Source: Forsyth FJ, Salorio CF, Christensen JR. Modelling early recovery patterns after paediatric traumatic brain injury. Arch Dis Child. 2010; 95(4): 266– 270; doi: 10.1136/adc.2008.147926Investigators from Newcastle University, UK, and the Johns Hopkins School of Medicine longitudinally evaluated children admitted for inpatient rehabilitation after traumatic brain injury (TBI), in an attempt to predict outcomes. The study population consisted of children consecutively admitted between 1998 and 2008 with moderate or severe TBI, defined as an initial Glasgow Coma Score (GCS) <12 or presence of abnormal intracranial imaging abnormalities. Study patients were assessed serially using the WeeFIM (an age-dependent pediatric adaptation of the adult Functional Independence Measure)1 and other clinical and demographic factors including time to follow commands (TFC). TFC was defined as the post-injury day on which a child was able to follow two simple commands within a 24-hour period.A total of 103 children with a median age of 10.5 years were enrolled. The majority (68%) were boys. The mean number of days between injury and admission to the rehabilitation unit was 13; the median TFC was nine days. At the time of admission to rehabilitation, the initial mean WeeFIM was 32 (maximal possible score of 126 typically achieved at a developmental age of 7); the median GCS was 5. The typical recovery followed a sigmoid curve with an initial slow phase, followed by rapid change, and then a late plateau. Final WeeFIM scores ranged from 18 to 125 (median 105). Children who made faster early progress had a better ultimate recovery. TFC correlated with both final WeeFIM and time to reach 50% final WeeFIM. The ultimate WeeFIM score was reduced by 0.6 units for every day’s delay in the ability to follow commands. The authors conclude that models can be used to predict recovery.The cognitive and behavioral sequelae of TBI can be profound. Even mild TBI can be disruptive to the child’s functioning and is stressful to families. This study confirms that most children experience slow, rapid, and plateau phases of function recovery related to activities of living, and that TFC can be used to predict ultimate recovery.A number of factors complicate studying outcomes from TBI in children. Children with normal development may develop differently from each other, making it difficult to establish the impact of the brain injury itself given the backdrop of normal changes children experience with aging. Children with a TBI are more likely to have preexisting behavioral difficulties such as attention deficit/hyperactivity disorder.3 In addition, the child’s adaptation to brain injury may be influenced by the family’s coping ability.4 Therefore, a child’s recovery from TBI may be related to pre-injury morbidities, injury characteristics, and family functioning.An additional challenge in understanding behavioral and cognitive outcomes of TBI is the difficulty of quantifying the severity of TBI. The classic definition of mild TBI is a GCS of 13 to 15; moderate TBI is a GCS of 9 to 12; and severe TBI is a GCS score ≤ 8.5 This scale, however, is inaccurate in young children and infants.6 The number of lesions on brain computerized tomography may prove to be more sensitive to predict recovery after pediatric injury.7Previously young children were thought not to suffer as much damage from brain injury due to greater plasticity of the brain. This concept is now being challenged; young children may be even more vulnerable to the consequences of brain injury than older children.8 Longitudinal studies of brain-injured young children show less positive acceleration in mean intelligence quotient scores over one year compared to school-aged children and adolescents.9 In a study of children less than 6 years of age, an age effect was seen in executive functioning (working memory and inhibitory control) with children injured at a younger age exhibiting more problems.10 As executive functioning is rapidly developing in the preschool years, this supports the theory that skills in a rapid stage of development may be more vulnerable to TBI.Academic growth curve analyses of children following TBI showed that recovery curves in the most severely injured children decelerated over time, while recovery curves in children with mild to moderate injury were linear, suggesting continued improvement.11 Some growth curves did not decelerate until several years post-injury, with scores in the youngest children dropping one to two years after TBI.Physicians who care for children with TBI need to work with the parents and educational systems to monitor the child’s evolving academic performance and utilize testing evaluation and support services to help the child cope with limitations and achieve his maximum ability.
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Jun 18, 2019
Chung‐Lin Lee + 16
