Vegetative state following coma in childhood: evolution and outcome

Defining catastrophic brain injury in children leading to coma and disorders of consciousness and the scope of the problem

PURPOSE OF REVIEW

Severe brain injury in children resulting in coma and disorders of consciousness (DOC) is a catastrophic event for the life and function of children and their families. The present article summarizes the recently published pediatric literature on validated diagnostic assessments, potential predictors of recovery, and outcome measures used in children with catastrophic brain injury (CBI). Literature search terms included variants of consciousness, diagnostic tests, predictors of outcome, and outcome measures.

RECENT FINDINGS

Developmentally appropriate diagnostic tools, outcome predictors, and outcome measures are lacking for children with CBI leading to coma and DOC. Individual case prognosis relies on serial clinical examinations and experience. Evidence regarding optimal diagnosis of the highest level of consciousness and management of children with CBI is needed. Global efforts through the ongoing Curing Coma Campaign are aimed at: developing common data elements for information capture; streamlining the classification of coma endotypes; describing trajectories with biomarkers to monitor recovery or disease progression; and devising effective treatments for adults and children.

SUMMARY

Standardized, developmentally appropriate diagnostic and outcome assessments for CBI in children are needed. Future research should use these content standards to update our understanding of children with CBI leading to coma and DOC, and evaluate effective practices using acute adjunctive and rehabilitation therapies.

Recovery from vegetative state of patients with a severe brain injury: a 4-year real-practice prospective cohort study

Patients who have suffered severe traumatic or nontraumatic brain injuries can show a progressive recovery, transitioning through a range of clinical conditions. They may progress from coma to a vegetative state (VS) and/or a minimally conscious state (MCS). A longer duration of the VS is known to be related to a lower probability of emergence from it; furthermore, the literature seems to lack evidence of late improvements in these patients. This real-practice prospective cohort study was conducted in inpatients in a VS following a severe brain injury, consecutively admitted to a vegetative state unit (VSU). The aim of the study was to assess their recovery in order to identify variables that might increase the probability of a VS patient transitioning to MCS. Rehabilitation treatment included passive joint mobilisation and helping/placing patients into an upright sitting position on a tilt table. All the patients underwent a specific assessment protocol every month to identify any emergence, however late, from the VS. Over a 4-year period, 194 patients suffering sequelae of a severe brain injury, consecutively seen, had an initial Glasgow Coma Scale score ≤ 8. Of these, 63 (32.5%) were in a VS, 84 (43.3%) in a MCS, and 47 (24.2%) in a coma; of the 63 patients admitted in a VS, 49 (57.1% males and 42.9% females, mean age 25.34 ± 19.12 years) were transferred to a specialist VSU and put on a slow-to-recover brain injury programme. Ten of these 49 patients were still in a VS after 36 months; of these 10, 3 recovered consciousness, transitioning to a MCS, 2 died, and 5 remained in a VS during the last 12 months of the observation. Univariate analysis identified male sex, youth, a shorter time from onset of the VS, diffuse brain injury, and the presence of status epilepticus as variables increasing the likelihood of transition to a MCS. Long-term monitoring of patients with chronic disorders of consciousness should be adequately implemented in order to optimise their access to rehabilitation services.

Infant Videofluoroscopic Swallow Study Testing, Swallowing Interventions, and Future Acute Respiratory Illness

OBJECTIVES

Tube feedings are commonly prescribed to infants with swallowing abnormalities detected by videofluoroscopic swallow study (VFSS), but there are no studies demonstrating efficacy of these interventions to reduce risk of acute respiratory illness (ARI). We sought to measure the association between swallowing interventions and future ARI, among VFSS-tested infants.

METHODS

Retrospective cohort of all infants (<12 months) tested with VFSS at a children's hospital between January 1, 2010, and January 1, 2012. Hospital ARI encounters (emergency, observation, or inpatient status) in a 22-hospital integrated health care delivery system, between the first VFSS and age 3 years, were measured. VFSS results were grouped by normal, intermediate, and oropharyngeal aspiration (OPA), with OPA further subdivided by silent versus cough and thin versus thick liquid OPA. Cox regression modeled the association between swallowing interventions (thickened or nasal tube feedings) and ARI, accounting for changes in swallowing and interventions over time.

RESULTS

576 infants were tested with a VFSS in their first year of life, receiving a total of 1051 VFSSs in their first 3 years of life. More than 60% of infants received a measured feeding intervention. With the exception of infants with silent OPA who received thickened feedings, neither thickening nor nasal tube feedings, compared with no intervention, were associated with a decreased risk of subsequent ARI.

