The Glasgow Coma Scale (GCS) is a useful tool for assessing the level of consciousness in pediatric patients, but it requires some adaptations depending on the child's age and developmental stage. While the basic principles of the GCS are the same for both adults and children, scoring is adjusted to account for age-related differences in responses, particularly in younger children and infants.

Here’s how to assess and score the GCS in pediatric patients, with emphasis on how it varies with age:

1. Eye Opening (E)

• Score of 4: Spontaneous – The child opens their eyes without any stimulus.

• Score of 3: To speech – The child opens their eyes in response to verbal stimulation (e.g., calling their name or saying "wake up").

• Score of 2: To pain – The child opens their eyes in response to painful stimuli (e.g., squeezing the child’s hand or pressing on the nail bed).

• Score of 1: No response – The child does not open their eyes in response to any stimulus.

Age considerations:

• In newborns and infants, eye opening in response to light, voice, or pain is typical, while older children are expected to open their eyes more readily to speech or commands.

2. Verbal Response (V)

This is the most variable category for pediatric patients because verbal communication is dependent on the child’s developmental age.

• Score of 5: Oriented – The child is fully awake, alert, and able to respond appropriately to questions, demonstrating awareness of their environment.

  • For infants, this would be assessed as smiling and engaging with familiar caregivers or responding appropriately to stimuli.

• Score of 4: Confused speech – The child can speak, but their responses may be disoriented or inappropriate for the situation.

  • For younger children, confused speech could be characterized by incoherent or non-logical babbling.

• Score of 3: Inappropriate words – The child speaks, but their speech is random or inappropriate for the situation (e.g., crying without clear reason or uttering nonsensical words).

• Score of 2: Incomprehensible sounds – The child may make moaning, groaning, or other non-verbal vocalizations, but no clear words are uttered.

• Score of 1: No verbal response – The child does not make any vocal sounds.

Age considerations:

• For infants and toddlers, their verbal responses may be non-verbal sounds, such as crying, cooing, or babbling.

• Older children (preschool-age and above) are expected to use age-appropriate words and phrases.

3. Motor Response (M)

This category assesses the child's ability to respond to commands or pain through movement.

• Score of 6: Obeys commands – The child can follow simple commands such as "wiggle your fingers" or "touch your nose".

  • For infants, this could be assessed as purposeful movement such as turning toward a caregiver or grasping their finger.

• Score of 5: Localizes pain – The child moves purposefully toward a painful stimulus (e.g., moving their hand toward the source of the pain).

• Score of 4: Withdraws from pain – The child will move away from the painful stimulus (e.g., pulling their body part away from where the pain is being applied).

• Score of 3: Abnormal flexion (decorticate posturing) – The child displays abnormal flexion of the upper limbs (arms flexed at the elbows) and extension of the legs in response to pain.

  • Decorticate posturing is seen as a sign of significant brain injury, indicating damage to the brain's motor pathways.

• Score of 2: Abnormal extension (decerebrate posturing) – The child demonstrates abnormal extension of both the arms and legs, which is a more severe sign of brain injury.

  • Decerebrate posturing is indicative of damage to the brainstem.

• Score of 1: No response – The child shows no movement in response to any stimulus.

Age considerations:

• Infants (under 1 year) may not be able to obey commands, so their response would be assessed based on movements such as crying or withdrawing from pain.

• Older children are expected to follow commands or show purposeful responses to painful stimuli. Abnormal posturing (flexion or extension) should be considered a red flag for severe brain injury.

Scoring the GCS in Pediatric Patients

For pediatric patients, the total GCS score is calculated by adding up the individual scores for eye opening (E), verbal response (V), and motor response (M).

• Total GCS Score = E + V + M
  The total score ranges from 3 (deep coma) to 15 (full consciousness).

Interpretation of GCS in Pediatric Patients:

• GCS 15: Fully alert and oriented, normal responses to all stimuli.

• GCS 13-14: Mild impairment in consciousness, may show confusion or drowsiness but can respond appropriately.

• GCS 9-12: Moderate impairment, potentially needing further monitoring and care, possibly in an intensive care unit (ICU).

• GCS 8 or below: Severe impairment, indicating a deep coma, which may require life support and intensive monitoring.

Example of GCS Assessment in Pediatric Patients

1. Newborn (2 days old):

   • Eye opening: Spontaneous (4)

   • Verbal response: Crying loudly, no words (2)

   • Motor response: Moves all limbs spontaneously (6)

   • Total GCS = 4 (eye) + 2 (verbal) + 6 (motor) = 12

   • Interpretation: The newborn is generally responsive, but there is some difficulty in assessing verbal responses.

2. 2-Year-Old:

   • Eye opening: To speech (3)

   • Verbal response: Saying "mama" but not full sentences (3)

   • Motor response: Obeys commands, such as "touch your nose" (6)

   • Total GCS = 3 (eye) + 3 (verbal) + 6 (motor) = 12

   • Interpretation: The 2-year-old is moderately responsive and can follow commands but is not fully oriented or verbal.

3. 8-Year-Old:

   • Eye opening: To speech (3)

   • Verbal response: Confused speech, does not respond appropriately (4)

   • Motor response: Withdraws from pain (4)

   • Total GCS = 3 (eye) + 4 (verbal) + 4 (motor) = 11

   • Interpretation: The child is confused and shows some difficulty in responding, requiring ongoing monitoring and care.