The developing nervous system responds to injury differently from the adult brain. Before the cranial sutures fuse, an infant's skull can expand, so rising intracranial pressure (ICP) shows first as a bulging fontanel and increasing head circumference rather than early headache. Children also have a relatively large head, weaker neck muscles, and a lower seizure threshold during fever.

Simple vs. complex febrile seizure

About one-third of children have a recurrence. Simple febrile seizures do not cause brain damage and carry only a slightly higher risk of later epilepsy than the general population.

Meningitis

• Older children: fever, headache, vomiting, photophobia, nuchal rigidity, altered consciousness, seizures
• Kernig sign — supine, hip and knee flexed to 90°, extending the knee causes pain and resistance; Brudzinski sign — flexing the neck causes hip and knee flexion
• Infants: signs are subtle — fever or hypothermia, poor feeding, vomiting, irritability, high-pitched cry, bulging fontanel; neck stiffness is often absent
• Petechial or purpuric rash that does not blanch suggests meningococcal disease — an emergency

Increased ICP

Late signs: decreasing level of consciousness, abnormal posturing, sluggish or dilated pupils, and Cushing triad (bradycardia, widening pulse pressure with rising systolic BP, irregular respirations).

Cerebral palsy — early signs: delayed motor milestones, persistent primitive reflexes, stiff or "floppy" tone, scissoring of the legs, arching of the back, feeding difficulty, and hand preference before about 12 months of age.

Myelomeningocele: sac on the back (usually lumbosacral); assess leg movement first (motor level), then sensation, bladder and bowel function, head circumference, and the fontanel.

CSF from lumbar puncture (LP)

• Blood cultures before antibiotics; CT before LP only if signs of raised ICP or focal deficits — never delay antibiotics for imaging
• Glasgow Coma Scale (GCS) — pediatric version adapts the verbal score for preverbal children (coos, babbles, cries). 13–15 mild, 9–12 moderate, 8 or less severe (protect the airway)
• EEG for epilepsy; not needed after a simple febrile seizure in a well child
• CT or MRI for hydrocephalus, tumor, or injury; cranial ultrasound through the open fontanel in infants
• Seizure workup in a febrile child: find the fever source; LP when meningitis is suspected (e.g., meningeal signs, ill appearance, unimmunized infant, or antibiotic pretreatment, which can mask meningitis)

LP nursing care: record baseline vital signs and neuro status; position side-lying with knees to chest and neck gently flexed, or sitting and leaning forward; hold securely without compressing the chest or airway (monitor SpO₂ in infants); label CSF and send promptly; afterward monitor the puncture site, headache, and neuro status.

Bacterial meningitis

• Empiric IV antibiotics immediately (after cultures if they do not delay treatment): beyond the neonatal period, typically a third-generation cephalosporin (ceftriaxone or cefotaxime) plus vancomycin; neonates receive ampicillin plus gentamicin or a third- or fourth-generation cephalosporin (cefotaxime, or ceftazidime or cefepime where cefotaxime is unavailable, as in the US). Doses are weight-based and verified with a pediatric reference
• Ceftriaxone — avoid in neonates with hyperbilirubinemia and do not give with IV calcium-containing solutions in neonates (precipitation). Vancomycin — trough or AUC monitoring, kidney function, infusion reaction ("red man" or vancomycin infusion reaction) if infused too fast. Gentamicin — levels, nephrotoxicity, ototoxicity
• Dexamethasone — when used (e.g., Hib, and considered for pneumococcal disease in children older than 6 weeks), give before or with the first antibiotic dose. Watch glucose and GI bleeding
• Close contacts of meningococcal disease receive chemoprophylaxis (rifampin, ciprofloxacin, or ceftriaxone)
• Hearing evaluation after bacterial meningitis — sensorineural loss is the most common sequela

Seizures

• A seizure lasting 5 minutes or more is treated as status epilepticus: first-line benzodiazepine (IV lorazepam 0.1 mg/kg, max 4 mg; or IM, intranasal, or buccal midazolam; or rectal diazepam), repeated once after 5–10 minutes if seizures continue — no more than two doses (respiratory depression). If seizures persist (about 20 minutes from onset), a second-line agent: levetiracetam, fosphenytoin (ECG and BP monitoring — hypotension, dysrhythmia), or valproate (avoid under 2 years or with suspected metabolic or mitochondrial disease — fatal hepatotoxicity; also pancreatitis, teratogenic)
• Febrile seizure: treat the cause of fever; no long-term antiseizure medication for simple febrile seizures
• Epilepsy: antiseizure medications; the ketogenic diet (high fat, adequate protein, very low carbohydrate) for drug-resistant epilepsy; epilepsy surgery or vagus nerve stimulation for selected children

Hydrocephalus — ventriculoperitoneal (VP) shunt or endoscopic third ventriculostomy.

Myelomeningocele — surgical closure usually within 24–72 hours of birth (or prenatal repair in selected cases); shunt if hydrocephalus develops.

Cerebral palsy — physical, occupational, and speech therapy; orthoses; oral baclofen (sedation, weakness; taper — abrupt withdrawal can cause seizures and hallucinations); intrathecal baclofen pump (abrupt interruption can cause high fever, altered mental status, rebound spasticity, and rhabdomyolysis — an emergency); botulinum toxin injections (boxed warning: distant spread causing swallowing or breathing difficulty); orthopedic surgery.

Myasthenia gravis — pyridostigmine timed before meals and activity; watch for myasthenic crisis (respiratory weakness).

