Inflicted traumatic brain injury: relationship of developmental outcome to severity of injury

Inflicted traumatic brain injury (TBI) is a frequent consequence of physical child abuse in infants and children. Twenty-eight children who were 2-42 months of age when hospitalized for moderate to severe TBI were enrolled in a prospective, longitudinal study of neurobehavioral outcome following acquired brain injury. Relative to a comparison group, the children with inflicted TBI had significant deficits in cognitive, motor and behavioral domains when assessed with the Bayley Scales of Infant Development-II 1 and 3 months after the injury. Nearly half of the injured children showed persisting deficits in attention/arousal, emotional regulation and motor coordination. Greater injury severity, as indicated by lower coma scale scores, longer periods of unconsciousness and the presence of edema/cerebral infarctions was associated with poorer outcomes in all domains.     

Recovery of intellectual ability following traumatic brain injury in childhood: impact of injury severity and age at injury

Traumatic brain injury (TBI) may have a profound impact on a child's ongoing development. Various risk factors have been found to predict outcome, but considerable variability remains unexplained. This study used a prospective, longitudinal design to examine the relationship between recovery, injury severity, age at injury and pre-injury ability. 124 children were divided according to (1) age at injury: 'young' (3-7 years) 'old' (8-12) and (2) injury severity (mild, moderate, severe). Children were evaluated acutely (T1) and at 12 months post-injury (T2), using standardized intellectual measures (IQ). Results showed a relationship between greater injury severity and poorer IQ. Age at injury was not predictive of outcome for children with mild/moderate TBI. For severe TBI, younger age at injury led to minimal recovery in IQ, while recovery from later injury was similar to that for adults. Findings suggest that children sustaining severe TBI in early childhood may be particularly at risk for residual problems post-injury.     

Functional memory skills following traumatic brain injury in young children

Traumatic brain injury (TBI) may have a profound impact on a child's ongoing development. Various risk factors have been found to predict outcome, but considerable variability remains unexplained. This study used a prospective, longitudinal design to examine recovery of memory function following TBI within the pre-school period. Forty-four children with TBI were divided according to injury severity (mild, moderate, severe), and compared to age and SES matched healthy controls (n = 26). Children were evaluated acutely and at 12 months post-injury using the Rivermead Behavioural Memory Test for Children. Results failed to show a clear dose-response relationship between injury severity and memory function during the acute phase of recovery. However, this relationship developed over time, with greater memory impairments evident for children with more severe TBI by 12 months post-injury. Children with mild TBI exhibited few memory problems.     

Proton spectroscopy detected myoinositol in children with traumatic brain injury

Previous studies have shown that proton magnetic resonance spectroscopy (MRS) is useful in predicting neurologic prognosis in children with traumatic brain injury (TBI). Reductions in N-acetyl derived metabolites and presence of lactate have been predictive of poor outcomes. We examined another spectroscopy metabolite, myoinositol (mI), to determine whether it is altered after TBI. Found primarily in astrocytes, mI functions as an osmolyte and is involved in hormone response pathways and protein-kinase C activation. Myoinositol is elevated in the newborn brain and is increased in a variety of diseases. We studied 38 children (mean age 11 y; range 1.6-17 y) with TBI using quantitative short echo time occipital gray and parietal white matter proton MRS at a mean of 7 d (range 1-17 d) after injury. We found that occipital gray matter mI levels were increased in children with TBI (4.30 +/- 0.73) compared with controls (3.53 +/- 0.48; p = 0.003). We also found that patients with poor outcomes 6-12 mo after injury had higher mI levels (4.78 +/- 0.68) than patients with good outcomes (4.15 +/- 0.69; p < 0.05). Myoinositol is elevated after pediatric TBI and is associated with a poor neurologic outcome. The reasons for its elevation remain unclear but may be due to astrogliosis or to a disturbance in osmotic function.     

Nerve growth factor expression correlates with severity and outcome of traumatic brain injury in children.

