Stages of hepatic encephalopathy, children 3 to 18 years

Stage	Clinical	Reflexes	Neurologic signs	EEG changes
0	None	Normal	Psychological testing only	Normal
I	Confused, mood changes, altered sleep habits, loss of spatial orientation, forgetful	Normal or hyperreflexic	Tremor, apraxia, impaired handwriting	Normal or diffuse slowing to theta rhythm, triphasic waves
II*	Drowsy, inappropriate behavior, decreased inhibitions	Hyperreflexic	Dysarthria, ataxia	Abnormal generalized slowing, triphasic waves
III*	Stuporous, obeys simple commands	Hyperreflexic, upgoing toes (Babinski sign)	Rigidity	Abnormal generalized slowing, triphasic waves
IV	Comatose, arouses with painful stimuli (IVa), or no response (IVb)	Usually absent	Decerebrate or decorticate	Abnormal, very slow delta activity

EEG: electroencephalography.

* Asterixes is a common feature of stages II and III encephalopathy in adults but may be difficult to assess in children.

Adapted from: Ng VL, Li R, Loomes KM, et al. Outcomes of Children With and Without Hepatic Encephalopathy from the Pediatric Acute Liver Failure (PALF) Study Group. J Pediatr Gastroenterol Nutr 2016; 63:357. DOI: 10.1097/MPG.0000000000001178. Copyright © 2016 ESPGHAN and NASPGHAN. Adapted with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited.

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Stages of hepatic encephalopathy, children 3 to 18 years