak and the muscles aren’t well developed...combine that with
this huge heavy head and you have a high high risk for spinal cord injury in traumas, even if there is no breakage
of bone...the neck can still get injured to the point of causing a spinal cord injury.
• Incomplete ossification of vertebral bodies
• Wedge shaped
• C1-C2 more lax movement (until age 8 y/o)
Pediatric Differences: Brain
• Brain
• Smaller volume CSF than adults. This means they have less ability to shunt out CSF as a way to keep ICP in
balance.
• Brain growth continues until 12-15 y/o (brain needs fuel!)
• High metabolic (oxygen/glucose) needs. Children’s brains are more sensitive to oxygen deprivation.
• Born with all nerve cells but mature after birth
• Glial cells and dendrites (receipt of nerve impulses) increase until 4 y/o. The lack of maturity of these nerves is
what makes children unable to localize pain.
• Myelination incomplete at birth
• Presence of primitive reflexes (know when these are supposed to be gone...if they are present or reappear
after this time, this is a bad sign for your pt.)
Cerebral Proportions
• Infant head = 1/4 total body height, 12% wt
• Adult head= 1/8 total body height, 2% wt
Pediatric Neuro Assessment
• Know NORMAL: Know when a child is expected to reach a milestone, and when a reflex is supposed to be lost.
Know what a normal neuro result is for all parts of the assessment.
• Know Expected: Know what is expected for that particular child and for that particular situation.
• Compare to baseline: Compare to baseline and talk to the parents! Look through the charting and get info from
report r/t how that child has been doing throughout this hospitalization.
, Pediatric CNS, pg 2 of 12
• LOC, pupils: If child won’t let you shine light in their eyes, or you have to engage in a lot of play with them, then
they are probably fine in the pupil department.
• VS: Know the ranges and when to be worried.
• Cranial nerves
• Fontanel/sutures: separating sutures is abnormal; a bulging fontanel is abnormal unless child is crying...otherwise
it is a sign of increased ICP.
• Cognitive function
• Posture and movement
• Neck stiffness
• Pain
Assessment: LOC
• Dr. Tobar says this is kind of hard to do b/c it is very much attached to what is normal for that particular child. Also,
the best way to get the info is to observe the child and get as much data as you can before you approach.
One way to assess LOC Infant LOC Pediatric Glasgow
Alert: responsive to parent; coos/ Quality of cry Best eye opening:
babbles/smiles Spont = 4
To speech = 3
To pain = 2
None = 1
Verbal: response to verbal Strong suck with feeding Best verbal:
stimulation Coos, Babbles = 5
Irritable = 4
Cries to Pain = 3
Moans to Pain = 2
None = 1
Pain: responsive to pain only Coordinated suck/swallow Best motor:
Normal spont movements = 6
Withdraw to touch = 5
Withdraw to pain = 4
Abnormal flexion = 3
Abnormal extension = 2
None = 1
Unresponsive to pain Presence of appropriate reflexes
Vital Signs
• VS changes w/ ICP (should make sure these aren’t due to another cause such as crying or pain)
• Increased systolic B/P
• Widened pulse pressure
• Bradycardia
• Airway assessment
• Check for gag/cough reflex
• Respiratory pattern and rate
The key points!
• Understand pediatric differences - Assessment
• Nursing care with ALOC – Overarching themes
• Increased ICP
• Seizures
• DI/SIADH
• Structural abnormalities
• Hydrocephalus
• Spina Bifida
• Infections of the Neurological system
• Cerebral Palsy
Pediatric Differences: Neonatal
• Dr. Tobar says to keep in mind that the brain and spinal cord are formed very early in embryonic development. Any
insult early in gestation is likely to cause congenital malformations.
• 1/3 of congenital malformation in live births = CNS malformations
• 90% are neural tube defects...MOST COMMON!
• Account for 40% deaths in first year of life
Pediatric Differences: Structure
• Head proportionately large/ thin bones/ unfused sutures/ fontanels. The head is also heavier in relation to the
child’s body than in an adults...so if there’s a car accident or a fall the head is what makes impact first. Unfused
sutures allow for some expansion, meaning there is a little bit of wiggle room.
• Immature muscles/ligaments: The neck is pretty weak and the muscles aren’t well developed...combine that with
this huge heavy head and you have a high high risk for spinal cord injury in traumas, even if there is no breakage
of bone...the neck can still get injured to the point of causing a spinal cord injury.
• Incomplete ossification of vertebral bodies
• Wedge shaped
• C1-C2 more lax movement (until age 8 y/o)
Pediatric Differences: Brain
• Brain
• Smaller volume CSF than adults. This means they have less ability to shunt out CSF as a way to keep ICP in
balance.
• Brain growth continues until 12-15 y/o (brain needs fuel!)
• High metabolic (oxygen/glucose) needs. Children’s brains are more sensitive to oxygen deprivation.
• Born with all nerve cells but mature after birth
• Glial cells and dendrites (receipt of nerve impulses) increase until 4 y/o. The lack of maturity of these nerves is
what makes children unable to localize pain.
• Myelination incomplete at birth
• Presence of primitive reflexes (know when these are supposed to be gone...if they are present or reappear
after this time, this is a bad sign for your pt.)
Cerebral Proportions
• Infant head = 1/4 total body height, 12% wt
• Adult head= 1/8 total body height, 2% wt
Pediatric Neuro Assessment
• Know NORMAL: Know when a child is expected to reach a milestone, and when a reflex is supposed to be lost.
Know what a normal neuro result is for all parts of the assessment.
• Know Expected: Know what is expected for that particular child and for that particular situation.
• Compare to baseline: Compare to baseline and talk to the parents! Look through the charting and get info from
report r/t how that child has been doing throughout this hospitalization.
, Pediatric CNS, pg 2 of 12
• LOC, pupils: If child won’t let you shine light in their eyes, or you have to engage in a lot of play with them, then
they are probably fine in the pupil department.
• VS: Know the ranges and when to be worried.
• Cranial nerves
• Fontanel/sutures: separating sutures is abnormal; a bulging fontanel is abnormal unless child is crying...otherwise
it is a sign of increased ICP.
• Cognitive function
• Posture and movement
• Neck stiffness
• Pain
Assessment: LOC
• Dr. Tobar says this is kind of hard to do b/c it is very much attached to what is normal for that particular child. Also,
the best way to get the info is to observe the child and get as much data as you can before you approach.
One way to assess LOC Infant LOC Pediatric Glasgow
Alert: responsive to parent; coos/ Quality of cry Best eye opening:
babbles/smiles Spont = 4
To speech = 3
To pain = 2
None = 1
Verbal: response to verbal Strong suck with feeding Best verbal:
stimulation Coos, Babbles = 5
Irritable = 4
Cries to Pain = 3
Moans to Pain = 2
None = 1
Pain: responsive to pain only Coordinated suck/swallow Best motor:
Normal spont movements = 6
Withdraw to touch = 5
Withdraw to pain = 4
Abnormal flexion = 3
Abnormal extension = 2
None = 1
Unresponsive to pain Presence of appropriate reflexes
Vital Signs
• VS changes w/ ICP (should make sure these aren’t due to another cause such as crying or pain)
• Increased systolic B/P
• Widened pulse pressure
• Bradycardia
• Airway assessment
• Check for gag/cough reflex
• Respiratory pattern and rate