BACKGROUND: Secondary brain damage after traumatic brain injury (TBI) involves neuro-inflammatory mechanisms, mainly dependent on the intracerebral production of cytokines. In particular, interleukin 1beta (IL-1beta) is associated with neuronal damage, while interleukin 6 (IL-6) exerts a neuroprotective role due to its ability to modulate neurotrophins biosynthesis. However, the relationship between these cytokines and neurotrophins with the severity and outcome of TBI remains still controversial. AIMS: To determine whether the concentration of IL-1beta and IL-6 and neurotrophins (nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), glial-derived neurotrophic factor (GDNF)) in the cerebrospinal fluid (CSF) of children with TBI correlates with the severity of the injury and its neurologic outcome. METHODS: Prospective observational clinical study in a university hospital. CSF samples were collected from 27 children at 2h (Time T1) and 48 h (Time T2) after severe TBI, and from 21 matched controls. Severity of TBI was evaluated by GCS and neurologic outcome by GOS. CSF concentrations of cytokines and neurotrophins were measured by immunoenzymatic assays. RESULTS: Early NGF and IL-1beta concentrations (T1) correlated significantly with the severity of head injury, whereas no correlation was found for IL-6, BDNF, and GDNF. Furthermore, higher NGF and IL-6 and lower IL-1beta expression at T2 were associated with better neurologic outcomes. No significant association was found between BDNF or GDNF expression and neurologic outcome. CONCLUSIONS: NGF concentration in CSF is a useful marker of brain damage following severe TBI and its up-regulation, in the first 48 h after head injury together with lower IL-1beta expression, correlates with a favorable neurologic outcome. Clinical and prognostic information may also be obtained from IL-6 expression.     

Practitioner Review: Beyond shaken baby syndrome: what influences the outcomes for infants following traumatic brain injury?

Background: Traumatic brain injury (TBI) in infancy is relatively common, and is likely to lead to poorer outcomes than injuries sustained later in childhood. While the headlines have been grabbed by infant TBI caused by abuse, often known as shaken baby syndrome, the evidence base for how to support children following TBI in infancy is thin. These children are likely to benefit from ongoing assessment and intervention, because brain injuries sustained in the first year of life can influence development in different ways over many years. Methods: A literature search was conducted and drawn together into a review aimed at informing practitioners working with children who had a brain injury in infancy. As there are so few evidence‐based studies specifically looking at children who have sustained a TBI in infancy, ideas are drawn from a range of studies, including different age ranges and difficulties other than traumatic brain injury. Results: This paper outlines the issues around measuring outcomes for children following TBI in the first year of life. An explanation of outcomes which are more likely for children following TBI in infancy is provided, in the areas of mortality; convulsions; endocrine problems; sensory and motor skills; cognitive processing; language; academic attainments; executive functions; and psychosocial difficulties. The key factors influencing these outcomes are then set out, including severity of injury; pre‐morbid situation; genetics; family factors and interventions. Conclusions: Practitioners need to take a long‐term, developmental view when assessing, understanding and supporting children who have sustained a TBI in their first year of life. The literature suggests some interventions which may be useful in prevention, acute care and longer‐term rehabilitation, and further research is needed to assess their effectiveness.     

Predictors of outcome following traumatic brain injury in young children

The relationship between clinical and neuroimaging variables and multiple outcome measures was examined in a longitudinal, prospective study of 60 children less than 6 years of age who sustained either inflicted or noninflicted traumatic brain injury. Hierarchical multiple regression indicated that the modified Glasgow Coma Scale score, the duration of impaired consciousness and the number of intracranial lesions visualized on CT/MRI accounted for a significant amount of the variance in the Glasgow Outcome Scale (GOS), cognitive and motor scores at baseline, 3- and 12-month evaluations. Inflicted brain injury adversely affected both GOS and cognitive outcomes. Pupillary abnormalities were associated with poorer motor outcome. Neither age at injury nor the Injury Severity Score accounted for significant variability in outcomes.     

Assessment of attention following pre-school traumatic brain injury: a behavioural attention measure

This study investigated attentional impairments and recovery in pre-school children following traumatic brain injury (TBI). Children aged between 3-8 years were assigned to two groups on the basis of severity of injury: (i) mild TBI and (ii) severe TBI. Children were evaluated at the acute stage postinjury (0-3 months) and again at 6 months on a range of standardized intellectual and attention measures. In addition, a specifically developed behavioural attention measure was employed. Results revealed a tendency for children with severe injuries to exhibit greater attentional impairments in the acute phase post-injury. In addition, children who sustained a severe TBI demonstrated significant recovery in attentional functioning over time. Results indicated differential recovery rates for separate components of attention. Both groups demonstrated a trend towards recovery of arousal and motivation over time, while focused attention, impulsivity and hyperactivity remained stable.     

