Author(s): Charnette Lercara, MD, Jayne Ha, DO, Elver Ho, BA, Lon Yin Chan, BA
Originally published: April 5, 2017 Last updated: January 18, 2024
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Disease/Disorders

Definition

Traumatic brain injury (TBI) is a leading cause of pediatric disability and death. TBI is categorized as mild, moderate, and severe according to the Glasgow Coma Scale (GCS). Mild, moderate and severe TBI is defined by a GCS of 13-15, 9-12 and 3-8 respectively. TBI can also be categorized as a primary injury, in which the injury is caused by an incidence of impact, or a secondary injury, which is induced by a permutation of inflammation, ischemia, vasospasms, apoptosis.1

The Pediatric Glasgow Coma Scale (pGCS) has been modified from the original GCS to appropriately assess pediatric TBI cases, particularly in children less than 2 years old.2 Similar to the GCS, the pGCS is scored from 3-15 and includes modifications for motor (2 out of 6 items) and verbal (4 out of 5 items) assessments for preverbal children.

Etiology

Principal causes of TBI include motor vehicle crashes, unintentional falls, being struck by or against an object, suicide, homicide and other miscellaneous causes.3 Non-accidental trauma (NAT) causes of pediatric TBI, though less likely, should be recognized especially in children less than 2-years-old.1

Epidemiology including risk factors and primary prevention

16,070 TBI-related hospitalizations consisted of children ages 0-17 years old in 2019. According to the Centers for Disease and Control Prevention Surveillance Report of 2022, children from ages 0-17 years accounted for 4.1% of all TBI-related deaths. TBI-related deaths in children ages 0-17 were most commonly caused by motor vehicle crashes and homicide.3 Of note, these statistics may not fully account for all mild TBI as it is often underreported. Male children are at greater risk of TBI-related injuries and deaths than females. Children from lower medial family incomes were more likely to experience TBI and more likely to die.4

Patho-anatomy/physiology

Mild to moderate TBI results from a mechanical insult generated by acceleration–deceleration and rotational forces. This same mechanism can subsequently lead to diffuse axonal injury, commonly affecting the corpus callosum, parasagittal white matter, and midbrain.

Calcium homeostasis is critical for neurons – intracellular calcium in neurons is five times lower than the extracellular concentration. However, rapid brain movements can cause neurons to stretch, activating NMDA receptors which allow calcium to enter the cell, disrupting calcium homeostasis. This disruption causes a greater demand for adenosine triphosphate (ATP) and glucose.5 In efforts to restore homeostasis, ATP-dependent ion pumps are upregulated, causing a depletion of reserve.1  The excess calcium and subsequent ATP depletion leaves the cell especially vulnerable to injury during times of brain healing.6,7-9 Calcium binding proteins will often sequester the sudden abundance of calcium but young developing brains have lower levels of calcium binding protein expression and thus are more susceptible to injury.5

Inflammation following a TBI may be both protective as well as damaging. Healing may arise from cytokine upregulation as well as neuroimmune cell activation, migration and recruitment; however, inflammation may diffusely spread and contribute to secondary causes of brain injury.Adolescent children also experience pulsatile release of sex hormones, which may leave them exceptionally vulnerable after a TBI.5

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Following mild TBI, symptoms can manifest immediately or up to 72 hours following injury and symptoms can be categorized into the following:

  • Physical: headaches, nausea, vomiting, fatigue, vestibular disturbance, blurry vision, photosensitivity
  • Cognitive: difficulty thinking clearly, concentrating, or remembering new information, feeling slowed down
  • Emotional: irritability, sadness, increase sensitivity, nervousness, anxiety not explained by other psychological cause
  • Sleep: increased or decreased amount of sleep, difficulty falling asleep

Certain symptoms to consider that may warrant further evaluation include abnormal posturing, extremity weakness or numbness, differing pupil size, worsening headache, repetitive vomiting, acute onset confusion, increased irritability, decreased level of consciousness, or seizures.

