[Assessment of the deepness of coma in children. Evolution of clinical thoughts]

Clinical assessment is an essential fundamental element in the evaluation of comatose states, particularly in children. Paediatricians quickly recognized that the early Glasgow Coma Scale, used for over 20 years in adults, is inadapted for children because it lacks brain stem criteria, involves interpretation of motor response (particularly difficult in infants) and uses verbal response which is of little value before language acquisition. The first attempt at standardized coma assessment in children was the Paediatric Coma Scale, developed in Australia in 1982. This scale improved on the Glasgow scale, removing the motor retraction response, modifying the verbal response scale (normal, words, sounds, crying, or none) and quantifying the best possible score as a function of age. In 1983 a fundamental modification was proposed in the Jacob scale. Besides removing the motor retraction response, this scale replaced the verbal scale with one based on ocular behaviour, thus evaluating consciousness of presence or stimulation. The vestibular response and pupil reactions were also included to assess brain stem activity. In 1987, we introduced the Bicêtre scale which uses ocular behaviour instead of verbal response and separates ocular diameter as a specific criteria. Assessment of four reflexes (mimic, photomotor, cornea and cough) provides precise information on the activities of the different levels of the brain stem. Several comparative studies have been conducted to determine the positive predictive value and interpersonal variability of these scales. In a prospective multicentric study of 277 comatose children aged 6 months to 15 years, we found that the Bicêtre scale had a positive predictive value of 94% for good outcome at 24 hours and that interpersonal disagreement occurred in only 10.1% of 65 cases studied (compared with 13.5% for the Glasgow scale which was studied simultaneously). Paediatricians now have reliable clinical scales for assessing the conscious level in children.