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CHOP Infant Coma Scale ("Infant Face Scale"): a novel coma scale for children less than two years of age
S R Durham1, R R Clancy, E Leuthardt
1Division of Neurosurgery, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, 19104, USA.
Insights
The Infant Face Scale (IFS) shows better reliability than the Glasgow Coma Scale (GCS) for assessing neurologic injury in infants. This new scale offers a more accurate bedside tool for evaluating brain injury severity in young children.
Area of Science:
- Pediatric Neurology
- Neurotrauma Assessment
- Clinical Outcome Measurement
Background:
- The Glasgow Coma Scale (GCS) is standard for assessing neurologic injury but has limitations in infants and young children.
- Existing pediatric coma scales often lack objective measures or fail to assess both cortical and brainstem function.
- A reliable and objective tool is needed for assessing brain injury severity in non-verbal or intubated infants.
Purpose of the Study:
- To compare the interrater reliability of the novel Infant Face Scale (IFS) against the established Glasgow Coma Scale (GCS).
- To evaluate the efficacy of the IFS in children under two years of age, including those who are intubated.
- To determine if the IFS offers improved assessment of neurologic injury severity in infants compared to the GCS.
Main Methods:
- A prospective study involving 75 hospitalized infants (<2 years) assessed by paired observers using both IFS and GCS.
- Interrater reliability was calculated using the kappa statistic for both scales and their subtests (eye-opening, motor, verbal/face).
- A subset of 10 intensive care unit infants with acute brain injury (traumatic or hypoxic/ischemic) underwent similar simultaneous assessments.
Main Results:
- For the 75 hospitalized infants, IFS demonstrated higher interrater reliability ('almost perfect' to 'substantial') across subtests compared to GCS ('slight' to 'fair').
- In the intensive care unit cohort with severe brain injury, IFS achieved 'almost perfect' reliability, while GCS scores were only in the 'fair' range.
- The IFS showed particular strength in the 'verbal/face' component, an area often deficient in other pediatric coma scales.
Conclusions:
- The Infant Face Scale (IFS) exhibits superior interrater reliability compared to the Glasgow Coma Scale (GCS) in infants and young children.
- The IFS provides a more objective and reliable bedside assessment of brain injury severity, especially in challenging pediatric populations.
- The IFS is a promising, practical tool for evaluating neurologic status in children under two years, including intubated patients.
Abstract:
The Glasgow Coma Scale (GCS) is the most frequently used tool worldwide for assessing the severity of neurologic injury after brain trauma, although applying this scale to infants and younger children can be problematic. The CHOP Infant Coma Scale, or Infant Face Scale (IFS), is a novel scale for children under 2 years of age which differs from other pediatric coma scales in the following ways: (1) it relies on objective behavioral observations; (2) it assesses cortical as well as brainstem function; (3) it parallels the GCS in scoring but is based on infant-appropriate behaviors; and (4) it can be applied to intubated patients. We report the results of a prospective study designed to compare interrater reliability between the IFS and GCS in children less than 2 years of age. Seventy-five hospitalized children less than 2 years of age were assessed simultaneously by a pair of observers, representing a spectrum of health care professionals, who scored the children using both the IFS and GCS. Interrater reliability for each pair of observers for each scale was assessed using the kappa statistic. A second series of 10 infants in the intensive care unit with specific diagnoses of acute traumatic or hypoxic/ischemic brain injury were similarly assessed. In the 75 hospitalized infants with a variety of diagnoses, interrater reliability for the GCS was in the "almost perfect," "slight," and "fair" range for the eye-opening, motor, and verbal subtests, respectively. In contrast, the IFS showed interrater reliability in the "almost perfect," "substantial," and "almost perfect" ranges for the three subtests. When applied to infants in an intensive care unit with acute traumatic brain injury or hypoxia/ischemia, the GCS interrater reliability scores were in the "fair" range, while the IFS scores were in the "almost perfect" range. The IFS demonstrates improved interrater reliability in direct comparison to the GCS, particularly in the "verbal/face" component where most pediatric coma scales are deficient. The IFS may prove to be a simple and practical bedside index of brain injury severity in children less than two years of age.