CONCLUSIONS

Swallowing interventions and repeated testing are common among VFSS-tested infants. However, the importance of diagnosing and intervening on VFSS-detected swallowing abnormalities for the majority of tested infants remains unclear.

Pediatric feeding and swallowing disorders after bone marrow transplant

Reduced oral intake is a known complication of bone marrow transplant (BMT) and may result in short-term tube feedings. Although most children return to typical eating habits, a subgroup of children requires intervention. The focus of the current investigation was to retrospectively identify the incidence and characteristics of feeding and swallowing disorders in pediatric patients during the first 100 days after BMT and to determine what factors contribute to feeding/swallowing disorders past the BMT acute phase (100+ d). The charts of 292 sequential patients undergoing BMT were reviewed. Seventy-two children (25%) were referred for feeding and/or swallowing intervention with a mean age of 78.6 months (SD=±63.4). Sixteen patients underwent instrumental evaluation with swallowing dysfunction identified in 50% (n=8) of the patients. Oral-motor dysfunction was reported in 33% (n=24) and feeding disorders occurred in 61% (n=44) of the patients referred for treatment. This single-institution review describes the impact of this interruption in the first 100 days after transplant on feeding and swallowing and determined what factors place a child at an increased risk for requiring tube feeding for 100+ days after transplant. The type of BMT, the use of a tube during the first 100 days, and the age were all significant predictors of requiring a tube when considered together for the individual patient. Children who do not require a tube in the first 100 days are significantly less likely to require one in future, approximately 85% less likely to require one whereas children receiving an autologous transplant are approximately 70% less likely to require a tube than children receiving an allogenic transplant. Providers should consider an intervention for younger children undergoing BMT to help maintain or facilitate the development of their feeding and swallowing skills. This may lead to improved feeding outcome in the pediatric BMT population.

Cardiac arrest and post resuscitation of the brain

Primary out-of-hospital cardiac arrest in childhood is rare but survival is a little better for children than for adults, although the prognosis for infants is very poor. Hypoxic-ischaemic encephalopathy after in-hospital cardiac arrest in children undergoing complicated treatment for previously untreatable conditions is now a common problem and is probably increasing. An additional ischaemic insult worsens the prognosis for other encephalopathies, such as that occurring after accidental or non-accidental head injury. For near-drowning, the prognosis is often good, provided that cardiopulmonary resuscitation (CPR) is commenced immediately, and the child gasps within 40 minutes of rescue and regains consciousness soon afterwards. The prognosis is much worse for the nearly drowned child admitted to casualty or the emergency room deeply unconscious with fixed dilated pupils, requiring continuing CPR and with an arterial pH <7, especially if there is little recovery by the time of admission to the intensive care unit. The use of adrenaline, sodium bicarbonate and calcium appears to worsen prognosis. Neurophysiology, specifically serial electroencephalography and evoked potentials, is the most useful tool prognostically, although neuroimaging and biomarkers may play a role. In a series of 89 patients studied after cardiac arrest in three London centres between 1982 and 1985, 39% recovered consciousness within one month. Twenty seven percent died a cardiac death whilst in coma, and the outcome in the remainder was either brain death or vegetative state. EEG and initial pH were the best predictors of outcome in this study. Seizures affected one third and were associated with deterioration and worse outcome. The advent of extracorporeal membrane oxygenation (ECMO) and the positive results of hypothermia trials in neonates and adults have rekindled interest in timely management of this important group of patients.

Salivary gland surgery for control of chronic pulmonary aspiration in children with cerebral palsy

OBJECTIVE

To evaluate the outcome of surgical saliva reduction to decrease pulmonary aspiration in children with cerebral palsy and its repercussions in respiratory infection control.

METHODS

Twenty-nine children with neurological impairment and diagnosis of chronic pulmonary aspiration were submitted to bilateral submandibular gland excision and bilateral parotid duct ligation at the Association for the Welfare of Physically Handicapped Children, from December 2001 to December 2004. Postoperative frequency of lower respiratory tract infection, hospitalization rate due to pulmonary infection and airway secretion level after the surgery were compared to preoperative period.

RESULTS

Twenty-nine children with cerebral palsy aged 18 months to 9 years were submitted to submandibular glands excision and parotid ducts ligation. All children had gastrostomy and no oral intake. There were no major complications; two children had reopening of one parotid duct. Frequency of lower respiratory tract infections, rate of hospitalization for treatment of pulmonary infections and level of airway secretion were statistically reduced. Preoperative mean rate of lower respiratory tract infection was 6.9/year; in postoperative period, rate was 2.4/year (p<0.001). Pneumonia hospitalization mean rate was 63.4 days/year preoperatively and 17.5 days/year postoperatively (p<0.001). There was also a significant improvement in the need for suctioning of upper airway secretion (mean 11 times/day in preoperative period and 3.1 times/day in the postoperative period; p<0.001).