Neuroprotection in paediatric traumatic brain injury

Traumatic brain injury (TBI) is the leading cause of trauma-related death and disability in children worldwide. The outcome from TBI can be improved by early aggressive management of oxygenation and blood pressure. There is evidence to suggest that adhering to guidelines when managing these patients can have a positive effect on the outcomes. In this article we review the general supportive and targeted neuroprotective measures that are outlined in international paediatric guidelines and are most widely used in the critical care management of patients with TBI; we further review how these measures can influence the underlying evolving pathophysiology in these patients. The aim of critical care management of patients with TBI is to prevent or limit secondary brain injury by optimizing cerebral perfusion and oxygenation to improve survival and clinical outcomes. We also discuss how to monitor patients with traumatic brain injury on the paediatric intensive care unit and we give a practical approach on how to respond to deteriorating patients and to the complications arising during the course of their management.     

Predictors of acute child and family outcome following traumatic brain injury in children

OBJECTIVE: To examine the relative contributions of injury severity, level of physical and cognitive disability, child behavior and family function to short-term outcome 6 months following traumatic brain injury (TBI) in children. DESIGN: Prospective, longitudinal, between-group design, comparing preinjury and postinjury measures of functional outcome across three levels of injury severity. SUBJECTS: One hundred and twelve children, aged 2-12 years admitted to the Royal Children's Hospital, Melbourne, with a diagnosis of TBI. The sample was divided into three groups, according to injury severity: mild TBI (n = 31), moderate TBI (n = 52) and severe TBI (n = 29). Children with a history of neurologic, developmental and psychiatric disorder were excluded from participation. MAIN OUTCOME MEASURES: Levels of postinjury functioning in the following domains: physical function, cognitive ability (incorporating intellect, memory and attention), behavioral and family functioning, and level of family burden. RESULTS: A clear dose-response relationship for physical and cognitive outcomes was found, with severe TBI associated with greater impairment of physical, intellectual, memory and attentional function. For psychosocial outcome, results were less clearly linked to injury severity. Preinjury behavioral and family functioning were closely related to postinjury function in these domains, with an interaction identified between family function and child behavior at 6 months postinjury. Family functioning remained unchanged postinjury, although level of burden was high, and predicted by injury severity, functional impairment and postinjury behavioral disturbance. CONCLUSIONS: These results suggest ongoing functional problems for the child and significant family burden 6 months following TBI. The nature and severity of physical and cognitive problems are most closely related to injury severity, with family functioning and child behavior better predicted by psychosocial and premorbid factors.     

126例儿童颅脑外伤患者致伤因素及临床特点回顾性分析

目的 分析需住院或留院观察的颅脑外伤（TBI）患儿的致伤因素及临床特点。方法 收集2014年1月1日至2016年8月31日于急诊科就诊且需留院治疗的126例TBI患儿的临床资料,对其致伤因素及部分临床特点做回顾性分析。结果 126例TBI患儿中,男95例,女31例,年龄2.8（0.8,5.5）岁,以 < 1岁者最多（48/126,38.1%）,死亡26例。TBI类型前2位是硬膜外血肿（54.0%）、蛛网膜下腔出血（50.8%）,入院24 h内有83例（65.9%）患儿Glasgow昏迷量表评分≤ 8分。不同年龄组TBI致伤因素、发生场所各不相同。TBI最常见的前2位致伤因素为坠落/摔伤（51.6%）和道路交通伤害（42.9%）。与其他年龄段相比,< 1岁患儿最易发生坠落/摔伤（46%,P=0.023）。道路交通伤害所致TBI高发年龄段为3~6岁（35%,P < 0.001）。伤害发生场所集中于家中（47.6%）和公路/街道（45.2%）;所有家中致伤患儿中,< 1岁组所占比例最高（48%,P=0.002）,3~6岁患儿主要受伤地点为公路/街道（53%）。造成TBI患儿死亡的首位致伤因素是道路交通伤害（69%）;死亡病例中,以 < 1岁患儿最多（62%）。结论 不同年龄组TBI患儿的致伤因素和发生场所不尽相同。1岁以下儿童发生TBI比例高、死亡人数最多,多为家中发生坠落/摔伤所致。3~6岁儿童易因道路交通伤害发生TBI。道路交通伤害最易导致死亡。     

