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Neurological checks in children: paediatric Glasgow, fontanelle, raised intracranial pressure and head-injury observation

  • Assessment

In a child, neuro checks adapt the Glasgow scale to age, include the fontanelle in infants and lean on the parent who knows the child's normal behaviour.

Updated

What it is

Neurological observation in children follows the adult logic (level of consciousness, pupils, movement, vital signs) with age adaptations. Preverbal children cannot answer questions, so a paediatric version of the Glasgow Coma Scale changes the verbal part to vocalisation, crying and consolability, and the motor response becomes the most informative part. In infants the anterior fontanelle gives a window on intracranial pressure. After a head injury, the nurse repeats checks at the ordered interval and reports any change.

Reference values

  • Glasgow Coma Scale: three parts (eyes, verbal, motor), total 3 to 15; 15 is the best response.
  • Paediatric Glasgow: verbal part adapted to vocalisation and consolability; 14 or lower is altered mental status.
  • Posterior fontanelle usually closes by 1 to 2 months; anterior between about 7 and 19 months.
  • Normal fontanelle: firm and slightly curved inward when the infant is calm and upright.

What you need

  • Age-appropriate paediatric Glasgow chart used by the institution.
  • Penlight; neuro observation chart; watch.
  • Monitor for heart rate, respiratory rate, blood pressure and SpO2.
  • The parent or caregiver who knows the child's usual behaviour.

How to measure it (and why)

  1. Ask the caregiver how the child usually behaves, speaks and feeds — change from the child's own normal is the key sign.
  2. Observe first, before touching: alertness, cry, spontaneous movement, interest — handling can wake or upset the child.
  3. Score eyes, verbal (adapted to age) and motor response with the paediatric scale — the same scale each time allows comparison.
  4. In preverbal children, weight the motor response: purposeful movement or response to touch — speech cannot be tested.
  5. Check pupil size, equality and reaction to light — a new inequality can mean rising pressure.
  6. In infants, feel the anterior fontanelle with the baby calm and upright — crying and lying down make it look full.
  7. Look at the scalp: size and place of any swelling — some patterns suggest a high-energy or repeated injury.
  8. Take heart rate, breathing pattern and blood pressure with every check — apnoea and breathing changes are red flags.
  9. Record each check at the ordered interval and compare with the last — trends matter more than a single value.

How to read it

  • Raised intracranial pressure in infants: drowsiness, bulging fontanelle, separated sutures, vomiting.
  • In older children: headache, vomiting, behaviour change, decreased alertness, seizures, vision changes, weakness.
  • In toddlers after a head injury, inconsolable crying or refusal to feed is a danger sign.
  • Bruising in a pre-mobile infant (ear, neck, trunk, buttocks) or a torn frenulum are sentinel injuries for abuse.

Next step: when to call for help

  • Fall of the Glasgow score, new unequal pupils, a seizure or apnoea: call the doctor and the nurse in charge at once.
  • Repeated vomiting, worsening headache, increasing confusion or a child who cannot be kept awake: report immediately.
  • A truly bulging fontanelle with fever or drowsiness: emergency care.
  • Suspected maltreatment: record the findings objectively and follow the institutional protocol and the duty to report.

Test yourself

Think of the answer, then tap the question to see it.

Why is the Glasgow scale adapted for preverbal children?

They cannot give a verbal answer, so the verbal part is scored by vocalisation and consolability and the motor part becomes more important.

How should the anterior fontanelle be examined?

With the infant calm and upright; crying, lying down or vomiting can make it look bulging when it is not.

Which signs after a head injury in a toddler need urgent help?

Repeated vomiting, seizures, lethargy, unequal pupils, inconsolable crying, refusing to feed or not recognising people.

Why does the nurse ask parents about the child's usual behaviour?

Because the most useful sign is a change from the child's own normal, which the caregiver knows best.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Diagnostic Approach and Clinical Considerations in Infant Head Trauma: A Comprehensive Review (Kim HR), Korean J Neurotrauma (Europe PMC (open access), 2026); Fontanelles - bulging (MedlinePlus, U.S. National Library of Medicine, 2024); HEADS UP: Signs and Symptoms of Concussion (Centers for Disease Control and Prevention, 2024); Nursing Skills (Open RN), 6.4 Assessing Mental Status (Open RN, Chippewa Valley Technical College (CC BY 4.0), via LibreTexts, 2021).

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