Pitfalls

Review all the possible causes of reduced conscious level concurrently rather than sequentially.  No individual cause is more important than another and several may coexist in the same child. If you encounter problems in making the diagnosis, it is worth starting from the beginning with the history and performing a full physical examination rather than relying on information passed on by another clinician.

No clinical clues to the cause

If there are no obvious clinical signs broad spectrum antibiotics and acyclovir should be started and supportive treatment implemented.  Further investigations include a CT, lumbar puncture, urine toxicology screen, urine organic and amino acids and plasma lactate.  If the cause remains unknown an EEG to exclude non-convulsive status epilepticus; ESR and autoimmune screen to exclude cerebral vasculitis; thyroid function test and antibodies to exclude Hashimoto’s encephalitis should be performed. [20] Further management should involve a paediatric neurologist.

Non-accidental injury (NAI)

Non-accidental injury or other child protection issues may be behind the cause of reduced consciousness in children. NAI has the highest prevalence in infants. [15]