Outcomes following childhood head injury: a population study

Association of concussion/brain injury symptoms and diagnosis with mental and social well-being in 2020 National Health Interview Survey (NHIS) children

BACKGROUND

Population-based data regarding the associations between prior concussion or brain injury symptoms/diagnosis and mental/social well-being is lacking for U.S. children.

METHODS

Associations between prior concussion or brain injury symptoms/diagnosis (reported by parents of children ages 5-17 from the 2020 National Health Interview Survey) and current mental/social well-being were determined in multivariable models.

RESULTS

Amongst 2020 US children, 8.7% and 5.3% had previous symptoms and diagnosis of concussion/brain injury, respectively. 23% of children with symptoms were never checked for a concussion/brain injury, with younger children at higher risk of not getting checked after symptomatic head trauma. Prior concussion or brain injury symptoms/diagnosis was associated with a higher likelihood of current depressive symptoms (odds ratio [OR] = 1.60; 95% CI = 1.21-2.14; p < 0.001), anxiety (OR = 2.07; 95% CI = 1.52-2.82; p < 0.001), difficulty making friends (OR = 1.57; 95% = 1.06-2.33; p = 0.03), use of medications for mental/social/behavioral issues (OR = 1.69; CI = 1.21-2.36; p = 0.002), and mental health therapy/counseling (OR = 1.52; 95% CI = 1.13-2.04; p = 0.006).

CONCLUSION

U.S. children with prior concussion or brain injury symptoms/diagnosis have a higher rate of mental and social disturbances and a more frequent need for mental health services. Nearly one-quarter of children with significant symptoms after head trauma are never checked for a concussion/brain injury; routine concussion evaluation after head trauma should be emphasized especially in younger children.

Childhood Physical Health and Attention Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis of Modifiable Factors

Although neurobiologic and genetic factors figure prominently in the development of attention deficit/hyperactivity disorder (ADHD), adverse physical health experiences and conditions encountered during childhood may also play a role. Poor health is known to impact the developing brain with potential lifelong implications for behavioral issues. In attempt to better understand the relationship between childhood physical health and the onset and presence of ADHD symptoms, we summarized international peer-reviewed articles documenting relationships between a select group of childhood diseases or health events (e.g., illnesses, injuries, syndromes) and subsequent ADHD outcomes among children ages 0-17 years. Drawing on a larger two-phase systematic review, 57 longitudinal or retrospective observational studies (1978-2021) of childhood allergies, asthma, eczema, head injury, infection, or sleep problems and later ADHD diagnosis or symptomatology were identified and subjected to meta-analysis. Significant associations were documented between childhood head injuries, infections, and sleep problems with both dichotomous and continuous measures of ADHD, and between allergies with dichotomous measures of ADHD. We did not observe significant associations between asthma or eczema with ADHD outcomes. Heterogeneity detected for multiple associations, primarily among continuously measured outcomes, underscores the potential value of future subgroup analyses and individual studies. Collectively, these findings shed light on the importance of physical health in understanding childhood ADHD. Possible etiologic links between physical health factors and ADHD are discussed, as are implications for prevention efforts by providers, systems, and communities.

Incidence, and factors associated with moderate/severe pediatric traumatic brain injury in children aged 5-15 years in western, Mexico

OBJECTIVE

The study objectives were to estimate the standardized incidence and evaluate factors associated with moderate/severe pediatric traumatic brain injury (p-TBI) in children aged 5-15 years in Western, Mexico.

METHODS

The study was cross-sectional in design. We estimated the standardized incidence of moderate/severe p-TBI using the direct methods of the World Health Organization (WHO) standard populations. We utilized the Glasgow Coma Scale (GCS) to identify moderate/severe p-TBI patients (GCS ≤ 13). Logistic regression analysis was applied to evaluate variables associated with moderate/severe p-TBI.

RESULTS

The standardized incidence of patients diagnosed with moderate/severe p-TBI was 31.0/100,000 person-years (95 % CI 28.7-33.4). According to age, the moderate/severe TBI group was included. A total of 254 (38.5 %) patients were aged 5-9 years, 343 (52.0 %) were aged 10-14 years, and 62 (9.5 %) were aged 15 years. Factors associated with moderate/severe TBI in the crude analysis were male sex (OR 5.50, 95 % CI 4.16-7.39, p < 0.001), primary school (OR 2.15, 95 % CI 1.62-2.84, p < 0.001), and falls (OR 1.34, 95 % CI 1.02-1.77, p = 0.035). Factors associated with moderate/severe p-TBI in the adjusted analysis were male sex (OR 6.12, 95 % CI 4.53-8.29, p < 0.001), primary school (OR 3.25, 95 % CI 2.31-4.55, p < 0.001), and falls (OR 1.78, 95 % CI 1.28-2.47, p < 0.001).

CONCLUSION

The incidence of moderate/severe p-TBI in children aged 5-15 years in western Mexico in this study was higher than that in other studies. One of the biggest factors associated with moderate/severe p-TBI was male sex, specifically those with lower education levels and those who were prone to falls.

Decision-Making and Ethical Considerations of Tracheostomy and Chronic Mechanical Ventilation in Children with Acute Neurological Injury

The decisions around whether or not to provide tracheostomy and chronic mechanical ventilation to children with acute neurologic injury are difficult for medical providers and surrogate decision makers. Consideration of the 4 primary principles of medical ethics-autonomy, beneficence, non-maleficence, and justice-can provide a framework from which constructive discussions can form. Determination of the goals of care is a good first step in navigating these complex decisions. A shared decision model should be used, including education of decision-makers by medical providers and appropriate recommendations based on the stated goals of care. In this paper, 2 illustrative cases are discussed highlighting the utility of this decision-making framework.

A Child Presenting with a Glasgow Coma Scale Score of 13: Mild or Moderate Traumatic Brain Injury? A Narrative Review

OBJECTIVE

The objective of this article was to compare children with traumatic brain injury (TBI) and Glasgow Coma Scale score (GCS) 13 with children presenting with GCS 14 and 15 and GCS 9 to 12.

DATA SOURCE

We searched PubMed for clinical studies of children of 0 to 18 years of age with mild TBI (mTBI) and moderate TBI, published in English language in the period of 2000 to 2020.

STUDY SELECTION

We selected studies sub-classifying children with GCS 13 in comparison with GCS 14 and 15 and 9 to 12. We excluded reviews, meta-analyses, non-U.S./European population studies, studies of abusive head trauma, and severe TBI.

DATA SYNTHESIS

Most children (>85%) with an mTBI present at the emergency department with an initial GCS 15. A minority of only 5% present with GCS 13, 40% of which sustain a high-energy trauma. Compared with GCS 15, they present with a longer duration of unconsciousness and of post-traumatic amnesia. More often head computerized tomography scans show abnormalities (in 9-16%), leading to neurosurgical intervention in 3 to 8%. Also, higher rates of severe extracranial injury are reported. Admission is indicated in more than 90%, with a median length of hospitalization of more than 4 days and 28% requiring intensive care unit level care. These data are more consistent with children with GCS 9 to 12. In children with GCS 15, all these numbers are much lower.

CONCLUSION

We advocate classifying children with GCS 13 as moderate TBI and treat them accordingly.

Estimated incidence and case fatality rate of traumatic brain injury among children (0-18 years) in Sub-Saharan Africa. A systematic review and meta-analysis

INTRODUCTION

Studies from Sub-Saharan Africa (SSA) countries have reported on the incidence and case fatality rate of children with Traumatic Brain Injury (TBI). However, there is lack of a general epidemiologic description of the phenomenon in this sub-region underpinning the need for an accurate and reliable estimate of incidence and outcome of children (0-18 years) with TBI. This study therefore, extensively reviewed data to reliably estimate incidence, case fatality rate of children with TBI and its mechanism of injury in SSA.

