Traumatic Brain Injury in Paediatrics
Original Editor - Jayati Metha
Traumatic brain injury is a leading cause of death and disability in children. Although children have better survival rates than adults with traumatic brain injury, the long-term sequelae and consequences are often more devastating in children because of their age and developmental potential. They can 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. Evidence suggests that children exhibit a specific pathological response to traumatic brain injury with distinct accompanying neurological symptoms, and considerable efforts have been made to elucidate their pathophysiology. In addition, recent technical advances in diagnostic imaging of traumatic brain injury in paediatrics has facilitated accurate diagnosis, appropriate treatment, prevention of complications, and helped predict long-term outcomes. The costs involved in the care of a child with severe traumatic brain injury, extended over the individual’s lifetime, are significant.
- 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 hospitalised.
- 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.
- Hospitalisation for traumatic brain injury was most commonly observed in adolescents (129 per 100,000).
- More boys were found to undergo emergency consultation and hospitalisation than girls.
- The most common mechanisms of traumatic brain injury in paediatrics vary according to age. Falls are the leading cause of traumatic brain injury 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.
Characteristics of injury
The clinical presentation of children with a brain injury is extremely variable depending on the severity of trauma. The Paediatric 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 brain injuries and should be carefully investigated. The following table represents the injury characteristics according to age and development.
|Age||Type of Injury|
|Toddlers and School Children||
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 haematomas. 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 fibres.
Most traumatic brain injuries 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.
Traumatic brain injury can result from a primary injury or a secondary injury. Severity of traumatic brain injury may be categorised as mild, moderate, or severe, based on the extent and nature of injury, duration of loss of consciousness, Post Traumatic 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 Traumatic Brain Injury (mTBI) is a loss of consciousness for less than 30 minutes, an initial Glasgow Coma Scale (GCS) or Paediatric GCS of 13 - 15 after 30 minutes of injury onset, and Post Traumatic Amnesia 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 Traumatic Brain Injury is a loss of consciousness and/or Post Traumatic Amnesia for 1 - 24 hours and a GCS of 9 - 12 (CDC, 2015).
- Severe Traumatic Brain Injury is a loss of consciousness for more than 24 hours and Post Traumatic Amnesia for more than 7 days with a GCS of 3 - 8 (CDC, 2015).
In general, Primary Traumatic Brain Injury includes:
- Extra-parenchymal Injury, which may include epidural haematoma, subdural haematoma, subarachnoid haemorrhage, and intraventricular haemorrhage
- Intra-parenchymal Injury, which may include intracerebral haemorrhage, diffuse axonal injury [DAI], and intracerebral haematoma
- Vascular Injury, which may include vascular dissection, carotid artery-cavernous sinus fistula, dural arteriovenous fistula, and pseudo-aneurysm 
Physical Signs and Symptoms
- Changes in Level of Consciousness, ranging from brief loss of consciousness to coma
- Impaired Movement, Balance, and/or Coordination
- Motor Speed and Programming Deficits (Dyspraxia/Apraxia)
- Reduced Muscle Strength (Paresis/Paralysis)
- Changes in Bowel and Bladder Function 
Other Signs and Symptoms
- Cognitive (Attention, Executive Functioning, Information Processing, Memory and Learning, Metacognition)
- Speech, Language and Voice
- Feeding and Swallowing
- Emotional 
In Infants and Toddlers
- Changes in the ability to pay attention
- Changes in eating or nursing habits
- Changes in play (e.g., loss of interest in favourite toys/activities)
- Changes in sleeping habits
- Irritability, persistent crying, and inability to be consoled
- Loss of acquired language
- Loss of new skills, such as toilet training
- Sensitivity to light and/or noise
- Unsteady walking, loss of balance
Medical treatment for children with moderate and severe traumatic brain injury 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, behavioural problems, apnea, and diminished intellectual functioning. Fortunately, most children who sustain a head injury have only a minor traumatic brain injury (score of 13 to 15 on the GCS). Children with residual minor traumatic brain 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 traumatic brain injuries typically follow a behavioural 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 generalised 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 their 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. A systematic review of randomized controlled trials suggests better outcomes with noninvasive brain stimulation (NIBS) of the paediatric patient's with brain injury. Significant improvement was seen on upper extremity functions, balance, gait parameters.
An interdisciplinary approach is essential. Following stabilisation 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 optimisation 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.
Working with Traumatic Brain Injury - Toolkit F: Paediatric Brain Injury Rehabilitation Resources - This Toolkit includes a wide range of resources relevant for paediatric brain injury rehabilitation. There are more than 180 different resources.
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