Pediatric Traumatic Brain injury

Posted on November 23, 2021

The management and pathophysiology of TBI differ in children as compared to adults. The leading cause of death and disability in children is Traumatic Injury to the scalp, brain, and skull. Even without external bleeding, a slight blood loss can lead to hemorrhagic shock in a newborn child, infant, or toddler. 

To evaluate and diagnose children with TBI, advances in diagnostic imaging have improved the quality of care. Magnetic resonance imaging has enabled proper diagnosis, treatment selection, and prevention of further complications, such as post-traumatic seizures and brain dysfunction. 

TBI patterns according to age and development

According to CDC, an estimated 475,000 people in the age group of 0-14 sustain TBI annually, of which 90% return home with mild injuries, 2,685 die, and 37000 are hospitalized because of injuries. 

The high death rate in children younger than four years is due to abusive injuries in infants and young children because of anatomic differences that contribute to the higher incidence of diffuse cerebral edema and parenchymal injuries. 

Falls and motor vehicle accidents, shaken baby syndrome, and abusive head trauma account for TBI- related hospitalization and deaths related among infants aged less than two years. 

Toddlers and school children suffer accidental head injuries due to road accidents and pedestrian injuries. Adolescents are prone to bicycle, motorcycle, and sports-related accidents leading to TBI. The severity and mortality of TBI have dropped with child safety seats and protective sports gear.  

Clinical presentation of children with TBI

The Pediatric Glasgow Coma Scale (PGCS) is used to determine the severity of the head trauma. The high risk of pediatric brain injury is due to the infant skull being less rigid due to higher plasticity and deformity. Intra and extracranial hemorrhages during delivery and by the use of obstetric instruments can lead to hematomas.

Shaking infants produces slight deformation of the skull, and high plasticity results in stretching and sharing injuries of the vessels. Children have bigger heads than adults in relation to their body size. Hence, the chances of the head being hit are higher than that in adults. 

The extent of myelination affects the susceptibility of traumatic forces. The head is relatively heavy, making it more vulnerable to TBI, the neonatal brain is watery with little myelin. Cerebral contusion is high because of its softness. 

The protruding forehead in young children increases the risk of being directly hit on the head. Also, the neck muscles are weak, and the head is relatively heavy. Hence any injury makes the head prone to fractures and injuries. 

Signs and symptoms

Depending on the extent and area of injury to the brain, the age when the injury occurred, and functions affected, effects can be temporary or permanent. The functional impact of TBI in children can differ from that in adults because the pediatric brain is still developing.

Some children may not present with the immediate effects of TBI but may experience challenges later on when academic demands increase. These problems can affect educational and vocational outcomes, participation in home, school, community, friendships, and overall quality of life. 

Signs and symptoms can exist with other developmental disorders such as ADHD, Autism, learning disability, intellectual disability, spoken and written language disorders, childhood fluency disorders, childhood apraxia of speech, late language emergence, and social communication disorders.  

The full sequelae of pediatric TBI can persist well into adulthood; hence TBI in children is not a ine-time rather a chronic disease.