Which of the following is a late sign of increased intracranial pressure in children?

• A. Headache
• B. Bulging fontanel
• C. Increase in head circumference
• D. Changes in respiratory pattern such as Cheyne-Stokes

Answer: (D)

Rising intracranial pressure in children progresses from earlier, nonspecific symptoms to signs showing brainstem involvement. Cheyne-Stokes respiration—periods of gradual breathing increases and decreases followed by apnea—reflects that the brainstem respiratory centers are being compromised. This pattern indicates a high, decompensated ICP and possible brainstem irritation or herniation, which is why it’s considered a late sign.

Other options tend to appear earlier: headaches (and vomiting) can occur as ICP begins to rise, bulging fontanel and increasing head circumference are especially early indicators in infants, signaling that the skull hasn't yet rigidly fixed the pressure. Seeing Cheyne-Stokes respiration signals a dangerous progression, prompting urgent management to reduce ICP.