Comparison of 15-Month Motor and 18-Month Neurological Outcomes of Term Infants with and without Motor Delays at 10-Months-of-Age

Fifteen-month motor outcomes and 18-month neurological outcomes of term infants with (Group 1, n + 18) and without (Group 2, n + 18) low scores on the Alberta Infant Motor Scale (AIMS) at 10-months-of-age were compared. Their scores on the AIMS did not differ at 15-months. Infants in Group 1, however, obtained significantly lower scores on the locomotor skill area of the Peabody Developmental Motor Scales at 15 months and walked an average of 2 months later than infants in Group 2. Nevertheless, infants in both groups were functioning within the range of normal at 15 months and had neurologically normal 18-month outcomes, as assessed by a pediatrician using the Neurological Examination of the Collaborative Perinatal Project, except for one child in Group 1 who was identified as “suspicious” because he was not yet walking. The results suggest that motor delays detected at 10-months will not necessarily persist. Pediatric therapists are encouraged to consider normal variations in both rate and pattern of early motor development when making judgements about the results of norm-referenced tests. Instituting a practice of serial assessments, rather than relying on the results of one assessment, will improve the accuracy of identification of infants who exhibit persistent motor delay.     

Epidemiology of traumatic brain injury in children receiving intensive care in the UK

Aims: To describe the epidemiology of children with traumatic brain injury (TBI) admitted to paediatric intensive care units (PICUs) in the UK. Methods: Prospective collection of clinical and demographic information from paediatric and adult intensive care units in the UK and Eire between February 2001 and August 2003. Results: The UK prevalence rate for children (0–14 years) admitted to intensive care with TBI between February 2001 and August 2003 was 5.6 per 100 000 population per year (95% Poisson exact confidence intervals 5.17 to 6.05). Children admitted to PICUs with TBI were more deprived than the population as a whole (mean Townsend score for TBI admissions 1.19 v 0). The commonest mechanism of injury was a pedestrian accident (36%), most often occurring in children over 10. There was a significant summer peak in admissions in children under 10 years. Time of injury peaked in the late afternoon and early evening, a pattern that remained constant across the days of the week. Injuries involving motor vehicles have the highest mortality rates (23% of vehicle occupants, 12% of pedestrians) compared with cyclists (8%) and falls (3%). In two thirds of admissions (65%) TBI was an isolated injury. Conclusions: TBI in children requiring intensive care is more common in those from poorer backgrounds who have been involved in accidents as pedestrians. The summer peak in injury occurrence for 0–10 year olds and late afternoon timing give clear targets for community based injury prevention.     

Epidemiology of traumatic brain injury in children receiving intensive care in the UK.

AIMS: To describe the epidemiology of children with traumatic brain injury (TBI) admitted to paediatric intensive care units (PICUs) in the UK. METHODS: Prospective collection of clinical and demographic information from paediatric and adult intensive care units in the UK and Eire between February 2001 and August 2003. RESULTS: The UK prevalence rate for children (0-14 years) admitted to intensive care with TBI between February 2001 and August 2003 was 5.6 per 100,000 population per year (95% Poisson exact confidence intervals 5.17 to 6.05). Children admitted to PICUs with TBI were more deprived than the population as a whole (mean Townsend score for TBI admissions 1.19 v 0). The commonest mechanism of injury was a pedestrian accident (36%), most often occurring in children over 10. There was a significant summer peak in admissions in children under 10 years. Time of injury peaked in the late afternoon and early evening, a pattern that remained constant across the days of the week. Injuries involving motor vehicles have the highest mortality rates (23% of vehicle occupants, 12% of pedestrians) compared with cyclists (8%) and falls (3%). In two thirds of admissions (65%) TBI was an isolated injury. CONCLUSIONS: TBI in children requiring intensive care is more common in those from poorer backgrounds who have been involved in accidents as pedestrians. The summer peak in injury occurrence for 0-10 year olds and late afternoon timing give clear targets for community based injury prevention.     