Listed in priority order.

1. During a seizure — airway and injury prevention
   • Stay with the child, time the seizure, turn the child on the side to let secretions drain, loosen clothing, move hard objects away, give oxygen and suction as needed
   • Nothing in the mouth; do not restrain limbs
   • Prepare rescue benzodiazepine if the seizure reaches 5 minutes; monitor respirations afterward (benzodiazepines depress breathing)
   • Afterward: recovery position, neuro checks, document onset, movements, duration, and postictal state
2. Suspected meningitis
   • Droplet precautions until 24 hours of effective antibiotics (Neisseria meningitidis or Hib), or until those organisms are ruled out
   • Obtain cultures and give the first antibiotic dose without delay
   • Frequent neuro checks, vital signs, seizure precautions; quiet, dim room
   • Monitor fluid balance and sodium (SIADH can occur); daily head circumference in infants
   • Watch for shock and purpura (meningococcemia)
3. Increased ICP
   • Head of bed 15–30°, head midline (avoid neck flexion or rotation), avoid hip flexion and abdominal compression
   • Minimize suctioning and cluster care; preoxygenate before suctioning; treat pain; prevent straining and constipation
   • Report bradycardia, rising systolic BP, pupil changes, or falling GCS immediately
4. VP shunt care
   • Postoperative position per surgeon (often flat at first to avoid rapid CSF drainage), on the non-operative side
   • Watch for malfunction — infants: bulging fontanel, rising head circumference, sunset eyes, vomiting, irritability; older children: headache, vomiting, lethargy, visual change, declining school performance — and infection (fever, redness along the tract, irritability, abdominal pain) — highest risk in the first months
   • Daily head circumference and fontanel check in infants
5. Myelomeningocele before closure
   • Prone or side-lying; keep the sac covered with a sterile, moist (saline), non-adherent dressing; no diaper over the sac; protect from stool
   • Measure head circumference daily; assess leg movement and output
   • Latex precautions from birth (high risk of latex allergy)
   • After closure: keep pressure off the incision; begin clean intermittent catheterization and bowel program as ordered
6. Cerebral palsy
   • Slow, gentle range-of-motion to the end of range (never forced or painful) to prevent contractures; alternate positions; splints as ordered
   • High-calorie diet; upright feeding, thickened liquids per swallow evaluation; aspiration precautions; oral care
   • Goal: maximize function and promote normal growth and development — not complete correction
7. Head injury — spinal precautions until cleared, GCS and pupils frequently, report vomiting and worsening headache; for severe injury (GCS 8 or less) prepare for airway management.
8. Myasthenia gravis — monitor respiratory rate, effort, and swallowing; schedule activity when strength peaks after medication; small frequent meals; balance rest and activity (complete bed rest is not the goal).

• Febrile seizure first aid: lay the child on the side, nothing in the mouth, time the seizure; call emergency services if it lasts 5 minutes or more, if breathing is difficult, or if the child does not recover. Fever medicine makes the child comfortable but does not prevent seizures. Recurrence is possible but not certain; simple febrile seizures do not cause brain damage
• Antiseizure medication: give at the same time daily; never stop suddenly (risk of status epilepticus); report rash. Carbamazepine: report rash immediately (Stevens-Johnson syndrome risk — HLA-B*15:02 screening is recommended for at-risk Asian ancestry before starting); report fever, sore throat, bruising (blood dyscrasia); drowsiness and dizziness — supervise bicycling and swimming; periodic blood levels, CBC, and sodium
• Rescue medication at home: when and how to give intranasal, buccal, or rectal forms as prescribed
• Ketogenic diet: strict measured ratios; no "free" snacks; use sugar-free medicines and toothpaste; vitamin and mineral supplements are needed; do not restrict fluids; report vomiting, lethargy, or kidney-stone symptoms
• VP shunt at home: normal cuddling and handling are safe; routine immunizations continue; report vomiting, irritability, lethargy, headache, bulging fontanel, increasing head size, or fever; shunt revisions are common as the child grows
• Spina bifida prevention: everyone who could become pregnant takes folic acid 400 mcg (0.4 mg) daily; after an affected pregnancy, a higher dose (commonly 4 mg daily) as prescribed
• Cerebral palsy: home stretching, orthoses, skin checks under braces, safe feeding, respite resources
• Helmets for cycling and sports; car seats; window guards

• Infant meningitis: bulging fontanel, irritability, poor feeding — neck stiffness may be absent
• Bacterial CSF: cloudy, neutrophils, low glucose, high protein
• Kernig: extend the knee with the hip at 90°; Brudzinski: neck flexion causes hip and knee flexion
• Droplet precautions for suspected bacterial meningitis until 24 hours of effective antibiotics
• Seizure: side-lying, time it, nothing in the mouth, no restraint; rescue medication at 5 minutes
• Febrile seizure: 6–60 months; simple = generalized, under 15 minutes, once in 24 hours; antipyretics do not prevent recurrence
• Increased ICP in infants: bulging fontanel, rising head circumference, sunset eyes, high-pitched cry; Cushing triad is late
• GCS 8 or less = severe; 9–12 moderate; 13–15 mild
• Myelomeningocele: prone, sterile moist saline dressing, latex precautions, check leg movement first
• CP is non-progressive; slow gentle ROM; goal is maximum function
• Carbamazepine: rash, blood dyscrasias, hyponatremia; never stop antiseizure drugs abruptly