Which of the following is a newly noted sign of shunt malfunction in school-aged children?

• A. Newly noted nystagmus
• B. Newly noted toothache
• C. Newly noted rash
• D. Newly noted cough

Answer: (A)

New onset nystagmus signals potential raised intracranial pressure affecting the brain’s visual and oculomotor pathways, which can happen when a shunt malfunctions in a school-aged child. In older children, shunt problems don’t always present with the classic infant sign of a bulging fontanelle; more often they show up as headaches, vomiting, or changes in vision. Nystagmus is a specific eye movement sign that reflects underlying pressure changes and warrants urgent evaluation for shunt obstruction or failure. The other options—toothache, rash, or cough—do not indicate shunt-related problems and point to unrelated dental, skin, or respiratory issues. When new nystagmus appears in a child with a shunt, prompt neuroimaging and shunt assessment are typically needed.