Specific secondary or associated conditions and complications

Secondary conditions can be divided into two different categories:

  • Post-concussion syndrome (PCS) is a constellation of physical, cognitive, behavioral, and emotional symptoms that occur after TBI. Symptoms can include headache, fatigue, visual changes, difficulty with balance, confusion, neuropsychiatric issues and difficulty concentration.9 While 90% of concussion symptoms are transient and resolve within two weeks, some patients will experience a lingering of symptoms. 15% of patients with concussion will experience PCS and a portion of those patients will require further evaluation.11
  • Second impact syndrome (SIS) describes a condition in which an individual experiences a second head injury prior to recovery of the initial insult. There are few confirmed cases but the exact incidence of this condition is not known. It is thought that the secondary injury results in dysfunctional cerebral blood flow regulation which results in an increase in intracranial pressure and eventual brain herniation, rapid deterioration and death.12 There is a limited understanding of this condition, lack of research, and controversy surrounding its nature.

Essentials Of Assessment

History

A detailed history including the inciting event, use of protective gear such as helmet or use of seatbelt, duration of any loss of consciousness, and associated injuries. History of the child’s baseline function should also be obtained. If any red flags are observed, then the patient should immediately be evaluated in the ED.

Physical examination

A thorough head-to-toe physical examination must be performed. The exam should include

  • Focused neurologic examination, including a Mental Status Examination (MSE), cranial nerve testing, extremity tone testing, deep tendon reflexes, strength, sensation, and postural stability (Romberg’s Test, dynamic standing)
  • A focused vision examination including gross acuity, eye movement, binocular function and visual fields/attention testing
  • A focused musculoskeletal examination of the head and neck testing for muscle strength, muscle tone, reflexes, passive and/or active range of motion. Cervical spine injuries must also be considered.

The examiner should pay close attention and be watchful for any concerning signs such as

  • Cranial nerve deficits, periorbital or postauricular ecchymosis, cerebrospinal fluid rhinorrhea or otorrhea, and hemotympanum (signs of basilar skull fracture).
  • Fundoscopic examination for retinal hemorrhages and papilledema (increased intracranial pressure).
  • Scalp examination for hematomas, fractures, and bony deformities. In infants, any open fontanelles should be examined for fullness or tenseness.
  • Auscultation for carotid bruits which may be an indication for carotid dissection.
  • Evaluation for spinal tenderness, paresthesias, incontinence, extremity weakness, priapism which may indicate spinal cord injury.
  • Deep tendon reflexes, presence of Babinski sign, clonus and Hoffman’s sign.

Functional assessment

There are various tools that have been validated for the assessment of mild TBI. These tools can be grouped into five main groups13

  • Common hospital assessment tools
  • Neuropsychological tests (written and computerized)
  • Postural stability testing
  • Sideline Assessment Tools
  • Symptoms Checklists

In this review, we will cover a select number of tools used for assessment of mild to moderate TBI.

Neuropsychological tests

A commonly used neuropsychological test is the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT), which provides a baseline assessment for patients. This computerized test provides scores for four areas: verbal memory, visual memory, reaction time, visuomotor speed. Demographic information, history data, current concussion details and somatic and cognitive symptoms are also taken into account. ImPACT is used for patients ages 10 and above. There is also an adapted version for ages 5-9 years old called the Pediatric ImPACT.14

While the ImPACT is useful and easily accessible, there are some limitations to its usefulness. Limitations include insufficient research in its usage for pre-existing cognitive issues (i.e. ADHD, learning disability, psychiatric diagnoses), its use in non-sports related concussion, and the ceiling effect that may diminish its reliability.6,15 More importantly, clinicians, especially sideline clinicians, should be aware of sandbagging by high school athletes who intentionally underperform in their baseline ImPACT assessment.16

Sideline assessment tools

There are three main tools to assess concussions on the sidelines: the Sport Concussion Assessment Tool (SCAT5) for ages 13 and above, the Child SCAT5 for ages 5 to 12, and the Standardized Assessment of Concussions (SAC). The SCAT5 (2017) is the most updated version, revised from the prior SCAT3 (2013). Certain modifications include extended and clarified instructions, required clearance by a health professional before return to play, and emphasis on an initial rest period of 24-48 hours.17 The SCAT5 should not be used as a standalone tool for assessment and its utility decreases after 3-5 days post-injury.18 These measure the patient’s memory, orientation, and concentration (reference: page 300 – acute evaluation) using a checklist and the assessment of cognitive performance. Physicians can use the results of these assessments to guide their management.