METHODS

Electronic databases were systematically searched in English via Medline (PubMed), Google Scholar, and Africa Journal Online (AJOL). Two independent authors performed an initial screening of studies based on the details found in their titles and abstracts. Studies were assessed for quality/risk of bias using the modified Newcastle-Ottawa Scale (NOS). The pooled case fatality rate and incidence were estimated using DerSimonian and Laird random-effects model (REM). A sub-group and sensitivity analyses were performed. Publication bias was checked by the funnel plot and Egger's test. Furthermore, trim and fill analysis was used to adjust for publication bias using Duval and Tweedie's method.

RESULTS

Thirteen (13) hospital-based articles involving a total of 40685 participants met the inclusion criteria. The pooled case fatality rate for all the included studies in SSA was 8.0%; [95% CI: 3.0%-13.0%], and the approximate case fatality rate was adjusted to 8.2%, [95% CI:3.4%-13.0%], after the trim-and-fill analysis was used to correct for publication bias. A sub-group analysis of sub-region revealed that case fatality rate was 8% [95% CI: 2.0%-13.0%] in East Africa, 1.0% [95% CI: 0.1% -3.0%] in Southern Africa and 18.0% [95% CI: 6.0%-29.0%] in west Africa. The pooled incidence proportion of TBI was 18% [95% CI: 2.0%-33.0%]. The current review showed that Road Traffic Accident (RTA) was the predominant cause of children's TBI in SSA. It ranged from 19.1% in South Africa to 79.1% in Togo.

CONCLUSION

TBI affects 18% of children aged 0 to 18 years, with almost one-tenth dying in SSA. The most common causes of TBI among this population in SSA were RTA and falls. TBI incidence and case fatality rate of people aged 0-18 years could be significantly reduced if novel policies focusing on reducing RTA and falls are introduced and implemented in SSA.

Application of machine learning to predict the outcome of pediatric traumatic brain injury

PURPOSE

Traumatic brain injury (TBI) generally causes mortality and disability, particularly in children. Machine learning (ML) is a computer algorithm, applied as a clinical prediction tool. The present study aims to assess the predictability of ML for the functional outcomes of pediatric TBI.

METHODS

A retrospective cohort study was performed targeting children with TBI who were admitted to the trauma center of southern Thailand between January 2009 and July 2020. The patient was excluded if he/she (1) did not undergo a CT scan of the brain, (2) died within the first 24 h, (3) had unavailable complete medical records during admission, or (4) was unable to provide updated outcomes. Clinical and radiologic characteristics were collected such as vital signs, Glasgow coma scale score, and characteristics of intracranial injuries. The functional outcome was assessed using the King's Outcome Scale for Childhood Head Injury, which was thus dichotomized into favourable outcomes and unfavourable outcomes: good recovery and moderate disability were categorized as the former, whereas death, vegetative state, and severe disability were categorized as the latter. The prognostic factors were estimated using traditional binary logistic regression. By data splitting, 70% of data were used for training the ML models and the remaining 30% were used for testing the ML models. The supervised algorithms including support vector machines, neural networks, random forest, logistic regression, naive Bayes and k-nearest neighbor were performed for training of the ML models. Therefore, the ML models were tested for the predictive performances by the testing datasets.

RESULTS

There were 828 patients in the cohort. The median age was 72 months (interquartile range 104.7 months, range 2-179 months). Road traffic accident was the most common mechanism of injury, accounting for 68.7%. At hospital discharge, favourable outcomes were achieved in 97.0% of patients, while the mortality rate was 2.2%. Glasgow coma scale score, hypotension, pupillary light reflex, and subarachnoid haemorrhage were associated with TBI outcomes following traditional binary logistic regression; hence, the 4 prognostic factors were used for building ML models and testing performance. The support vector machine model had the best performance for predicting pediatric TBI outcomes: sensitivity 0.95, specificity 0.60, positive predicted value 0.99, negative predictive value 1.0; accuracy 0.94, and area under the receiver operating characteristic curve 0.78.

CONCLUSION

The ML algorithms of the present study have a high sensitivity; therefore they have the potential to be screening tools for predicting functional outcomes and counselling prognosis in general practice of pediatric TBIs.

Activities and Participation in the First 6 Months After Mild Traumatic Brain Injury in Children and Adolescents

OBJECTIVE

To investigate the natural course of activities and participation of children up to 6 months after a mild traumatic brain injury (mTBI).

METHODS

A prospective longitudinal cohort study with complete data sets of 231 children diagnosed with mTBI and their caregivers.

MAIN MEASURES

Activities and participation assessed with the Child and Adolescent Scale of Participation (CASP) and the Children's Assessment of Participation and Enjoyment (CAPE) measured at 2 weeks, 3 months, and 6 months post-mTBI. Because of a ceiling effect, the primary outcome measure (CASP) was divided into deviant (not maximum score) or full functioning.

RESULTS

Friedman's, Cochran's Q, and McNemar's tests (CASP) and repeated-measures analyses of variance (CAPE) showed significant increases in activities and participation between 2 weeks and 3 and 6 months after mTBI. Based on the parents' perspective, 67% of the children returned to full functioning at 6 months postinjury, with only 38% of the children describing themselves as functioning at their premorbid level.

DISCUSSION

Findings indicate that most children return to maximum level of activities and participation over time after mTBI. In a substantial number of children, however, the level of activities and participation at 6 months postinjury is evaluated as lower than that of peers. The importance of investigating predictors for child and caregiver perspectives is emphasized.

Headache long after pediatric concussion: presence, intensity, interference, and association with cognition

Objective: Document headache presence, intensity, and interference after concussion(s), as well as examine its association with cognition.Participants: Participants 8-19 years of age were assessed on average 34 months (SD = 21.5) after an orthopedic injury (OI, n = 29), single concussion (n = 21), or multiple concussions (n = 15).Measures: Headache intensity was rated using the Headache Rating Scale and headache interference was rated using the Post-Concussion Symptom Inventory (PCSI). Cognition was rated using the PCSI and measured using CNS Vital Signs.Results: Type of injury did not differ significantly in headache presence or intensity. However, there was a dose-response relationship found for children's ratings of headache interference, which was rated highest among children with multiple concussions, intermediate among those with single concussion, and lowest among children with OI. Both headache intensity and interference ratings correlated significantly with self and parent ratings of cognition on the PCSI, but not with cognitive test performance.Conclusions: Youth with single or multiple concussions report greater headache interference - but not higher headache intensity - compared to youth without concussion. Although higher headache intensity and interference were associated with more self-reported cognitive symptoms, headaches did not correlate with cognitive test performance.

Predictors of activities and participation six months after mild traumatic brain injury in children and adolescents

OBJECTIVE

This study aimed to identify predictors of long-term consequences for activities and participation in children and adolescents with mild traumatic brain injury (mTBI).

METHODS

A multicentre prospective longitudinal cohort study was conducted. The primary outcome measure was activities and participation measured with the Child and Adolescent Scale of Participation - CASP and completed by children (N = 156) and caregivers (N = 231) six months post-mTBI. The CASP items were categorized into home, community, school, and environment. Predictors were categorized according to the International Classification of Functioning, Disability and Health for Children and Youth. Predictors included pre-injury personal- and environmental factors, injury-related factors, symptoms, and resumption of activities in the first two weeks after mTBI. Univariate and multivariate logistic regression analyses were used to determine the predictive value of these factors.