CONCLUSION

In children with cerebral palsy, surgical saliva reduction by submandibular glands excision and parotid ducts ligation is an effective and safe technique for frequency reduction of lower respiratory tract infection and level of airway secretion.

Aspiration lung disease

The term aspiration lung disease describes several clinical syndromes, with massive aspiration and chronic lung aspiration being at two extremes of the clinical spectrum. Over the years, significant advances have been made in understanding the mechanisms underlying dysphagia, gastroesophageal function, and airway protective reflexes and new diagnostic techniques have been introduced. Despite this, characterizing the presence or absence of aspiration, and under what circumstances a child might be aspirating what, is extremely challenging. Many children are still not adequately diagnosed or treated for aspiration until permanent lung damage has occurred. A multidisciplinary approach is mandatory for a correct diagnosis in addition to timely and appropriate care.

Children and young adults in a prolonged unconscious state due to severe brain injury: outcome after an early intensive neurorehabilitation programme

PRIMARY OBJECTIVE

The Rehabilitation Centre Leijpark in The Netherlands provides an Early Intensive Neurorehabilitation Programme (EINP) to children and young adults in a prolonged unconscious state after severe brain injury. In an extensive research project the effects of EINP were studied. This part of the project focused on the outcome in terms of level of consciousness (LOC) in relation to the specific characteristics of a retrospectively studied cohort.

RESEARCH DESIGN

This study was executed according to a one-group archived pre-test-post-test design.

SUBJECTS

Subjects were all consecutively admitted patients (n=145, 72% male) between December 1987-January 2001. Inclusion criteria were: age 0-25 years, within 6 months after injury, LOC at admission vegetative state (VS) or minimally conscious state (MCS). One hundred and four patients (72%) suffered a traumatic injury and 41 patients (28%) a non-traumatic injury.

METHODS AND PROCEDURES

All patients had received EINP until they reached consciousness or until it was concluded that no progress was achieved during 3 months after the start of EINP. Medical files were investigated to collect the patients' characteristics and injury data, to determine the LOC at admission and at discharge and to determine the discharge destination.

RESULTS

Almost two-thirds of the patients reached full consciousness. LOC at admission, aetiology and interval since injury were found to be significant prognostic factors. Traumatic patients had a much better outcome than non-traumatic patients. A comparison with earlier outcome studies showed a more favourable outcome than expected. It is argued that a multi-centre study is needed to confirm possible effects of EINP.

Incidence, aetiology, and outcome of non-traumatic coma: a population based study

AIM

To determine the incidence, presentation, aetiology, and outcome of non-traumatic coma in children aged between 1 month and 16 years.

METHODS

In this prospective, population based, epidemiological study in the former Northern NHS region of the UK, cases were notified following any hospital admission or community death associated with non-traumatic coma. Coma was defined as a Glasgow Coma Score below 12 for more than six hours.

RESULTS

The incidence of non-traumatic coma was 30.8 per 100 000 children under 16 per year (6.0 per 100 000 general population per year). The age specific incidence was notably higher in the first year of life (160 per 100 000 children per year). CNS specific presentations became commoner with increasing age. In infants, nearly two thirds of presentations were with non-specific, systemic signs. Infection was the commonest overall aetiology. Aetiology remained unknown in 14% despite extensive investigation and/or autopsy. Mortality was highly dependent on aetiology, with aetiology specific mortality rates varying from 3% to 84%. With follow up to approximately 12 months, overall series mortality was 46%.

Patient selection for primary laryngotracheal separation as treatment of chronic aspiration in the impaired child

Chronic aspiration in the neurologically impaired child is associated with significant medical and social complications. Traditional surgical management has often relied on tracheotomy. This may well fail to control aspiration. The purpose of this retrospective study was to determine which neurologically impaired children would benefit from a laryngotracheal separation (LTS), as opposed to tracheotomy, as the primary surgical procedure to control chronic salivary aspiration. Patient selection was based on neurologic status, verbal communication ability, likelihood of neurologic recovery, and failure of previous treatments to control aspiration. Nineteen neurologically impaired children aged 8-172 months with chronic salivary aspiration underwent LTS. A total of 73.6% of these patients had prior tracheotomies, yet they continued to aspirate. Two early and three late complications were noted. No instances of fistula formation were noted. There were no deaths related to complications of the surgery or persistent aspiration. Follow-up 1-62 months after surgery demonstrated that complete control of the aspiration was achieved in all of these children. Two of the children who had achieved verbal communication prior to the procedure lost this ability. Improved general health and ability to resume oral intake was noted in all patients. This, combined with a decrease in the need of frequent suctioning, was felt by the families of these children to be a major improvement in the quality of life. Laryngotracheal separation appears to be a simple and effective means of controlling chronic aspiration. It should be considered as a primary treatment of aspiration in the properly selected child with neurologic disease.