The Standardized Assessment of Concussions (SAC) is another screening tool available for sideline evaluation. The SAC is a brief evaluation of cognitive function and includes standard questions of orientation (place, time, date, month, year), working memory via the immediate recall of 5 words, concentration by recalling a list of digits and the months backward, and remote memory via delayed recall.19 Certain modifications have been made including increasing the recall to 10 words to prevent the ceiling effect.18

Postural stability testing

The vestibular/ocular motion screening (VOMS) tool is also used to measure vestibular and ocular impairments specially to evaluate concussion after sport-related activities. The tool evaluates smooth pursuits, horizontal and vertical saccades, the near point of convergence, horizontal and vertical vestibular ocular reflexes, and visual motion sensitivity, and should be used in tandem with pre- and post-symptoms assessments to determine provocation severity (e.g., dizziness).20

Symptoms checklists

The post-concussion symptoms scale (PCSS) is a 22-item self-reported questionnaire recommended by the 5th International Conference on Concussion in Sport as a means to monitor clinical recovery. It asks patients to rate the severity of various symptoms they may be experiencing with higher scores indicating more severe levels of dysfunction.18 The Graded Symptom Checklist (GSC) is another self-report measure for concussion symptoms where symptom severity is rated up to 72 hours after the inciting event.21 A combination of the computerized assessments with the PCSS or GSC have demonstrated confidence in distinguishing pediatric patients with and without mTBI.22

Laboratory studies

Currently, mild to moderate TBI is a clinical diagnosis. There are no standard laboratory studies or markers that have been adopted in the diagnosis of mild-moderate TBI in pediatric patients. However, research is underway to identify markers that may be useful in the future for diagnosis and prognosis. S100B, neuron-specific enolase (NSE), glial fibrillary acidic protein (GFAP), and ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1) are among the most commonly measured brain-specific biomarkers. Though studies have demonstrated overall increased levels of these biomarkers in pediatric patients suffering TBI with links to worse outcomes, there is still insufficient evidence regarding its significance and accuracy in the setting of mild and moderate TBI.22,23

Imaging

Noncontrast computed tomography (CT) of the head is typically the imaging modality of choice in a child with a GCS <15.24 The Pediatric Emergency Care Applied Research Network (PECARN) algorithm delineates recommendations for obtaining a head CT in pediatric patients with mild TBI. According to the PECARN algorithm, children younger than the age of 2 with a GCS<14, a palpable skull fracture or signs of altered mental status (AMS) warrant a CT head. The child may also warrant a CT if he or she presents with loss of consciousness for 5 seconds, experienced a severe mechanism of injury, has a scalp hematoma (excluding frontal), or is “not acting normally” per the parent.1

If the child is older than two, a GCS score of 14 or less, signs of basilar skull fracture, or AMS warrants a CT head. If the child of this age has loss of consciousness, severe headache, vomiting, or severe mechanism of injury, they may warrant a CT head. If the CT is inconclusive, magnetic resonance imaging may be indicated.