RESULTS

Results show that predictors differ across settings and perspectives (child or caregiver). Decreased activities and participation in children with mTBI can be predicted by adverse pre-injury behavioral functioning of the child (p < .000 - p = .038), adverse pre-injury family functioning (p = .001), lower parental SES (p = .038), more stress symptoms post-injury (p = .017 - p = .032), more post-concussive symptoms (p = .016 - p = .028) and less resumption of activities (p = .006 - p = .045).

DISCUSSION

Pre-injury factors, more symptoms post-injury and less resumption of activities should be considered when children are screened for unfavorable outcomes. Additional factors may add to the prediction, but injury-related factors do not. It is recommended that future research explores psychosocial factors, such as coping styles, emotion-regulation, personality traits, social support, and other comorbid problems of both children and caregivers.

Anxiety Disorders in Adults With Childhood Traumatic Brain Injury: Evidence of Difficulties More Than 10 Years Postinjury

OBJECTIVE

To explore long-term psychiatric outcomes in individuals with a history of childhood traumatic brain injury (TBI) or orthopedic injury (OI).

SETTING

Hospital emergency department, medical admission records and outpatient settings.

PARTICIPANTS

There were 95 males (M = 22.78 years, SD = 3.44 years) and 74 females (M = 22.27 years, SD = 3.09 years), 65 with mild TBI (M = 23.25 years, SD = 3.58 years), 61 with moderate-severe TBI (M = 22.34 years, SD = 2.79 years), and 43 with OI (M = 21.81 years, SD = 3.36 years).

DESIGN

Longitudinal, between-subjects, cross-sectional design using retrospective and current data.

MAIN MEASURES

Semistructured interview to obtain psychiatric diagnoses and background information, and medical records for identification of TBI.

RESULTS

Group with moderate-severe TBI presented with significantly higher rates of any anxiety disorder (χ2 = 6.81, P = .03) and comorbid anxiety disorder (χ2 = 6.12, P < .05). Group with overall TBI presented with significantly higher rates of any anxiety disorder (χ1 = 5.36, P = .02), panic attacks (χ1 = 4.43, P = .04), specific phobias (χ1 = 4.17, P = .04), and depression (χ1 = 3.98, P < .05). Prediction analysis revealed a statistically significant model (χ7 = 41.84, P < .001) explaining 23% to 37% of the variance in having any anxiety disorder, with significant predictors being group (TBI) and gender (female).

CONCLUSIONS

Children who have sustained a TBI may be vulnerable to persistent anxiety, panic attacks, specific phobias, and depression, even 13 years after the injury event.

Psychological Resilience as a Predictor of Symptom Severity in Adolescents With Poor Recovery Following Concussion

OBJECTIVES

Examine the mediating effects of anxiety and depressive symptoms on the relationship between psychological resilience and post-concussive symptoms (PCS) in children with poor recovery following concussion.

PARTICIPANTS AND METHODS

Adolescents (N=93), ages 13 to 18 years, were assessed at a neuropsychology screening clinic at a children's hospital. They sustained concussions more than 1 month before the clinic visit (median time since injury=5.1 months; range=42-473 days) and were seen on the basis of poor recovery (i.e., presence of persistent PCS and complaints of cognitive problems). Self-reported psychological resilience was measured using the 10-item version of the Connor-Davidson Resilience Scale; self- and parent-reported anxiety and depressive symptoms were measured using the Behaviour Assessment System for Children - Second Edition; and self- and parent-reported PCS were measured using the Post-Concussion Symptom Inventory. All variables were measured concurrently. Regression-based mediation analyses were conducted to examine anxiety and depressive symptoms as mediators of the relationship between psychological resilience and PCS.

RESULTS

Psychological resilience significantly predicted self-reported PCS. Self-reported anxiety and depressive symptoms significantly mediated the relationship between resilience and self-reported PCS, and parent-reported child depressive symptoms significantly mediated the relationship between resilience and self- and parent-reported PCS.

CONCLUSIONS

Psychological resilience plays an important role in recovery from concussion, and this relationship may be mediated by anxiety and depressive symptoms. These results help shed light on the mechanisms of the role of psychological resilience in predicting PCS in children with prolonged symptom recovery. (JINS, 2019, 25, 346-354).

Current State of the Literature on Psychological and Social Sequelae of Sports-Related Concussion in School-Aged Children and Adolescents

Considerably less attention has been paid to psychological and social sequelae of concussion in youth athletes compared with neurocognitive outcomes. This narrative review consolidates the literature on postconcussive emotional and psychosocial functioning in school-aged children and adolescents, highlighting athlete-specific findings. MEDLINE and PsycINFO databases were queried for pediatric concussion studies examining psychological and/or social outcomes, and 604 studies met search criteria (11 of those specific to sport). Results were organized into domains: emotional and social dysfunction, behavioral problems, academic difficulties, sleep disturbance, headache, and quality of life. The small body of literature regarding psychological and social issues following pediatric concussion suggests behavioral disturbances at least temporarily disrupt daily life. Extrapolation from samples of athletes and nonathletes indicates postconcussive anxiety and depressive symptoms appear, although levels may be subclinical. Social and academic findings were less clear. Future well-controlled and adequately powered research will be essential to anticipate concussed athletes’ psychosocial needs.

The Brains Ahead! intervention for children and adolescents with mild traumatic brain injury and their caregivers: rationale and description of the treatment protocol

PURPOSE:

Approximately 20% of the children and adolescents after mild traumatic brain injury will not fully recover. They suffer long-term postconcussive symptoms and may experience limitations in activities and participation. Research suggests that early psychoeducational interventions may prevent long-term postconcussive symptoms. The Brains Ahead! intervention was developed to prevent long-term symptoms and, furthermore, to establish a more successful return to activities and participation after mild traumatic brain injury in children and adolescents. The intervention is currently being evaluated in a multicenter randomized controlled trial.

RATIONALE:

Providing individualized information and personal advice in addition to standardized information about the injury and possible consequences early after the injury may enable patients and caregivers to recognize and anticipate on relevant symptoms at an early stage and to prevent problems in activities and participation.

THEORY INTO PRACTICE:

The Brains Ahead! intervention is a psychoeducational intervention for children and adolescents who sustained a mild traumatic brain injury and for their caregivers. The patients will receive a partially standardized and partially individualized psychoeducational session and a telephone follow-up within the first two to eight weeks after the injury.

Predictors of Long-Term Psychosocial Functioning and Health-Related Quality of Life in Children and Adolescents With Prior Concussions

OBJECTIVES

Individual differences in long-term psychosocial functioning after concussions in children and adolescents are poorly understood. The aim of the study was to investigate potential predictors of long-term psychosocial functioning and health-related quality of life in youth after prior concussion.

METHODS

Participants (N=75; mean age=14.3 years old; 52% girls) with one prior concussion (n=24), multiple prior concussions (n=24), or a prior orthopedic injury and no concussion (n=27) were seen on average 2.7 years after their most recent injury. Psychosocial functioning was assessed using the self-report versions of the Behavior Assessment System for Children (BASC-2; Anxiety and Depression scales only), the Strengths and Difficulties Questionnaire, and the Pediatric Quality of Life Inventory TM 4.0. Pre-existing conditions (attention problems, learning difficulties, mood concerns, anxiety concerns, and migraines) were reported by parents using a checklist and examined as predictors of long-term functioning. Other potential predictors included age at testing, sex, time between most recent injury and testing, and number of prior concussions.