Post-traumatic apallic syndrome following head injury. Part 1: clinical characteristics

Epidemiological studies made within the western countries indicate an incidence of 200-300 traumatic head injuries per 100 000 residents each year. Severe head injuries account for 5-25% of all head injuries; 10-14% of all severe head-injured patients develop into a vegetative state, in which a sleep-wake rhythm is apparent, but however in which there is no evidence of awakeness or reactivity to the environment. The most commonly used labels, in the German and international literature, for these patients are 'vegetative state', 'apallic syndrome' and 'coma vigile'. This clinical characterization is not sufficient. It is necessary to employ additional criteria to distinguish subsets of vegetative patients e.g. computerized tomography, magnetic resonance imaging, single photon emission tomography, electroencephalography, brainstem reflexes, evoked potentials, assessment scales, age, premorbid brain disorders. Diagnostic and prognostic parameters must form the basis for various decisions relating to patients' care and intervention.

Medical aspects of the persistent vegetative state (1)

This consensus statement of the Multi-Society Task Force summarizes current knowledge of the medical aspects of the persistent vegetative state in adults and children. The vegetative state is a clinical condition of complete unawareness of the self and the environment, accompanied by sleep-wake cycles, with either complete or partial preservation of hypothalamic and brain-stem autonomic functions. In addition, patients in a vegetative state show no evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli; show no evidence of language comprehension or expression; have bowel and bladder incontinence; and have variably preserved cranial-nerve and spinal reflexes. We define persistent vegetative state as a vegetative state present one month after acute traumatic or nontraumatic brain injury or lasting for at least one month in patients with degenerative or metabolic disorders or developmental malformations. The clinical course and outcome of a persistent vegetative state depend on its cause. Three categories of disorder can cause such a state: acute traumatic and non-traumatic brain injuries; degenerative and metabolic brain disorders, and severe congenital malformations of the nervous system. Recovery of consciousness from a posttraumatic persistent vegetative state is unlikely after 12 months in adults and children. Recovery from a nontraumatic persistent vegetative state after three months is exceedingly rare in both adults and children. Patients with degenerative or metabolic disorders or congenital malformations who remain in a persistent vegetative state for several months are unlikely to recover consciousness. The life span of adults and children in such a state is substantially reduced. For most such patients, life expectancy ranges from 2 to 5 years; survival beyond 10 years is unusual.

Outcome of severe anoxic/ischemic brain injury in children

The outcome of 25 children who had anoxic or ischemic brain injuries at 2 months to 14 years of age is reported. Follow-up was from 1 to 14 years after injury; causes were near-drowning, 11; suffocation, 7; cardiac arrest, 3; electrocution with cardiac arrest, 2; strangulation, 1; aborted sudden infant death syndrome, 1. All patients were unconscious for at least 24 hours. Of 11 remaining in vegetative states, 5 died. Seven children regained some language skills and are in special education or self-contained classrooms. Seven are profoundly impaired and show only a social smile. Cognitive and motor outcomes were correlated with the severity of injury as indicated by the duration of unconsciousness. All children who regained language skills or the ability to walk were unconscious less than 60 days. Dystonic rigidity was observed in all children who were nonambulatory. Outcome was also correlated with the cause of injury; mortality, cognitive outcome, feeding outcome, and duration of unconsciousness were all worse in children with near-drowning.

Outcome of children with prolonged unconsciousness and vegetative states

The outcomes of 60 children unconscious for 90 days or longer following acquired brain injury are reported. Eight children who died had remained in persistent vegetative states. As expected, most neurologic improvement occurred within the first year after injury, although some delayed improvements were observed. Outcomes were strongly correlated with causes of brain injury. Better cognitive and motor function was observed with nonanoxic injuries. No child in this report with anoxic brain injury regained functional cognitive or motor skills, although 3 became socially responsive. The remarkable contrast with adults following acquired brain injury is the significantly longer survival of children. The only children who died had remained in persistent vegetative states.