Early predictions of outcomes

Studies indicate that pediatric patients with concussions who initiate clinical care (i.e., go to the clinic) within 7 days post-injury rather than later have faster recoveries and are less likely to have prolonged recovery times.19

The pediatric population may be subject to prolonged recovery periods compared to adults because of the following reasons

  • Larger head-to-body ratios
  • Reduced neck and shoulder musculature, leading to increased force transmission to the head
  • Larger subarachnoid space within brain
  • Decreased myelination within brain

However, many often achieve full and rapid recovery. Most patients with mild TBI will recover within 2 weeks. If symptoms last >3 months for any group, it is important to evaluate for other contributing conditions that may be prolonging the recovery or present as post-concussive syndrome.6

Other factors that predict a prolonged recovery include: previous concussions, female gender, mood disturbances (premorbid anxiety, depression, or PTSD), dizziness present at time of injury, retrograde amnesia, mental status change >5 minutes, poorer scores on ImPACT testing.6 Dizziness at 2 weeks post-injury is the single most predictive symptom for post-concussive syndrome.25

Social role and social support system

There may be changes in a child’s emotional, behavioral and social interactions after a TBI. The recovery process may be challenging for patients and family alike, which calls for additional support from an interdisciplinary team. Social workers, psychologists and educators may be necessary for coping and adjustment. Community support groups may be valuable as well.

Professional issues

If abuse is suspected, patients should be further evaluated by the medical team for signs of non-accidental trauma. Please see the Knowledge NOW submission on Child Abuse for further details regarding evaluation and reporting requirements.

Rehabilitation Management And Treatments

Initial recovery phase management

Recommend 2-3 days of rest with stepwise symptoms-limited activity. Introduce cognitive activity followed by physical activity as tolerated by following gradual return to play (RTP) and return to learn (RTL) protocols.

Progression through the stages of the RTP and RTL protocols will be based on symptoms exhibited, so close monitoring by clinicians, family, and school professionals is important.

  • Abortive headache medication (i.e. NSAID) may also be used
  • If sleep disturbances occur, melatonin may also be used
  • Monitor for mood changes

Return to learn protocol

Phase 1: “Brain rest” – No school/complete cognitive rest

24-48 hours

Definition:

High levels of symptoms; physical symptoms that are most prominent and may interfere with even basic tasks.

Interventions:

  • Avoid bright lights, avoid activities that worsen symptoms like screen time, reading, video games, loud music
  • Sleep as much as needed, drink fluids and eat healthy foods

Learning:

No school. No homework or take-home tests. Can ask for copies of notes from students or teachers

Phase 2: “Restful home activity”

Patient starts to improve but may still have some symptoms; may only be able to do cognitive activities for short periods of time

Intervention:

  • Easy tasks at home like drawing or cooking. Soft music and audiobooks.
  • Regular bedtime schedule to allow 8-10 hours of sleep and naps. Limiting screen time to less than 30 minutes a day

Learning:

No school. No homework or take-home tests. Can ask for copies of notes from students or teachers

Phase 3: Return to school – partial day

Once patients can complete 60-90 minutes of light mental activity from phase 2 and have fewer symptoms, consider returning to school partially.

Interventions:

  • 8-10 hours of sleep per night, avoid naps.
  • Continue eating healthy foods and drinking fluids; limit screen time to less than 1 hour a day.
  • Limited social time with friends

Learning:

Limited homework. Multiple choice or verbal assignments preferred over writing. Offer tutoring if needed. Take breaks in a quiet room as needed. Stop work when symptoms worsen.

Phase 4: Return to school – full day

Once patient can complete phase 3 without symptoms

Intervention:

  • Continue with 8-10 hours of sleep per night, drinking plenty of fluids and eating healthy foods

Learning:

Gradual progression to attending classes full days.

Phase 5: Full recovery

Full recovery is typically defined as being able to complete all assignments/tests without symptoms. Patients may initiate return to play protocol once they achieve full recovery for return to learn protocol.26

Return to play

Patients should not return to play on the same day of injury. It is recommended to complete RTL before proceeding with Return to Play (RTP).

Phase 1:  Patient completed their RTL protocol. Walking short distances is acceptable.

Phase 2: Light aerobic activity – 5-10 minutes on an exercise bike, walking or light jogging. No weightlifting.