RESULTS

The groups did not differ significantly on long-term psychosocial functioning. Moreover, only pre-existing mood concerns or attention problems significantly predicted psychosocial adjustment.

CONCLUSIONS

Children's functioning before a concussion is critical to understanding outcome. Pre-injury attention and mood concerns should be assessed in clinical settings to prevent and treat long-term psychosocial problems after concussion. (JINS, 2018, 24, 540-548).

Environmental enrichment, alone or in combination with various pharmacotherapies, confers marked benefits after traumatic brain injury

Traumatic brain injury (TBI) is a significant health care issue that affects over ten million people worldwide. Treatment options are limited with numerous failures resulting from single therapies. Fortunately, several preclinical studies have shown that combination treatment strategies may afford greater improvement and perhaps can lead to successful clinical translation, particularly if one of the therapies is neurorehabilitation. The aim of this review is to highlight TBI studies that combined environmental enrichment (EE), a preclinical model of neurorehabilitation, with pharmacotherapies. A series of PubMed search strategies yielded only nine papers that fit the criteria. The consensus is that EE provides robust neurobehavioral, cognitive, and histological improvement after experimental TBI and that the combination of EE with some pharmacotherapies can lead to benefits beyond those revealed by single therapies. However, it is noted that EE can be challenged by drugs such as the acetylcholinesterase inhibitor, donepezil, and the antipsychotic drug, haloperidol, which attenuate its efficacy. These findings may help shape clinical neurorehabilitation strategies to more effectively improve patient outcome. Potential mechanisms for the EE and pharmacotherapy-induced effects are also discussed. This article is part of the Special Issue entitled "Neurobiology of Environmental Enrichment".

Parent-Reported Mild Head Injury History in Children: Long-Term Effects on Attention-Deficit Hyperactivity Disorder

Objective. Consequences of mild head injury for behavioral adjustment have not been well researched, and little is known about the long-term effects of mild head injury for attention-deficit hyperactivity disorder (ADHD). Methods. In this longitudinal study of 418 children in Jintan City, China, parents reported children's history of head injury at age 6 years, and the Child Behavior Checklist was used to measure child iDSM-IV-oriented ADHD at ages 6 (Wave I) and 12 years (Wave II). Regression models were used to calculate the long-term (Wave II) effect of mild head injury on diagnosed ADHD, while controlling for diagnosed ADHD in Wave I. Results. Fifty-seven children (13.6%) had a single injury and 42 (10.0%) had multiple injuries before the age of 6 years. The long-term effect of multiple mild injury on ADHD at age 12 years was significant (R2 = 0.103, P < .05), even after controlling for ADHD at age 6 years. Conclusions. Multiple, but not single, mild head injuries before the age of 6 years had a significant long-term effect on ADHD. Thus, injuries traditionally overlooked and underreported still pose significant risks to children's long-term behavioral development.

Investigating the Variability in Mild Traumatic Brain Injury Definitions: A Prospective Cohort Study

OBJECTIVE

To prospectively compare the proportion of traumatic brain injuries (TBIs) that would be classified as mild by applying different published definitions of mild TBI to a large prospectively collected dataset, and to examine the variability in the proportions included by various definitions.

DESIGN

Prospective observational study.

SETTING

Hospital emergency departments.

PARTICIPANTS

Children (N=11,907) aged 3 to 16 years (mean age, 8.2±3.9y). Of the participants, 3868 (32.5%) were girls, and 7374 (61.9%) of the TBIs were the result of a fall. Median Glasgow Coma Scale score was 15.

MAIN OUTCOME MEASURES

We applied 17 different definitions of mild TBI, identified through a published systematic review, to children aged 3 to 16 years. Adjustments and clarifications were made to some definitions. The number and percentage identified for each definition is presented.

RESULTS

Adjustments had to be made to the 17 definitions to apply to the dataset: none in 7, minor to substantial in 10. The percentage classified as mild TBI across definitions varied from 7.1% (n=841) to 98.7% (n=11,756) and varied by age group.

CONCLUSIONS

When applying the 17 definitions of mild TBI to a large prospective multicenter dataset of TBI, there was wide variability in the number of cases classified. Clinicians and researchers need to be aware of this variability when examining literature concerning children with mild TBI.

Evaluating anxiety and depression symptoms in children and adolescents with prior mild traumatic brain injury: Agreement between methods and respondents

Psychological functioning can be adversely impacted after a mild traumatic brain injury (mTBI) and may be a potential target for intervention. Despite the use of symptom ratings or structured diagnostic interview to assess long-term anxiety and depression symptoms in children and adolescents post-injury, no known studies have considered the agreement between different assessment methods and between respondents. The objectives of this study were to investigate the agreement between symptom ratings and structured diagnostic interview and between children and parents' symptom reporting. Participants (N = 33; 9-18 years old) were recruited from the Emergency Department and assessed on average 22.8 months (SD = 5.6) after their mTBI. Anxiety and depression symptoms were evaluated via subscales of a questionnaire (Behavior Assessment System for Children) and parts of a computerized structured diagnostic interview (generalized anxiety disorder and major depressive episode; Diagnostic Interview Schedule for Children - C-DISC-IV) administered individually to children and their parents. Results showed that the inter-method agreement to identify high levels of anxiety and depression was moderate to perfect in children while it was lower in parents. Although a similar percentage of participants with elevated anxiety or depression were identified by both children and parents, the agreement between youth and parents was variable, ranging from poor to good for anxiety and poor to moderate for depression. These results highlight the importance of collecting youth and parents' reports of anxiety and depression symptoms and considering potential discrepancies between informants' answers.

Chronic post-traumatic headache in children and adolescents: systematic review of prevalence and headache features

The aim of this systematic review is to determine the prevalence and clinical features of chronic post-traumatic headache (CPTH) in children and adolescents. Literature search of PubMed, Embase, Cochrane databases and Google Scholar was carried out for all studies reporting on CPTH in children and young people under the age of 18 years between January 1980 and November 2016. Search command included post-traumatic headache, postconcussion syndrome, child and adolescent. Demographic data, diagnostic criteria of headache disorders, occurrence of headache after head injury and headache phenotypes were collected. The prevalence of nonspecific 'chronic headache' after head injury in children was 39% and prevalence of CPTH, as defined by the International Classification of Headache Disorders (2004), was 7.6% (95% CI: 5.9-9.7). Migraine-like headache was the most common presentation followed by tension-type headache. Other children had either mixed or unclassified headache disorders.

Influence of guidelines on management of paediatric mild traumatic brain injury: CT-assessment and admission policy

BACKGROUND

The annual number of paediatric injury-related emergency visits and application of computed tomography (CT) has substantially increased, with associated higher risk of malignancies. In 2010, a guideline for CT-assessment based on risk factors for patients with mild traumatic brain injury (mTBI) became effective in all Emergency Departments (ED) in the Netherlands. This study evaluated the influence of this guideline on the frequency of CT-assessments, hospital admissions and factors that are related to guideline adherence.

METHODS

Retrospective cohort study of paediatric mTBI (<18 years), defined by Glasgow Coma Scale score of 13-15 admitted to the ED of the University Medical Center Groningen from 2008 to 2014. Data before (pre-GL) and after (post-GL) introduction of the guideline were evaluated. Primary outcome parameters were frequency of CT-assessments and hospital admissions after ED.

