Caring for traumatic brain injury in children can be a challenge!

Traumatic brain injury is the most common cause of morbidity and mortality in children. However, it is still challengeable to early predict the outcome of individual patients with severe head injuries. Glasgow outcome scale is the most widely used scoring system in evaluating neurological outcome for head injury patients. Moreover, it is likely to underestimate morbidity and is not always readily applicable in children. It is an important issue to develop a practical, reliable and valid neurological outcome instrument in children in forwarding research.

INTRODUCTION

Traumatic brain injury (TBI) is the most common cause of morbidity and mortality in children. Many scoring systems have been established to predict the neurological outcomes in children with TBI. Clinically, different scoring systems may show different characteristics and various effects in estimating children with TBI. However, the golden standard scoring system for predicting neurological outcome in children with TBI is still unclear. Also, it is equivocal which clinical scoring system can be the most useful scale in the emergency department. This concern has led to renewed interest in clinical scoring systems to be better applied clinically and accurately predict neurological outcomes in children with TBI.

TBI is the most common cause of morbidity and mortality in children over 1 year of age and young adults.[1] Clinically, many scoring systems may aid clinicians in evaluating the neurologic conditions and predicting the outcomes in patients with TBI. However, different scoring systems may show different characteristics for clinicians to evaluate these patients. On the basis of Glasgow Coma Scale (GCS), the severity of the TBI is graded as mild (GCS 15-13), moderate (GCS 12-9) or severe (GCS 8-3). Since the Glasgow Outcome Scale (GOS) published by Jennett and Bond in 1975,[2] it becomes the most widely used scoring system in evaluating neurological outcome for head injury patients. The current recommendations are to use the GOS at 6 months to measure outcome after severe head injury. However, it is likely to underestimate morbidity in children and is not always readily applicable in this group. In 2001, Crouchman and colleagues developed a pediatric adaptation of the GOS, the King's Outcome Scale for Childhood Head Injury (KOSCHI).[3] They expand the five categories of GOS to provide more sensitivity at the milder end of the disability range. In the KOSCHI, the GOS category of “persistent vegetative state” was replaced by “vegetative”. “Severe disability”, “moderate disability” and “good recovery” were allocated two categories, in acknowledgement of the long-term importance of relatively minor sequelae in a developing child. In addition, they suggested that the KOSCHI could be used to (1) document recovery and monitor the burden of disability in individual children; (2) plan service and evaluate rehabilitation programs; and (3) assess effects of service and research interventions. In a prospective cohort study, Calvert et al. reported that KOSCHI scored at hospital discharge correlates with severity of injury and some cognitive, health status and health-related quality of life (HRQL) outcomes early after TBI. It is not helpful at predicting later difficulties, or behavioral and emotional problems. In addition, another neurological outcome score for children was developed by Okada et al. in 2003 such as Neurologic Outcome Scale for Infants and Children (NOSIC).[4] They recommended that the NOSIC was a practical, reliable, valid, nonproprietary instrument applicable to children with a broad range of ages and neurologic diagnoses. But the limitations of NOSIC were relatively low sensitivity to mild deficits, lacking much clinical experience and can not be administered by mail or telephone.

It is really a big challenge for primary clinicians to early predict the outcome of individual patients with severe head injuries. However, predicting and establishing the prognosis after TBI is an important question for doctors, patients and their families, as well as for health organizations and insurers. Previous studies had shown some important factors associated with poor outcome after pediatric TBI, including: low admission GCS score, poor pupil reflexes recovery, coagulopathy, brain computed tomography (CT) results: (Subarachnoid hemorrhage with brain swelling and edema, subdural, intracerebral hemorrhage, and basal ganglion lesions), hyperglycemia, hypoxia, impaired cerebral autoregulation and early hypotension.[5-8] In this issue entitled “Outcome Analysis and Outcome Predictors of Traumatic Head injury in Childhood-Analysis of 454 Observations” in Journal of Emergencies, Trauma, and Shock, the authors did their effort to evaluate the factors correlated with poor outcome in children with TBI. Based on the results of multivariate analysis, they found that factors associated with a bad outcome (GOS<4: death, persistent vegetative state, severe disability) were PRISM ≥24 (P=0.03; OR:5.75); GCS score ≤8 (P=0.04; OR:2.42); cerebral edema (P=0.03; OR: 2.23); lesion type VI on CT according to Traumatic Coma Data Bank Classification (P=0.002; OR:55.95); Hypoxemia (P=0.02; OR:2.97) and sodium level >145 mmol/l (P=0.04; OR:4.41). The authors concluded that the neurological outcome measure (GOS) was a very blunt instrument, especially for survivors who were not vegetative or severely disability. In addition, GOS was not only poor-sensitive to children with neurobehavioral impairments but also less sensitive to children with substantial impact on academic, social function and quality of life.

As most of previous studies mentioned,[5-8] GOS was commonly used to evaluate patients’ neurological conditions. Although GOS appears to be simple and easy-recorded, the variables of GOS involve more physical evaluation than cognitive, emotional and behavior surveys. This issue may lead clinicians to underestimate the severity and prognosis in TBI. Moreover, childhood with TBI may have deficits increasing with continuous development. The above study also has provided some important predictive factors associated with poor neurologic outcome. The results might be helpful for clinicians in further evaluation and management of TBI patients. However, even in TBI patients with initially good outcome indicators (good recovery and only mild-to-moderate disability), poor learning and poor social behavior functions may occur in 6 months after TBI events. During the recent 30 years, the survival rate and neurological outcome of TBI in children have improved a lot. However, the disabled survivors remain a significant financial burden on health, education and social-service budgets not only in developing countries but also in developed countries. In order to adequately evaluate neurological outcomes after TBI, some studies had used a variety of instruments from complex neuropsychological tests to simple clinical outcome scales. Nevertheless, which is the gold standard neurological outcome scoring system in children with TBI remains equivocal.

Until now, there have been several particular challenges for clinicians in evaluating outcomes after childhood TBI. Physical, behavioral, emotional and cognitive impairments make various contributions to the overall morbidity, depending on the age at injury, interval since injury and the severity of injury. In addition, measurements in children need to be considered to age-appropriate expectations, and since the process of development and growth continues after the injury, the shortfall between current functional status and age-dependent “normality” is dynamic. The dynamic correlation and interaction among the components of the morbidity developed after TBI may lead to dilemma in further management and evaluation. Therefore, we think that to develop a practical, reliable and valid neurological outcome instrument in children is an important issue in forwarding research. Furthermore, to achieve early accurate assessment, adequate rehabilitation and long-term follow-up is also the key point of improving neurological outcome in children with TBI.