Traumatic Brain Injury in Paediatrics

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Introduction[edit | edit source]

Traumatic brain injury (TBI) is the leading cause of death and disability in children. TBI in children result in a range of traumatic injuries to the scalp, skull, and brain that are comparable to those in adults but differ in both pathophysiology and management[1].Although children have better survival rates than adults with TBI, the long-term sequelae and consequences are often more devastating in children because of their age and developmental potential[2].Evidence suggests that children exhibit a specific pathological response to TBI with distinct accompanying neurological symptoms, and considerable efforts have been made to elucidate their pathophysiology. In addition, recent technical advances in diagnostic imaging of pediatric TBI has facilitated accurate diagnosis, appropriate treatment, prevention of complications, and helped predict long-term outcomes[1].The costs involved in the care of a child with severe TBI,extended over the individual’s lifetime, are significant[2].

Incidence[edit | edit source]

  • Unintentional injuries are the leading cause of death in children.
  • Of all the types of traumatic injuries, brain injuries are the most likely to result in death or permanent disability. 
  • A study with respect to age revealed that emergency consultations were most common among children aged 0–4 years (1,035 per 100,000 children), and of these, 80 per 100,000 children were hospitalized.
  • The annual death rate from traumatic injury in children <4 years is 5 per 100,000.
  • The death rate is higher for children <4 years than for those 5–14 years of age.
  • Hospitalization for TBI was most commonly observed in adolescents (129 per 100,000).
  • More boys were found to undergo emergency consultation and hospitalization than girls.
  • The most common mechanisms of pediatric TBI vary according to age. Falls are the leading cause of TBI in children younger than 14 years of age. Children younger than 4 years of age are injured mainly by falls but are also affected by abusive injuries and motor vehicle accidents.[1]

Characteristics of injury[edit | edit source]

The clinical presentation of children with head injury is extremely variable depending on the severity of trauma. The Pediatric Glasgow Coma Scale (PGCS) is commonly used to assess consciousness and to define the severity of head injuries. Generally, neurological deficits are found at the time of injury, and newly appeared clinical signs may indicate further progression of pathological changes due to head injuries and should be carefully investigated. The following table represents the injury characteristics according to age and development-[1]

Newborns
  • Delivery head injury
  • Intracranial hemorrhages
  • Cephalic hematoma
  • Subgaleal hematoma
Infants
  • Accidental head injury
  • Abusive Head Trauma
Toddlers and School children
  • Accidental head injury
Adolescents
  • Bicycle and motorcycle-related accidents
  • Sports-related head injuries

Classification[edit | edit source]

Head traumas are classified by the nature of the force that causes the injury and the severity of the injury. Forces that cause head trauma are referred to as either impact or inertial forces. Impact forces result from the head striking a surface or a moving object striking the head; these forces most often cause skull fractures, focal brain lesions, and epidural hematomas. Inertial forces are typically the result of rapid acceleration and deceleration of the brain inside the skull resulting in a shearing or tearing of brain tissue and nerve fibers.[2]

Most TBIs are the result of both types of forces. The severity of head injury is rated as a range, from relatively mild concussion to more serious injury. Damage to nervous system tissue occurs both at the time of impact or penetration and through secondary damage.[2]

TBI can result from a primary injury or a secondary injury. Severity of TBI may be categorized as mild, moderate, or severe, based on the extent and nature of injury, duration of loss of consciousness, posttraumatic amnesia (PTA; loss of memory for events immediately following injury), and severity of confusion at initial assessment during the acute phase of injury (Diagnostic and Statistical Manual of Mental Disorders, 5th ed. [DSM-5; American Psychiatric Association, 2013]; CDC, 2015).