Phase 3: Moderate aerobic activity – moderate jogging, brief running, moderate intensity weight lifting (less time and/or weight from their typical routine)

Phase 4: Heavy, non-contact activity – sprinting/running, regular weightlifting routine, non-contact sport-specific drills

Phase 5: Practice, full contact.

Phase 6: return to competition

An athlete should only move onto the next phase if they are asymptomatic at their current phase. If symptoms return at any phase, the athlete should stop and may resume at the same phase only after asymptomatic > 24 hours.

Long-term impacts

While many patients recover, some may suffer long-term consequences from their mild to moderate TBI. They may retain mood disturbances, cognitive deficits, memory issues, and other persistent symptoms. This may, in the long run, affect patients’ ability to learn and retain higher-level learning or social skills, thus contributing to developmental delay.27

Coordination of care

For children with a mild injury, a coordinated approach between involved care providers may provide the appropriate level of required services; however, an interdisciplinary approach is required for individuals requiring treatment for complex concussion where multiple providers may be providing care. School professionals, family members, and clinicians are important resources to help students gradually return to school activities.

Patient & family education

When the diagnosis of mild TBI is made, counsel parents that a majority of children (70-80%) recover within 1-3 months. Educate parents and family on warning signs of more serious injury, how to prevent further injury (e.g., gradual return to activities), how to monitor symptoms, management of recovery through rest, and instructions on returning to cognitive and physical activity/recreation.28

Patient education at an appropriate developmental and cognitive level is important to assist with coping and adjustment. Depending on injury severity, this may occur in the acute phase, subacute and/or chronic phase. Family education should be started in the acute phase and carried throughout all phases. Education should be adjusted as the deficiencies become more apparent and the interventions require changing. Parents should be educated on important topics including: prevention of repeat injury, contact sport guidelines, transition to home and school, legal resources, education resources, advocacy, transition to adulthood, and symptoms to look out for that would warrant attention in the ED.

Emerging/unique interventions

Though not a unique intervention, many studies have demonstrated the clinical efficacy of incorporating subthreshold aerobic exercise and neuromuscular training to reduce the sequelae to mild to moderate TBI and hasten recovery.29-31 Recent studies have also begun to explore the potential of utilizing virtual-reality based therapies to facilitate engagement in rehabilitation and improve daily function.32,33

Cutting Edge/Emerging And Unique Concepts And Practice

States are beginning to pass laws regarding return to play following a concussion. Washington was the first state to implement a sports concussion safety law in 2009, which was known as the Zackery Lystedt Law. Since then, many states have followed suit. The law requires school districts to create specific concussion guidelines and educational programs. It also requires guardian and athlete signed consent, immediate removal of youth from practice or games if suspected to have a concussion, and written clearance by a physician before return to play.

Gaps In The Evidence-Based Knowledge

There is limited evidence to support which neuropharmacological agents are best for mild to moderate TBI recovery and whether biomarkers are useful in the evaluation of TBIs. At this time, biomarkers play only a limited role in the evaluation and treatment of mild to moderate TBIs. Research is still ongoing to introduce new blood tests that could be used in clinical practice. For example, S-100β may begin to be utilized across emergency departments in the future when deciding whether or not to obtain a head CT for the assessment of concussion.

Optimal concussion management in children, including return to sports, and extent and duration of cognitive rest needs further evaluation. Further research is indicated to determine therapeutic interventions in patients with persistent functional decline refractory to conventional therapies. Information on mechanisms underlying recovery, factors that prolong recovery, and ability to predict specific long term outcomes is limited.

References

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Original Version of the Topic

Matthew McLaughlin, MD, Suzan Lisenby, BA, Sumita Sharma, BS. Mild to Moderate Pediatric Traumatic Brain Injury. 4/5/2017

Author Disclosure

Charnette Lercara, MD
Nothing to Disclose

Jayne Ha, DO
Nothing to Disclose

Elver Ho, BA
Nothing to Disclose

Lon Yin Chan, BA
Nothing to Disclose