GCS in Infants

The Glasgow Coma Scale (GCS) was originally designed for adults. Because infants and children under age 4 cannot be assessed for verbal responses or the ability to follow commands, the Modified Glasgow Coma Scale (MGCS) is utilized. It remains the gold standard for assessing the depth and duration of impaired consciousness and predicting outcomes in pediatric traumatic brain injury (TBI).

COMPONENTS OF THE SCALE

The scale assesses three parameters: Eye Opening (E), Best Motor Response (M), and Best Verbal Response (V). The total score ranges from 3 to 15.

1. EYE OPENING (E)

Identical to the adult version; assesses the integrity of the brainstem and arousal centers.

• 4: Spontaneous (Eyes open without stimulation)
• 3: To Speech/Sound (Eyes open to shouting or calling name)
• 2: To Pain (Eyes open to pressure on nail bed or supraorbital notch)
• 1: None (No response)

2. BEST MOTOR RESPONSE (M)

Modified for the developmental stage where children cannot follow complex commands.

• 6: Spontaneous (Obeys commands in older children; normal spontaneous movement in infants)
• 5: Localizes Pain (Withdraws to touch; purposeful movement toward painful stimulus)
• 4: Withdraws from Pain (Flexion withdrawal to painful stimulus)
• 3: Abnormal Flexion (Decorticate posturing; suggests damage above the brainstem)
• 2: Abnormal Extension (Decerebrate posturing; suggests brainstem involvement)
• 1: None (Flaccidity)

3. BEST VERBAL RESPONSE (V)

Significantly modified for the pre-verbal child

• 5: Smiles, oriented to sounds, follows objects, interacts
• 4: Consalable when crying; interacts inappropriately
• 3: Inconsistently consolable; moaning
• 2: Inconsolable; agitated; restless
• 1: None

INTERPRETATION AND SCORING

• Maximum Score: 15 (Fully conscious)
• Minimum Score: 3 (Deep coma or death)
• Total GCS = E + M + V

SEVERITY OF BRAIN INJURY (Paediatric TBI)

• Mild: GCS 13–15
• Moderate: GCS 9–12
• Severe: GCS ≤ 8 (Commonly defined as "Coma"; requires immediate airway protection/intubation)

LIMITATIONS

• Inter-observer variability, especially in the verbal component.
• Confounding factors: Sedation, neuromuscular blockade, endotracheal intubation (recorded as 'T' e.g., GCS 5T), and periorbital edema.
• Does not assess brainstem reflexes (pupillary light reflex, cough/gag) or lateralizing signs.

MANAGEMENT CORRELATION

1. GCS ≤ 8: Secure airway (Intubation), ICP monitoring, and neurosurgical consultation.
2. Serial GCS Monitoring: A drop of ≥ 2 points on the scale indicates significant neurological deterioration and necessitates an emergent CT scan.