Medical Management Considerations
Pediatric traumatic brain injury (TBI) is an injury to the brain caused by trauma resulting in a change in level of consciousness and/or anatomical abnormality of the brain. This injury may result in neurocognitive, intellectual, academic, functional and motor function deficits that may be either permanent or temporary impairments. Primary injury to the brain is the result of the transmission of accelerating and decelerating forces to the brain, which may cause stretching and breaking of the bridging vessels and axons. Secondary injury occurs when reduced cerebral perfusion fails to deliver adequate oxygen and clear waste or when hypoxic injury accompanies or follows direct trauma. Further damage after initial brain injury may occur in children under six years of age who may have an unusual autonomic response resulting in an increase in intracranial pressure.
Brain injury can be caused by impact or inertial forces, and many injuries involve both components. Common causes of pediatric brain injury include motor vehicle accidents, falls, pedestrian and bicycle motor vehicle accidents, shaken baby syndrome, and blows to the head, which may result in different types of brain injuries. Impact forces, caused by the brain being struck by a moving object or by striking a surface can produce scalp and skull injuries, brain contusions, and epidural and subdural hematomas and intercranial lacerations which may have results ranging from no neurological consequences to significant disabilities or even death. Inertial forces occurring by violent motion of the brain inside the skull may result in mild concussions to acute subdural hematomas and diffuse axonal injuries (DAI).
The prevalence of disability from traumatic brain injury is about 29,000 children and youth each year, where 10 percent of mild injuries, 90 percent of moderate injuries and 100 percent of severe injuries result in disabilities each year.
Approximately 20 percent of children with traumatic brain injury have preexisting attention-deficit/hyperactivity disorder (ADHD), which negatively affects outcomes. Chances of developing a full-blown psychiatric illness, including schizophrenia, paranoia and bipolar disorders, are higher in children with mild, moderate and severe traumatic brain injury than in the general population. According to reports, posttraumatic stress disorder (PTSD) occurs in between 17 and 33 percent of individuals after mild traumatic brain injury (MTBI). Findings show that postconcussive symptoms (PCS) are strongly correlated with PTSD symptoms. Personality change (PC) is frequently diagnosed following severe TBI in children, but is much less common following mild or moderate TBI.
Note: These considerations are in addition to the normal medical care provided to an individual without traumatic brain injury. Children and adolescents with traumatic brain injury are best cared for by a child development team working with parents and the primary care physician. This team regularly includes a developmental pediatrician or a pediatric psychiatrist, a medical social worker, a neurosurgeon, a nurse, an occupational therapist, a physical therapist, a psychologist and a speech-language pathologist. Other appropriate referrals include an orthotist, an orthopedist, a child neurologist, an ophthalmologist, a nutritionist and a feeding specialist.
Traumatic brain injury can be measured by the Glasgow Coma Scale (GCS, most often applied in the first few hours of acute injury rather than for chronic evaluation) using the modifications for infants and children, and is classified as follows:
Glasgow Scale pdf
Due to its unreliability in children under age 4, assessment for posttraumatic amnesia (PTA) is rarely used as a classification tool for this age level. PTA can be assessed in older children using the Children’s Orientation and Amnesia Test (COAT) or the Galveston Orientation and Amnesia Test (GOAT). Severity of TBI is determined as follows:
Annegers, J.F. et al. (1998). A Population-Based Study of Seizures after Traumatic Brain Injuries. The New England Journal of Medicine, 338(1), 20-24.
Bryant, R.A, & Harvey, A.G. (1999). Postconcussive Symptoms and Posttraumatic Stress Disorder after Mild Traumatic Brain Injury. The Journal of Nervous and Mental Disease, 187(5), 302-305.
Max, J.E., et al. (1998). Child and adolescent traumatic brain injury: correlates of injury severity. Brain Injury, 12(1), 31-40.
Max, J.E., et al. (2000). Personality change disorder in children and adolescents following traumatic brain injury. Journal of the International Neuropsychological Society, 6(3), 279-89.
Christensen, J.R. (1996). Pediatric Traumatic Brain Injury. In A.J. Capute & P.J. Accardo (2nd ed.), Developmental Disabilities in Infancy and Childhood (pp. 245- 260). Baltimore: Paul H. Brookes Publishing Co.
Cockrell, J.L. & Nickel, R.E., (2000). Traumatic Brain Injury. In R.E. Nickel & L. W. Desch (Eds), The Physician’s Guide to Caring for Children with Disabilities and Chronic Conditions (pp. 513-544). Baltimore: Paul H. Brooks Publishing Co.
Graber, M.A. (1999). Traumatic Brain Injury. In: Griffith’s 5 Minute Clinical Consult. Ed: M.R. Dambro. Baltimore: Lippincott Williams & Wilkins.
Michaud, L. et al. (1997). Traumatic Brain Injury. In: Children with Disabilities. Ed: M.L. Batshaw, (4th ed., 595-617). Baltimore: Paul H. Brooks Publishing Co.
National Institutes of Health, Office of the Director. (1998). October 26-28. Rehabilitation of Persons with Traumatic Brain Injury: NIH Consensus Statement Online, 16 (1), 1-41. Retrieved from http://consensus.nih.gov/1998/1998TraumaticBrainInjury109html.htm on February 24, 2006
Brain Injury Association, Inc.
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Alexandria, Virginia 22314
National Institute on Disability and Rehabilitation Research (NIDRR)
Office of Special Education and Rehabilitative Services
U.S. Department of Education
400 Maryland Avenue SW
Washington, D.C. 20202
Telephone: 800-USA-LEARN (872-53276)
The Brain Injury Information Network
National Rehabilitation Information Center (NARIC)
1010 Wayne Avenue, Suite 800
Silver Spring, Maryland 20910
Theodore A. Kastner, M.D., M.S.
Felice Weber Parisi, M.D., M.P.H.
Richard J. Brouette, M.D., F.A.A.F.P., D.A.B.F.P.
Leonard Magnani, M.D., Ph. D.
Terrance D. Wardinsky, M.D.
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This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.