Prehospital and in-hospital mortality: a comparison of intentional and unintentional traumatic brain injuries in Colorado children

OBJECTIVES: To describe the incidence and case-fatality rates of traumatic brain injury (TBI) in young children in Colorado, to compare these injuries based on intentionality and outcome (prehospital death, in-hospital death, or survival), and to model the association of intentionality with TBI-related mortality. METHODS: Cases were drawn from the 1994-2002 Colorado Traumatic Brain Injury Surveillance System. Incidence and case-fatality rates for intentional and unintentional TBI were calculated. We performed univariate comparisons based on the intentionality and outcome of the TBI. Multivariate logistic regression was used to estimate the association of intentionality and mortality, controlling for injury severity. RESULTS: Of the 1333 children aged 0 to 36 months with TBI, 340 had intentional and 993 had unintentional TBI. Incidence for intentional and unintentional TBI was 16.1 and 47.0 per 100,000, respectively. Children with intentional TBI had a higher case-fatality rate, in-hospital death rate, and injury severity. Intentional TBI deaths were twice as likely to occur in hospital than prehospital, whereas unintentional TBI deaths were twice as likely to occur prehospital. Intentionality was significantly associated with mortality, with the effect increasing with increasing age. CONCLUSION: Intentionality--independent of severity--raises the mortality of TBI in young children.     

Aquatic Therapy for a Child with Type III Spinal Muscular Atrophy: A Case Report

ABSTRACT

Spinal muscular atrophy (SMA) is a neuromuscular disorder characterized by degeneration of alpha motor neurons. This case report describes an aquatic therapy program and the outcomes for a 3-year-old girl with type III SMA. Motor skills were examined using the 88-item Gross Motor Function Measure (GMFM), the Peabody Developmental Motor Scales (PDMS-2), and the GAITRite system. The child received aquatic therapy twice per week for 45-min sessions, for 14 weeks. The intervention included aquatic activities designed to improve gross motor skills and age-appropriate functional mobility. The GMFM total score improved by 11% following the intervention. The Standing Dimension score improved by 28% and the Walking, Running, and Jumping Dimension score improved by 18%. The gross motor quotient for the PDMS-2 improved from 66 to 74. The child's gait showed improvement in walking velocity, stride length, and single-limb support time as a percentage of the gait cycle. The outcomes of this case report demonstrate the successful improvement of gross motor function and gait in a 3-year-old child with SMA. This study provides clinical information for therapists utilizing aquatic therapy as a modality for children with neuromuscular disorders.     

Follow-up of the term infant after hypoxic-ischemic encephalopathy

While the number of survivors of term hypoxic-ischemic encephalopathy (HIE) is lower than the number of survivors of extreme prematurity, the proportion of neonates with long-term sequelae is higher. All neonates with Sarnat stages 2 (moderate) and 3 (severe) should be enrolled in follow-up programs. The present paper discusses the clinical and imaging diagnostic criteria for HIE, which are essential to decisions about follow-up. Prognostic indicators are also summarized. The recommendations for follow-up and intervention are based on the clinical condition of the baby at the time of discharge from intensive care, including an assessment of feeding, vision, hearing and whether seizures continue to be present. Early assessments (at four to eight months) focus on head growth, general health and motor neurodevelopment. Assessments at 12 to 24 months focus on cognitive skills and language development. Preschool assessments are also strongly recommended to provide for the identification of children requiring early education programs. Knowledge of long-term outcome and its secular changes enhance prognostication, and the evaluation of new preventive and therapeutic approaches.     

A Critique of Therapeutic Intervention Programming with Reference to an Alternative Approach Based on Motor Learning Theory

As an alternative to current therapeutic intervention programming for developmentally delayed children, a rationale for intervention programmming based on theories of motor control and learning is presented. The authors believe that the keys to successful motor training programs are repetition, correctly performed practice of functional skills, and sufficient learning time to facilitate skill retention and transfer. In order for therapists to construct and implement the most appropriate motor training programs for developmentally delayed children, they must be knowledgeable of the sensory-motor basis of motor skill acquisition. Some of the more important concepts of motor control and learning are presented.