Pediatric Considerations in Traumatic Brain Injury Care

Christopher Giza, Daniel Shrey, Sharief Taraman

GENERAL PRINCIPLES

Definitions

Pediatric traumatic brain injury (TBI) is injury to the brain from a biomechanical etiology occurring in patients under 18 years of age, including inflicted abusive head trauma and sport-related concussions but excluding obstetrical complications.

Pediatric Concussion: A traumatically induced disturbance of neurological function and mental state, occurring with or without loss of consciousness; generally occurs without evidence of gross structural pathology on acute neuroimaging with functional disturbances resolving over time [1,2].

Epidemiology

TBI is a leading cause of morbidity/mortality among pediatric patients, and it is responsible for the majority of trauma-related hospitalizations and deaths in the pediatric population. While outcomes after TBI are generally viewed as better in children than adults, TBI sustained in younger age groups (less than 4 years) actually results in worse long-term prognosis [3,4].

It is estimated that 1.6 to 3.8 million sport concussions occur in the United States per year in all ages [5]. Among high school athletes, 5% to 6% of all injuries involve the head [6]. Youth athletes represent the largest at-risk population for sport concussion, with an estimated 135,000 high school athletes sustaining concussions/mild TBIs annually [7]. After a single concussion, the risk of sustaining another concussion during the same season increases threefold [8].

Classification

Uses modified pediatric Glasgow Coma Scale (see Table 59.1):

• Mild: GCS 13 to 15, includes concussion, constitutes 75% to 85% of all head injuries

• Complicated mild: GCS 13 to 15 with evidence of intracranial pathology (contusions, hemorrhage, axonal injury, etc.)

• Moderate: GCS 9 to 12

TABLE 59.1 Modified Glasgow Coma Scale for Infants and Children (Merck Manual)

• Severe: GCS 3 to 8 after initial resuscitation

• Limitations in pediatrics: difficult to assess verbal score in preverbal infants and older children with language/developmental delays

Pathophysiology

Specific pediatric implications:

• Abusive head trauma—major cause in infants, due to shaking and/or impact; may be recurrent or have delayed presentation, often with concurrent hypoxic-ischemic injury.

• Concussion and mild TBI—often recurrent in child and adolescent contact sports. Multiple potential physiological mechanisms may occur following concussion [9–12]. These include spreading neuronal depression/migraine, seizure activity, changes in cerebral blood flow, perturbations of brain metabolism, altered neuronal activation, and/or axonal dysfunction.

• Contusion—less common in infants/toddlers than in adolescents or adults.

• Diffuse cerebral edema—more common in infants/toddlers than adolescents or adults.

• Diffuse axonal/shearing injury—frontal white matter networks (controlling attention and executive function) are not fully mature until early 20s. In infants, unmyelinated white matter may be particularly vulnerable.

• Hypoxia-ischemia—particularly associated with abusive head trauma, especially infants.

• Penetrating injuries—rare in pediatrics.

• Seizures—more common in infants and younger children than adolescents/adults.

• Skull fractures—slightly more common in younger children.

Mechanism

The most common mechanisms of pediatric TBI vary by age group:

• Infants: Inflicted abusive head trauma, falls

• Toddlers: Falls

• Children/Adolescents: Motor vehicle accidents and sport-related concussions

PEDIATRIC CONCUSSION AND MILD TBI—ASSESSMENT

Signs and Symptoms

Usually self-limited, with the vast majority (80%–85%) resolving within 21 days. In general, however, high school patients and patients with certain pre-existing conditions have longer recovery periods [13,14].

• Acute symptoms and signs: Essentially mirror those seen in adults (see Chapters 6–9). Subjective symptoms are more challenging to assess in young children, and the practitioner should take care to avoid suggestibility that can bias symptom reporting. Commonly, freely available tools such as the SCAT3 and Child SCAT3 are used to quantify symptoms in a Likert scale; however, formal validation in pediatric patients is still lacking [2].

• Neuropsychological testing: May provide additional information and aid in the management of concussions, especially in situations of unreliability of patient self-report of symptoms [15]. Results from neuropsychological testing should be interpreted in the context of other variables, including academic history, mental health history, and effort to task, as these factors can influence test performance; it should never be used in isolation to diagnose TBI, determine injury severity, or make definitive return-to-play decisions.

PEDIATRIC CONCUSSION AND MILD TBI—MANAGEMENT

Guiding Principles

Specific pediatric-focused recommendations have recently been published by the AAN (2013) and AAP (2010). Pediatric considerations are also mentioned in the Consensus Statement on Concussion in Sport (2013) [1,2,16].

Management of Sport-Related Concussion (Discussed in Chapter 10)

Issues unique to pediatric concussion include:

• School: May require adjustments for cognitive, behavioral, and/or fine motor deficits [17–19]

Initial support: Alert school personnel to injury, reintegrate into school gradually with goal of preventing prolonged absence from school [20], provide extra assistance, adjust education, provide time to facilitate completion of makeup work.

General school-based support: Monitor student carefully for a period following recovery, watch for subtle cognitive or behavioral problems.

Specific classroom-based support: Delay or provide additional time for tests, offer flexibility for assignment due dates, provide preferential seating to allow for closer monitoring and less distraction, provide examples of completed work.

• Return to play: Concerns guiding return to play recommendations include risk of second impact syndrome (SIS) and/or worsened symptoms after repeated concussions. Additionally, concerns exist that multiple concussions may lead to postconcussion syndrome, chronic neurocognitive impairment, or chronic traumatic encephalopathy; however, a causal connection remains unproven [21,22]. (See Chapters 11 and 56 for a more thorough discussion of these issues.)

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