RESULTS

In total 633 patients were enrolled and data from pre-GL (n = 216) and post-GL (n = 315) were compared. Mean age was 7.9 years (SD 5.9), 59% were male. CT-assessments increased from 32% to 46% (p = .001), mostly in children aged 6-18 years. Hospital admissions increased from 38% to 54% (p < .001), mostly in children <6 years. No significant increase in CT-abnormalities is seen. Guideline adherence was 57%, although CT-assessments varied from 44 to 100% depending on presence of specific major risk factors.

CONCLUSIONS

Introduction of a new guideline on management of paediatric mTBI showed significant increase in CT-assessments and more hospital admissions. In clinical practice, despite increase of guideline adherence the applications of cranial CT-scan varies within age groups and depends on the weighing of risk factors.

Improving access to pediatric neurorehabilitation for patients with moderate and severe head injuries

INTRODUCTION

The majority of severely injured children in England have a significant head injury and will be seen in Major Trauma Centers (MTCs). The period following brain injury represents an opportunity to influence recovery of neurological function. The study sought to determine whether children who had sustained a head injury were referred for neurorehabilitation.

METHOD

The study was conducted over one year at one center. Children sustaining a moderate or severe head injury were identified and compared to those referred for neurorehabilitation.

RESULTS

A total of 41 patients were identified; 16/41 (39%) were referred for neurorehabilitation. Group comparison revealed significant associations between referral status and age (X²(3) = 8.35, p = 0.039), injury mechanism (X²(1) = 8.12, p = 0.017), injury severity (X²(1) = 21.3, p < 0.000), and imaging findings (X²(1) = 11.71, p = 0.001).

DISCUSSION

Data reveal concerns for access to neurorehabilitation. Improved access to neurorehabilitation permitting long-term follow-up is required. The establishment of MTCs provides an opportunity to enact this.

The chronic and evolving neurological consequences of traumatic brain injury

Traumatic brain injury (TBI) can have lifelong and dynamic effects on health and wellbeing. Research on the long-term consequences emphasises that, for many patients, TBI should be conceptualised as a chronic health condition. Evidence suggests that functional outcomes after TBI can show improvement or deterioration up to two decades after injury, and rates of all-cause mortality remain elevated for many years. Furthermore, TBI represents a risk factor for a variety of neurological illnesses, including epilepsy, stroke, and neurodegenerative disease. With respect to neurodegeneration after TBI, post-mortem studies on the long-term neuropathology after injury have identified complex persisting and evolving abnormalities best described as polypathology, which includes chronic traumatic encephalopathy. Despite growing awareness of the lifelong consequences of TBI, substantial gaps in research exist. Improvements are therefore needed in understanding chronic pathologies and their implications for survivors of TBI, which could inform long-term health management in this sizeable patient population.

The role of early intervention in improving the level of activities and participation in youths after mild traumatic brain injury: a scoping review

Mild traumatic brain injury in children can lead to persistent cognitive and physical symptoms which can have a negative impact on activities and participation in school and at play. Preventive treatment strategies are preferred because these symptoms are often not recognized and therefore not treated adequately. In this review clinical studies investigating interventions directed at pediatric mild traumatic brain injury are summarized, and clinical recommendations and directions for the future are provided. Results show that the literature is scarce and more high quality studies are needed. Information and education about the injury and its consequences are recommended, with additional follow-up consultation, including individualized advice and reassurance. The interventions should be family-centered and, ideally, the return to activity and participation should be graded and done step-by-step.

Sleep and quality of life in children with traumatic brain injury and ADHD

Objective Attention problems are common in children who sustain a traumatic brain injury (TBI). The differential features of TBI-related Attention Deficit Hyperactivity Disorder (ADHD) and primary ADHD are largely unknown. This study aimed to compare sleep problems and quality of life between children with TBI and ADHD and children with primary ADHD. Methods Twenty children with TBI (mean age = 12.7 ± 3.1 years) who had clinically significant ADHD symptoms according to the structured diagnostic interview and rating scales and a control group with primary ADHD (n = 20) were included. Parents completed Children's Sleep Habits Questionnaire (CSHQ) and Kinder Lebensqualitätsfragebogen: Children's Quality of Life Questionnaire-revised (KINDL-R). Neurology clinic charts were reviewed for TBI-related variables. Results When compared to children with primary ADHD, the Total Score and Sleep Onset Delay, Daytime Sleepiness, Parasomnias, and Sleep Disordered Breathing subscores of CSHQ were found to be higher in children with TBI and ADHD. The Total Score and Emotional Well-Being and Self-Esteem subscores of the KINDL-R were found to be low (poorer) in children with TBI and ADHD. The Total Score and certain subscores of KINDL-R were found to be lower in TBI patients with a CSHQ > 56 (corresponds to significant sleep problems) when compared to those with a CSHQ < 56. CSHQ Total Score was negatively correlated with age. Conclusion Children with TBI and ADHD symptoms were found to have a poorer sleep quality and quality of life than children with primary ADHD. ADHD in TBI may be considered as a highly impairing condition which must be early diagnosed and treated.

Prevalence of traumatic brain injury and mental health problems among individuals within the criminal justice system

Traumatic brain injury (TBI) is associated with increased aggression and antisocial behavior. This review examined existing literature regarding TBI prevalence and associated adverse mental health among individuals within the criminal justice system. TBI prevalence varied between 12 and 82% for youths, and 23 and 87% for adults. TBI was associated with a range of negative outcomes, particularly substance abuse. However, confounding factors, including differing control groups, lack of information for timing and severity of TBI, and use of self-report measures for TBI history made it difficult to determine whether TBI was a risk factor. Future research should eliminate or counter for these confounds, to provide accurate prevalence rates of TBI and the direction of association between TBI and offending behaviors.

Children in Vegetative State and Minimally Conscious State: A Survey of Sensory and Cognitive Intervention

There is little information available about the management of children in a vegetative state and a minimally conscious state (VS and MCS), including diagnosis, assessment and treatment. This study investigated the intervention of occupational therapists in VS and MCS in the United Kingdom paediatric population.

A survey design was used and a postal questionnaire was sent to a group of 892 occupational therapists who were members of a paediatric or a neurological specialist section. Two hundred and seventy-one completed questionnaires were returned and the results of these were analysed. Two hundred and six (76%) of the respondents worked in a rehabilitation setting.

Twenty-five occupational therapists who worked with children in VS and MCS completed further questions about their assessments and interventions. The results indicate that children in VS and MCS receive fragmented and inconsistent occupational therapy services. Adult assessments are used with a paediatric population and therapists are not wholly satisfied with their interventions. A core group of occupational therapists involved with this population was identified as a result of this survey. It is suggested that these therapists may be able to form a working party to investigate a consistent therapeutic approach for this complex group of children.

Epidemiology of children with head injury: a national overview

BACKGROUND

The National Confidential Enquiry describes the epidemiology of children admitted to hospital with head injury.

METHOD

Children (<15 years old) who died or were admitted for >4 h with head injury were identified from 216 UK hospitals (1 September 2009 to 28 February 2010). Data were collected using standard proformas and entered on to a database. A descriptive analysis of the causal mechanisms, child demographics, neurological impairment, CT findings, and outcome at 72 h are provided.