  • Mild TBI (mTBI) — loss of consciousness for less than 30 minutes, an initial Glasgow Coma Scale (GCS) or Pediatric GCS of 13–15 after 30 minutes of injury onset, and PTA for not greater than 24 hours (CDC, 2015; McCrory et al., 2013; Ontario Neurotrauma Foundation, 2013).
    • Uncomplicated — mTBI where there are no overt neuroimaging findings.
    • Complicated — mTBI where there are intracranial abnormalities (e.g., bruising or a collection of blood in the brain) seen on CT scan or MRI.
  • Moderate TBI — loss of consciousness and/or PTA for 1–24 hours and a GCS of 9–12 (CDC, 2015).
  • Severe TBI — loss of consciousness for more than 24 hours and PTA for more than 7 days with a GCS of 3–8 (CDC, 2015).[3]

Clinical features[edit | edit source]

In general, primary TBI includes-

  • Extra-parenchymal injury -epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and intraventricular hemorrhage
  • Intra-parenchymal injury - intracerebral hemorrhage, diffuse axonal injury [DAI], and intracerebral hematoma
  • Vascular injury -vascular dissection, carotid artery-cavernous sinus fistula, dural arteriovenous fistula, and pseudo-aneurysm[1]

Physical signs and symptoms-[edit | edit source]

  • Changes in bowel and bladder function
  • Changes in level of consciousness, ranging from brief loss of consciousness to coma
  • Dizziness
  • Fatigue
  • Headaches
  • Impaired movement, balance, and/or coordination
  • Motor speed and programing deficits (dyspraxia/apraxia)
  • Nausea
  • Pain
  • Reduced muscle strength (paresis/paralysis)
  • Seizures
  • Vomiting[3]

Other signs and symptoms-[edit | edit source]

  • audio-vestibular
  • visual
  • cognitive(attention,executive functioning, information processing,memory and learning,metacognition)
  • speech, language and voice
  • feeding and swallowing
  • behavioral and emotional

In infants and toddlers with TBI[edit | edit source]

  • Changes in the ability to pay attention
  • Changes in eating or nursing habits
  • Changes in play (e.g., loss of interest in favorite toys/activities)
  • Changes in sleeping habits
  • Irritability, persistent crying, and inability to be consoled
  • Lethargy
  • Loss of acquired language
  • Loss of new skills, such as toilet training
  • Sensitivity to light and/or noise
  • Unsteady walking, loss of balance

Medical management[edit | edit source]

Medical treatment for moderate and severe TBIs includes close monitoring and control of cerebral circulation and intracranial pressure through the use of sophisticated devices and control systems. If the intracranial pressure cannot be controlled by traditional means, a large dose of barbiturate (e.g., phenobarbital) may be administered. If this fails to control the pressure, lowering the body temperature may help.

Withdrawal from the barbiturate and body temperature treatments is difficult and may cause sleep disturbances, behavioral problems, apnea, and diminished intellectual functioning.Fortunately, most children who sustain a head injury have only a minor TBI (score of 13 to 15 on the GCS). Children with residual minor head injury deficits may require educational support, environmental modifications, and psychologic support.

In most cases, the prognosis for these children is very good.Children who have sustained moderate or severe brain injuries typically follow a behavioral pattern of gradual and full return to consciousness. Depending on the severity of damage,the individual initially does not respond to any external stimuli or responds in a stereotypic manner. Only a small number of children remain in comas.

At the first stage of recovery, children exhibit eye opening to external stimuli and generalized responses to noxious stimuli. The next stage of recovery can be the most difficult for family members because the individual is often agitated and combative; however, the child is rarely aware of his or her actions. As the agitation resolves, the child demonstrates increasingly appropriate responses to commands, ability to attend and concentrate, and recognition of family members. As the child progresses, intervention becomes more functional and goal oriented.[2]

Rehabilitation[edit | edit source]

An interdisciplinary approach is essential. Following stabilization and prevention of secondary complications, patients should receive physical therapy, occupational therapy, speech therapy, and neuropsychological testing. Rehabilitation will include teaching of strategies to compensate for impaired or lost functions and for optimization of the use of abilities as they return. Partnering with a child’s school is paramount to making sure the child receives the services needed to achieve academically in a safe and appropriate manner.[4]

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 Araki T, Yokota H, Morita A. Pediatric traumatic brain injury: characteristic features, diagnosis, and management. Neurologia medico-chirurgica. 2016:ra-2016.
  2. 2.0 2.1 2.2 2.3 2.4 Case-Smith, J. and O'Brien, J. (n.d.). Occupational therapy for children. 6th ed. Mosby Elsevier, pp.167-168.
  3. 3.0 3.1 https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942939&section=Overview
  4. https://www.aapmr.org/about-physiatry/conditions-treatments/pediatric-rehabilitation/pediatric-brain-injury