Pediatric Traumatic Brain Injury

BACKGROUND

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).

Occurrence

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.

Outcomes – There is significant variability in recovery time.

Motor Impairment

Weakness
Spasticity
Rigidity
Ataxia, including intention tremor (related to brain stem injury)
Dystonia (usually related to basal ganglia injury)
Motor apraxia
Development of progressive contractures rapidly in the weeks post-injury
Oculomotor impairments – when accompanied by orbital fractures, immediate consult is needed; children under 5 years of age with disconjugate gaze should be evaluated by a pediatric ophthalmologist as soon as possible following the injury
Dysphagia

Sensory Impairments and Cranial Nerve Dysfunction

Visual impairments
Anosmia
Hearing loss
Vertigo or lightheadedness

Speech- Language Impairments

Aphasia – disorder that results from damage to portions of the brain that are responsible for language
Apraxia – inability to execute a voluntary movement despite being able to demonstrate normal muscle function.
Aprosodia – the absence of normal variations of pitch, rhythm and stress in speech
Dysarthria – difficult, poorly articulated speech
Spastic dysphonia – impairment of the voice
Central auditory processing difficulties

Cognitive Impairments

Memory (including difficulty with encoding, decoding, and visual and auditory memory problems)
Integrative language function (including verbal reasoning, problem solving, concept formation and concept flexibility)
Attention span
Attention to visual or auditory detail
Executive functions (including mental flexibility, abstract thinking, organizational skills, judgment, a multi-tasking ability

Behavioral Problems

Reactive emotional problems (including anger, depression and acting-out behavior)
Sleep-wake cycle disturbances, common in acute phase
Eating disorders, common in acute and postacute phases (including anorexia nervosa, bulimia and hyperphagia)

Other Possible Injuries/Problems in Acute Phase

Secondary bleeding leading to subarachnoid, intraventricular or intracerebral hemorrhage
Bladder and bowel incontinence
Occult fractures
Intraabdominal injury
Nutritional disorders
Endocrine disorders
Pain
Seizure activity, common within the first few days postinjury, with degree dependent on severity of injury and time since the injury

Other Possible Injuries/Problems in Postacute Phase

Delayed bleeding, resulting in epidural or subdural hematomas
Edema, resulting in hypoperfusion injuries or herniation syndromes
Hydrocephalus
Metabolic events (increased excitatory amino acid and neurotransmitter release, increased lipid peroxidation), resulting in delayed nerve cell injury or death or increased susceptibility to other secondary injury
Nutritional disorders
Endocrine disorders
Seizure disorders

Common Associations

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.

MEDICAL MANAGEMENT CONSIDERATIONS

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:

Mild: GCS score of 13-15
Moderate: GCS score of 9-12
Severe: GCS score of 8 or less

Glasgow Coma Scale (GCS)

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:

Mild TBI: PTA less than 30 minutes
Moderate TBI: PTA from 30 minutes to 24 hours
Severe TBI: PTA longer than 24 hours

Management by Age

Pre-school Age (Birth to 5 years)

Evaluate growth parameters, diet record, nutrition and feeding, gastroesophageal reflux, and swallowing
Review oral hygiene and refer to dentist
Test vision and refer to ophthalmologist as needed
Test hearing and refer to audiologist as needed
Evaluate dizziness and vertigo and refer to otolaryngologist as needed
Perform EEG and refer to child neurologist as needed
Take chest x-ray when suspicious of pneumonia or aspiration as needed
Evaluate oral-motor skills (drooling) and refer for therapy as needed
Refer to speech-language pathologist as needed
Perform detailed musculoskeletal and neuromotor examinations
Assess fine motor skills
Screen visual perceptual skills
Administer behavior rating scales to parents and teachers as needed and regularly if on medication
Refer to mental health professional as needed
Encourage parent training in behavior management
Refer child for developmental screening and surveillance
Set up school conferences as needed

Childhood (6 to 12 years)

Refer for behavior, intellectual and achievement testing and neuropsychological assessment as needed
Reassess need for physical or occupational therapy services: perform complete neuromotor examination, assessing fine and gross motor skills and functional skills
Refer to community resources and mentor program
Coordinate teacher interviews and school conferences as needed

Adolescent and Young Adult (13-21 years)

Administer behavior rating scales to parents, child and teacher as needed, regularly if on medication
Refer for counseling as needed
Review medication management: check growth, blood pressure, heart rate, tics, side effects, EKG, and perform lab work as needed for specific medications
Consider inpatient rehabilitation evaluation as needed
Encourage independent living skills program and social skills training as needed
Perform driver training assessment
Refer sexually active women for gynecologic examination
Coordinate teacher interviews and school conferences as needed
Refer to State Department of Vocational Rehabilitation, career counseling or life skills program as needed
Encourage involvement in after-school and community activities and mentor programs

REFERENCES

Peer Reviewed Journal Articles/Academies

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.

Special Interest Groups/Other Publications

Christensen, J.R. (1996). Pediatric Traumatic Brain Injury. In A.J. Capute & P.J. Accardo (2^nd 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, (4^th 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

RESOURCES FOR FAMILIES

Brain Injury Association, Inc.

105 North Alfred Street

Alexandria, Virginia 22314

Telephone: 703-236-6000

Fax: 703-236-6001

http://www.biausa.org

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)

http://www.ed.gov/offices/OSERS/NIDRR

The Brain Injury Information Network

e-mail: [email protected]

http://tbinet.org

National Rehabilitation Information Center (NARIC)

1010 Wayne Avenue, Suite 800

Silver Spring, Maryland 20910

Telephone: 800-346-2742

Fax: 301-562-2401

http://www.naric.com

ADVISORY COMMITTEE

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.

PUBLICATION INFORMATION

Funded by a grant from the California Department of Developmental Services

For more information, contact:

Center for Health Improvement

1330 21st Street, Suite 100

Sacramento, CA 95814

(916) 901-9645

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.