RESULTS

Details of 5700 children, median age 4 years (range 0-14.9 years), were analysed; 1093 (19.2%) were <1 year old, 3500 (61.4%) were boys. There was a significant association of head injury with social deprivation 39.7/100 000 (95% CI 37.0 to 42.6) in the least deprived first quintile vs. 55.1 (95% CI 52.1 to 58.2) in the most deprived fifth quintile (p<0.01). Twenty-four children died (0.4%). Most children were admitted for one night or less; 4522 (79%) had a Glasgow Coma Scale score of 15 or were Alert (on AVPU (Alert, Voice, Pain, Unresponsive)). The most common causes of head injury were falls (3537 (62.1%); children <5 years), sports-related incidents (783 (13.7%); median age 12.4 years), or motor vehicle accidents (MVAs) (401 (7.1%); primary-school-aged children). CT scans were performed in 1734 (30.4%) children; 536 (30.9%) were abnormal (skull fracture and/or intracranial injury or abnormality): 269 (7.6%) were falls, 82 (10.5%) sports related and 100 (25%). A total of 357 (6.2%) children were referred to social care because of child protection concerns (median age 9 months (range 0-14.9 years)).

CONCLUSIONS

The data described highlight priorities for targeted age-specific head injury prevention and have the potential to provide a baseline to evaluate the effects of regional trauma networks (2012) and National Institute of Health and Care Excellence (NICE) head injury guidelines (2014), which were revised after the study was completed.

Activities and participation of children and adolescents after mild traumatic brain injury and the effectiveness of an early intervention (Brains Ahead!): study protocol for a cohort study with a nested randomised controlled trial

Background

Approximately 20 % of children and adolescents who have sustained mild traumatic brain injuries may experience long-term consequences, including cognitive problems, post-traumatic stress symptoms and reduced load-bearing capacity. The underestimation and belated recognition of these long-term consequences may lead to chronic and disruptive problems, such as participation problems in school and in social relationships. The aim of this study is to examine the level of activities and participation of children and adolescents up to 6 months after a mild traumatic brain injury and to identify possible outcome predictors. Another aim is to investigate the effectiveness of an early psychoeducational intervention and compare the results with those obtained with usual care.

Methods/design

This paper presents the Brains Ahead! study design, a randomised controlled trial nested within a multicentre, longitudinal, prospective cohort study. The eligible participants include children and adolescents between 6 and 18 years of age who have experienced a mild traumatic brain injury within the last 2 weeks. The cohort study will include 500 children and adolescents with a mild traumatic brain injury and their caregivers. A subset of 140 participants and their caregivers will be included in the randomised controlled trial. Participants in the randomised controlled trial will be randomly assigned to either the psychoeducational intervention group or the usual care control group. The psychoeducational intervention involves one face-to-face contact and one phone contact with the interventionist, during which the consequences of mild traumatic brain injury and advice for coping with these consequences to prevent long-term problems will be discussed. Information will be provided both verbally and in a booklet. The primary outcome domain is activities and participation, which will be evaluated using the Child and Adolescent Scale of Participation. Participants are evaluated 2 weeks, 3 months and 6 months after the mild traumatic brain injury.

Discussion

The results of this study will provide insight into which children with mild traumatic brain injury are at risk for long-term participation problems and may benefit from a psychoeducational intervention.

Trial registration

Netherlands Trial Register identifier NTR5153. Registered on 17 Apr 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1357-6) contains supplementary material, which is available to authorized users.

A Systematic Review of Psychiatric, Psychological, and Behavioural Outcomes following Mild Traumatic Brain Injury in Children and Adolescents

BACKGROUND

Evidence regarding longer-term psychiatric, psychological, and behavioural outcomes (for example, anxiety, mood disorders, depression, and attention disorders) following mild traumatic brain injury (mTBI) in children and adolescents has not been previously synthesized.

OBJECTIVE

To conduct a systematic review of the available evidence examining psychiatric, psychological, and behavioural outcomes following mTBI in children and adolescents.

MATERIALS AND METHODS

Nine electronic databases were systematically searched from 1980 to August 2014. Studies selected met the following criteria: original data; study design was a randomized controlled trial, quasi-experimental design, cohort or historical cohort study, case-control study, or cross-sectional study; exposure included mTBI (including concussion); population included children and adolescents (<19 years) at the time of mTBI, as well as a comparison group (for example, healthy children, children with orthopaedic injuries); and included psychiatric, psychological, or behavioural outcomes (for example, anxiety, mood disorders, depression, attention disorders). Two authors independently assessed the quality and level of evidence with the Downs and Black (DB) criteria and Oxford Centre of Evidence-Based Medicine (OCEBM) model, respectively, for each manuscript.

RESULTS

Of 9472 studies identified in the initial search, 30 were included and scored. Heterogeneity in methodology and injury definition precluded meta-analyses. The median methodological quality for all 30 studies, based on the DB criteria, was 15/33 (range 6 to 19). The highest level of evidence demonstrated by all reviewed studies was level 2b based on OCEBM criteria, with the majority (28/30 studies) classified at this level. Based on the literature included in this systematic review, psychological and psychiatric problems in children with a history of mTBI were found to be more prevalent when mTBI is associated with hospitalization, when assessment occurs earlier in the recovery period (that is, resolves over time), when there are multiple previous mTBIs, in individuals with preexisting psychiatric illness, when outcomes are based on retrospective recall, and when the comparison group is noninjured healthy children (as opposed to children with injuries not involving the head).

CONCLUSIONS

Overall, few rigorous prospective studies have examined psychological, behavioural, and psychiatric outcomes following mTBI. In the absence of true reports of preinjury problems and when ideally comparing mild TBI to non-TBI injured controls, there is little evidence to suggest that psychological, behavioural, and/or psychiatric problems persist beyond the acute and subacute period following an mTBI in children and adolescents.

Health-related quality of life in children and youth with acquired brain injury: Two years after injury

OBJECTIVE

To determine health-related quality of life (HRQoL) in children and youth with acquired brain injury (ABI) two years post-injury and explore associated factors.

DESIGN

Cross-sectional.

SUBJECTS

Children and youth (n = 72; aged 6-22 years) with mild to severe ABI (87% mild).

METHODS

The primary outcome measures self-reported and parent-reported HRQoL were assessed with the Paediatric Quality of Life Inventory (PedsQL) and compared with age-appropriate reference values of the Dutch population. Spearman correlation coefficients (Rs) were used to explore relationships between HRQoL and sociodemographic and ABI characteristics, severity of impairments and presence of post-injury problems.

RESULTS

Children and youth with ABI and the reference population had similar self-reported HRQoL. However, as reported by parents, children with ABI aged 6-7 years and youth aged 13-18 years had poorer HRQoL regarding psychosocial health. Children's post-injury cognitive, behavioural and social problems were moderately associated with poorer HRQoL, especially psychosocial health (Rs ≥ 0.40). Severity nor type of injury were associated with children's HRQoL.

CONCLUSION

Two years post-injury, in children and youth with mild to severe ABI, reported HRQoL is similar to that in the general population, whereas parents reported less favourable outcomes. Post-injury cognitive, behavioural and social problems require ongoing attention during long-term follow-up.

Targeting the Epidemic: Interventions and Follow-up Are Necessary in the Pediatric Traumatic Brain Injury Clinic

Traumatic brain injury is a major public health problem in the pediatric population. Previously, management was acute emergency department/primary care evaluation with follow-up by primary care. However, persistent symptoms after traumatic brain injury are common, and many do not have access to a specialized traumatic brain injury clinic to manage chronic issues. The goal of this study was to determine the factors related to outcomes, and identify the interventions provided in this subspecialty clinic. Data were extracted from medical records of 151 retrospective and 403 prospective patients. Relationships between sequelae, injury characteristics, and clinical interventions were analyzed. Most patients returning to clinic were not fully recovered from their injury. Headaches were more common after milder injuries, and seizures were more common after severe. The majority of patients received clinical intervention. The presence of persistent sequelae for traumatic brain injury patients can be evaluated and managed by a specialty concussion/traumatic brain injury clinic ensuring that medical needs are met.