The persistent vegetative state in children: report of the Child Neurology Society Ethics Committee

Increasing concern about children in a persistent vegetative state (PVS) prompted a survey of members of the Child Neurology Society regarding aspects of the diagnosis and management of this disorder. Major findings of those responding to this survey (26% response rate) were as follows: (1) 93% believed that a diagnosis of PVS can be made in children, but only 16% believed that this applied to infants younger than 2 months and 70% in the 2-month to 2-year group; (2) a period of 3 to 6 months was believed to be the minimum observation period required before a diagnosis of PVS could be made; (3) 86% believed that the age of the patient would affect the duration of time needed to make the diagnosis of PVS; (4) 78% thought a diagnosis of PVS could be made in children with severe congenital brain malformations; (5) 75% believed that neurodiagnostic studies would be of value and supportive of the clinical diagnosis of PVS; (6) members' opinions as to the average life expectancy (in years) for the following age groups after the patients were considered vegetative were: newborn to 2 months, 4.1; 2 months to 2 years, 5.5; 2 to 7 years, 7.3; and more than 7 years, 7.4; (7) 20% believed that infants and children in a PVS experience pain and suffering; and (8) 75% "never" withhold fluid and nutrition from infants and children in a PVS and 28% "always" give medication for pain and suffering.(ABSTRACT TRUNCATED AT 250 WORDS)

Recovery of cognition from persistent vegetative state in a child with normal somatosensory evoked potentials

The absence of bilateral early cortical SEPs in a PVS due to nontraumatic coma is usually associated with failure to recover cognition or awareness, although rarely patients with bilaterally absent cortical SEPs in posttraumatic PVS may regain cognition. On the other hand, normal cortical SEPs in nontraumatic coma may be related to favorable outcomes as shown in this patient and other reports. Our patient is unique in that he had had serial normal SEPs, was in a PVS for 7 1/2 months, and recovered cognition, but not without cost in terms of damage to intellectual capability. Further long-term clinical follow-up studies to correlate clinical outcome with serial SEP data may be indicated.

Laryngeal diversion in the treatment of chronic aspiration in children

Chronic aspiration in children can be life-threatening, especially in patients with underlying pulmonary disorders. Numerous surgical procedures have been described to treat chronic aspiration. In patients with severe chronic aspiration, laryngeal diversion is the most effective procedure for reducing soilage of the pulmonary tract. Over a 10-year period at the Children's Hospital of Philadelphia, 14 patients with life-threatening aspiration were managed with a laryngeal diversion. Surgical correction of aspiration resulted in stabilization or improvement of pulmonary function in these patients. The surgical management of chronic aspiration in the pediatric patient is discussed.

The Linares affair

On August 2, 1988, 6-month-old Samuel Linares aspirated a balloon at a birthday party and was unconscious and blue when his father, Rudolfo, found him. Nine months later, his father used a gun to keep medical staff at bay while he disconnected the respirator keeping his comatose son alive. Mr. Linares ignited much soul-searching among pediatricians, lawyers, and ethicists about treatment decisions for profoundly damaged children.

Public discussion of the ethics of forgoing life support in pediatric care moves like a pendulum betweeen fear of inappropriately allowing children to die and fear of unrestrained life-supporting technology. In the early 1970s, physicians’ and theologians challenged accepted tenets of law and ethics by proposing that pediatricians should allow critically ill or severely disabled babies to die without the most aggressive use of technology. By 1982, Baby Doe caught the nation's moral imagination and raised the possibility that withholding or withdrawing life-sustaining procedures amounted to sanctioned infanticide. This concern led to restrictions on the right of parents and doctors to decide to discontinue treatment. Public sympathy for Mr. Linares suggests that the pendulum may be swinging back toward a less restrictive public policy about forgoing life-sustaining treatment in children.

Laryngotracheal separation for intractable aspiration

Intractable aspiration may be a life-threatening problem for patients with altered laryngeal function secondary to neurologic disorders or abnormal laryngeal anatomy. Multiple surgical procedures have been devised to deal with this problem. An effective technique involves the creation of a tracheostoma and closure of the larynx at the first or second tracheal ring. Laryngotracheal separation is relatively easy to perform and potentially reversible. Experience with this technique in six patients who required laryngeal separation for intractable aspiration is described. The procedure was successful in preventing aspiration and recurrent pneumonia associated with neurologic dysfunction, unresectable neoplasm, and conservation laryngeal surgery. One patient of one has had a successful reconstruction.

CT appearance of children in a persistent vegetative state

A morphometric CT study was performed on 17 children who were in a persistent vegetative state. Four cases with compromised brain stem function (group 1) showed a significantly smaller lateral pontine ratio (LPR, width of pons/greatest internal diameter between temporal bone) than the remaining 13 cases with preserved brain stem function (group 2) and controls. LPR was considered a useful indicator of brain stem atrophy and to correlate well with brain stem function.