Ongoing daytime behavioural problems in university students following childhood mild traumatic brain injury

Sleep is often disrupted in traumatic brain injury (TBI) and may be related to persistent behaviour problems; however, little is known about this relationship in young adults. This study explored associations between TBI, behavioural problems and sleep disturbances in 247 university students (197 non-TBI, 47 mild TBI, two moderate TBI, one severe TBI) aged 18-25 years, who completed validated measures for behaviour, sleep quality and history of TBI. Because of small group numbers, participants reporting moderate to severe TBI were excluded from the analyses. Results indicated that students with mild TBI reported higher levels of daytime dysfunction, somatic complaints, withdrawal, other behavioural complaints and internalizing behaviours compared with students with no TBI history. A correlational analysis indicated a moderate relationship between the above significant variables. Our results suggest that university students with a history of mild TBI are more likely to experience certain ongoing daytime behavioural problems, which are likely to negatively influence their academic functioning in tertiary education. This study highlights the importance of research on long-term problems following mild TBI in young adults aged 18-25 years--an age group often overlooked within the literature.

Infrascanner in the diagnosis of intracranial lesions in children with traumatic brain injuries

BACKGROUND

The number of traumatic injuries among children is increasing. However, so-called mild TBI might result in unfavourable outcomes. Early diagnosis of intracranial haematomas prior to development of serious complications may be a decisive factor for a favourable outcome. InfraScan company developed and brought to the market the Infrascanner model 1000, which is a portable detector of blood collections that operates in the near infrared (NIR) band.

OBJECTIVE

To estimate the efficiency of the Infrascanner model 1000 for detection of intracranial haematomas among children with mild TBI.

MATERIALS AND METHODS

Ninety-five patients with mild TBI were examined. An indication for cerebral CT after mild TBI was the presence of risk factors of intracranial lesions. The Infrascanner was used by a neurosurgeon during primary examination. CT was performed in 43 patients (45%), while 52 patients (55%) with a low risk of intracranial lesions were under observation.

RESULTS

The results of examination of patients using CT and infrared scanning coincided in 39 cases and intracranial haematomas were detected in eight patients. False-positive results were obtained in three cases. The sensitivity of the procedure used in this group of patients with a medium and high risk of development of intracranial haemorrhages was 1.00 (0.66; 1.00). The specificity was 0.91 (0.81; 1.00)--the proportions and a 95% CI. The false-positive risk is 0.27 (0.00; 0.58). During infrared scanning in patients with low risk of intracranial lesions, false-positive results were obtained in four cases and false-negative results were absent.

CONCLUSION

Infra-scanning might be viewed as a screening technique for intracranial haemorrhages in ambulances and outpatient trauma centres in order to decide on hospitalization, CT scanning and referral to a neurosurgeon. Infra-scanning combined with evaluation of risk factors of intracranial damage might reduce the number of unnecessary radiological examinations.

5-hydroxytryptamine1A (5-HT1A) receptor agonists: A decade of empirical evidence supports their use as an efficacious therapeutic strategy for brain trauma

Traumatic brain injury (TBI) is a significant and enduring health care issue with limited treatment options. While several pre-clinical therapeutic approaches have led to enhanced motor and/or cognitive performance, the benefits of these treatments have not translated to the clinic. One plausible explanation is that the therapies may not have been rigorously evaluated, thus rendering the bench-to-bedside leap premature and subsequently unsuccessful. An approach that has undergone considerable empirical research after TBI is pharmacological targeting of 5-HT1A receptors with agonists such as repinotan HCl, 8-hydroxy-2-(di-n-propylamino) tetralin (8-OH-DPAT), and buspirone. The goal of this review is to integrate and interpret the findings from a series of studies that evaluated the efficacy of 5-HT1A receptor agonists on functional, histological, and molecular outcome after acquired brain injury. The overwhelming consensus of this exhaustive review is that a decade of empirical evidence supports their use as an efficacious therapeutic strategy for brain trauma. This article is part of a Special Issue entitled SI:Brain injury and recovery.

Supporting parents following childhood traumatic brain injury: a qualitative study to examine information and emotional support needs across key care transitions

INTRODUCTION

Traumatic brain injury (TBI) is the leading cause of death and acquired disability in childhood. Research has demonstrated that TBI can lead to long-term physical, cognitive, emotional and behavioural difficulties for children and parental stress. Less is known about how parents experience a childhood brain injury and their information and support needs. This study aimed to examine parents' experiences and support needs following a childhood TBI from the time of the accident to their child's discharge home.

METHODS

Qualitative semi-structured interviews were conducted with 29 parents/carers of children who had experienced a severe TBI. Participants were recruited from one children's tertiary centre in the UK. Data were analysed using the Framework approach.

RESULTS

Parents had unmet information and emotional support needs across the care trajectory from the time of the accident to their child's return home. Information needs related to the impact of the TBI on their child; current and future treatment/rehabilitation plans; helping their child and managing their behaviour; accessing services/support. They lacked information and support for care transitions. In different settings parents faced particular barriers to having their information needs met. Parents' felt they needed emotional support in coming to terms with witnessing the accident and the loss of their former child. Lack of community support related not only to service availability but to a general lack of understanding of the impact of TBI on children, particularly when this was invisible. Overall parents felt unsupported in coping with children's behavioural and psychological difficulties.

DISCUSSION

Taking a holistic approach to examining parents' experiences and support needs has enabled their changing needs to be highlighted across key care transitions within hospital and community settings and the service implications identified. Improvements in care co-ordination across care transitions are needed to ensure continuity of care and integration of support.

Epidemiology and treatment outcome of head injury in children: A prospective study

Summary:

Head injury in children is a major concern all over the world. The increasing level of poverty in the world is exposing more children to trauma situations. The future consequences of trauma in these children are enormous, hence prevention they say, is better than cure.

Aim of the Study:

The study was designed to determine the etiological pattern, age group affectation and treatment outcome in children managed for head injury in our center.

Methods:

It was a prospective, descriptive and cross-sectional study of children with head injuries managed in our center from July 2010 to December 2013. Data were collected using structured proforma that was part of our prospective Data Bank approved by our hospital Research and Ethics Committee. Data were collected in accident and emergency unit, Intensive Care Unit, wards and out-patient clinic. The data was analyzed using Epi Info 7 software.

Results:

Total of 76 children managed by the unit and followed-up to a minimum of 3 months qualified for the study. There were 42 males. The age ranged from 7 months to 18 years with a mean of 8.66 years. There were 30 adolescent/teenagers. Road traffic accident formed 63.15%. Pedestrian accident was more among preschool and school children. Thirty-seven patients had mild head injury. Sixty-six patients were managed conservatively. The commonest posttraumatic effect was seizure (15.79%). Good functional outcome (≥4) was seen in 92.1%. Mode of accident and severity of injury affected the outcome.

Conclusions:

The etiologies of traumatic brain injury, from our study, were age dependent with falls commonest in toddlers and pedestrian accident commonest in pre-school and school ages. The outcome of treatment was related to severity of injury.

A combined therapeutic regimen of buspirone and environmental enrichment is more efficacious than either alone in enhancing spatial learning in brain-injured pediatric rats

Buspirone, a 5-HT1A receptor agonist, and environmental enrichment (EE) enhance cognition and reduce histopathology after traumatic brain injury (TBI) in adult rats, but have not been fully evaluated after pediatric TBI, which is the leading cause of death in children. Hence, the aims of this study were to assess the efficacy of buspirone alone (Experiment 1) and in combination with EE (Experiment 2) in TBI postnatal day-17 male rats. The hypothesis was that both therapies would confer cognitive and histological benefits when provided singly, but their combination would be more efficacious. Anesthetized rats received a cortical impact or sham injury and then were randomly assigned to receive intraperitoneal injections of buspirone (0.08 mg/kg, 0.1 mg/kg, and 0.3 mg/kg) or saline vehicle (1.0 mL/kg) 24 h after surgery and once daily for 16 days (Experiment 1). Spatial learning and memory were assessed using the Morris water maze (MWM) on post-operative days 11-16, and cortical lesion volume was quantified on day 17. Sham controls for each condition were significantly better than all TBI groups. In the TBI groups, buspirone (0.1 mg/kg) enhanced MWM performance versus vehicle and buspirone (0.08 mg/kg and 0.3 mg/kg) (p<0.05) and reduced lesion volume relative to vehicle (p=0.038). In Experiment 2, buspirone (0.1 mg/kg) or vehicle was combined with EE after TBI, and the data were compared to the standard (STD)-housed groups from Experiment 1. EE lead to a significant enhancement of spatial learning and a reduction in lesion size versus STD. Moreover, the combined treatment group (buspirone+EE) performed markedly better than the buspirone+STD and vehicle+EE groups, which suggests an additive effect and supports the hypothesis. The data replicate previous studies assessing these therapies in adult rats. These novel findings may have important rehabilitation-relevant implications for clinical pediatric TBI.

Office management of mild head injury in children and adolescents

OBJECTIVE

To provide family physicians with updated, practical, evidence-based information about mild head injury (MHI) and concussion in the pediatric population.

SOURCES OF INFORMATION

MEDLINE (1950 to February 2013), the Cochrane Database of Systematic Reviews (2005 to 2013), the Cochrane Central Register of Controlled Trials (2005 to 2013), and DARE (2005 to 2013) were searched using terms relevant to concussion and head trauma. Guidelines, position statements, articles, and original research relevant to MHI were selected.

MAIN MESSAGE

Trauma is the main cause of death in children older than 1 year of age, and within this group head trauma is the leading cause of disability and death. Nine percent of reported athletic injuries in high school students involve MHI. Family physicians need to take a focused history, perform physical and neurologic examinations, use standardized evaluation instruments (Glasgow Coma Scale; the Sport Concussion Assessment Tool, version 3; the child version of the Sport Concussion Assessment Tool; and the Balance Error Scoring System), instruct parents how to monitor their children, decide when caregivers are not an appropriately responsible resource, follow up with patients promptly, guide a safe return to play and to learning, and decide when neuropsychological testing for longer-term follow-up is required.

CONCLUSION

A thorough history, physical and neurologic assessment, the use of validated tools to provide an objective framework, and periodic follow-up are the basis of family physician management of pediatric MHI.

Changes in saccadic eye movement and memory function after mild closed head injury in children

AIM

The aim of this study was to determine whether volitional saccadic impairments are present in children with mild closed head injury (mCHI) and whether these deficits are predictive of ongoing cognitive impairment.

METHOD

We analysed a sample of 26 children with mCHI (20 males, 6 females; mean age 13y 1mo, SD 2y) and 29 age-matched comparison children (20 males, 9 females; mean age 12y 2mo, SD 2y). Participants completed a battery of saccadic eye movement tasks and a set of computer-based cognitive tasks at three time points: within 2 weeks of mCHI, and at 3 months and 6 months.

RESULTS

The group with mCHI made fewer errors on the antisaccade task at the first time point and showed increased latencies on prosaccades, correct antisaccades, and corrected antisaccade errors at the third time point (6mo). The group with mCHI also showed poorer performance on the cognitive tasks assessing memory.

INTERPRETATION

Even very mild, uncomplicated mCHI in children may persistently affect aspects of executive control and visual processing.

A survey of the management of paediatric minor head injury

OBJECTIVES

To investigate present established routines and standards in managing minor head-injured children in Danish hospitals, a survey of present management practice was conducted.

MATERIALS AND METHODS

A cross-sectional mail survey, detailing clinical and radiological examinations, in-hospital observation, discharge criteria and follow-up, was performed on all 46 hospitals treating children with minor head injury in Denmark.

RESULTS

Of the 46 hospitals, 33% report having established written criteria for the referral and management of children with minor head injury. Ten (22%) of the 46 hospitals are so-called injury clinics, where only nurses are employed. All state that they use the Glasgow Coma Scale (GCS) and/or the paediatric GCS to assess the level of consciousness; 15% use the paediatric GCS exclusively. None perform routine radiological examinations. Criteria for early discharge are established in 98% of the hospitals. All hospitals provide written instructions for observations at home before discharge.

CONCLUSION

The management of children with minor head injury varies between hospitals in Denmark. Local management guidelines are either lacking or mainly based on those of adults. Hence, there is a need for the development of minor head injury guidelines specifically designed for the management of children.

Sleep disorders in children with traumatic brain injury: a case of serious neglect

AIM

The aim of this study was to review the basic aspects of sleep disturbance in children with traumatic brain injury (TBI).

METHOD

A search was performed on reports of sleep disturbances in children who had suffered TBI. Adults with TBI were also considered to anticipate the nature and significance of such disturbances in younger patients. Types of reported sleep disturbance were noted and their possible aetiology and management considered.

RESULTS

Sleep disturbance has consistently been associated with TBI but the literature suggests that this aspect of patient care is often inadequately considered and there has been little research on the subject, especially in relation to children. Excessive daytime sleepiness is often mentioned, less so insomnia and parasomnias, but there is little information about the specific sleep disorders underlying these problems.

INTERPRETATION

Sleep disorders with potentially important developmental consequences have been neglected in the care of children with TBI. Screening for sleep problems should be routine and followed, if indicated, by a detailed diagnosis of the child's underlying specific sleep disorder, the possible aetiology of which includes neuropathology and potential medical, psychological, or psychiatric comorbidities. Appropriate assessments and modern treatment options are now well defined although generally underutilized. Further well-designed research is needed for which guidelines are available.

Long-term outcome of medically confirmed and self-reported early traumatic brain injury in two nationwide samples

PRIMARY OBJECTIVES

To assess long-term effects of early traumatic brain injury (TBI) on mental health, cognition, behaviour and adjustment and to identify prognostic factors.

METHODS AND PROCEDURES

A 1-year nationwide cohort of all 0-19 year old Icelandic children and adolescents diagnosed with TBI in 1992-1993 (n = 550) received a questionnaire with clinical outcome scales and questions on TBI and socio-economic status (SES) by mail ∼16 years post-injury. A control group (n = 1232), newly selected from the National Registry, received the same questionnaire. Non-respondents answered a shorter version by telephone. Overall participation was 67%.

MAIN OUTCOMES AND RESULTS

Medically confirmed and self-reported TBI was reflected in worse outcome. Force of impact, number and severity of TBIs predicted poorer results. Parental SES and demographic factors had limited effects. Not reporting early, medically confirmed TBI did not exclude cognitive sequelae. In self-reported disability, absence of evaluation for compensation was not linked to outcome.

CONCLUSIONS

Clinical outcome was consistent with late complaints attributed to early TBI. TBI-related variables had greater prognostic value than other factors. Self-reporting of TBI sustained very early in life needs supplementary information from parents and medical records. More consistency in compensation evaluations following paediatric TBI is indicated.