Moderate-to-Severe Traumatic Brain Injury in Children

Complications and Rehabilitation Strategies

Myra L. Popernack, MSN, RN, CPNP; Nicola Gray, BSN, RN; Karin Reuter-Rice, PhD, CPNP-AC, FCCM, FAAN

Disclosures

J Pediatr Health Care. 2015;29(3):e1-e7. 

In This Article

Definition and Epidemiology of TBI

The CDC defines an acquired brain injury as being caused by "a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain" (CDC, 2014). The injury can be either diffuse, such as a closed head injury from head-to-head contact in football, or a focal penetrating injury from a bullet or sharp object. Acquired brain injuries may result from strokes or other embolic events, infectious diseases, hypoxia/anoxia events, or as postsurgical sequelae.

Recent data from the CDC have shown that about one-half million of the 1.7 million civilian Americans who sustain a TBI are children ages 14 years and younger. One study estimated that at least 145,000 children were living with a TBI-related disability in 2005 and that the overall total life costs (medical costs and productivity losses) of injuries for children younger than 14 years was $60.4 billion (Corso et al., 2006, Zaloshnja et al., 2008). Causes include falls, motor vehicle crashes, being struck in the head by a moving object or against a stationary one, and assault.

Falls account for about one third of the moderate to severe TBI in children 0–14 years of age, the majority of which occur on the playground for children younger than 10 years. Motor vehicle crashes remain the leading mechanism of injury for death and disability in pediatric TBI. Males are more likely to be injured than females and also have a greater likelihood of fatality as a result of higher injury acuity (CDC, 2014). The injured often have increased risk factors associated with pre-existing co-morbidities, such as risk-taking behaviors, learning disabilities, or mental health disorders.

For children who survive brain injury, the mechanism, location, and extent of injury and the immediate interventions used to minimize secondary brain injury significantly influence neurocognitive and motor recovery necessary for independent functioning. Frontal lobe dysfunction is frequently exhibited and results in executive functioning deficits. Executive function involves interrelated skills that are needed to achieve goal-directed behaviors, such as inhibition, attentional control, and a working memory for appropriate planning, problem solving, and processing information. These skills are necessary for success in advancing to functional independence. Impulsivity and perseveration are commonly associated with frontal lobe dysfunction. In addition to poor focus and attention, short- or long-term memory deficits impair new learning or retrieval of previously learned information (Catroppa & Anderson, 2006). Motor impairment may include paresis, flaccidity, tremors, or spasticity, which impedes the ability to perform activities of daily living. Coordination and proprioceptive or balance issues result in safety concerns. Alterations in sensation may yield auditory or visual impairment, as well as altered perception of touch, with neuropathies and paresthesias resulting in pain or discomfort. Emotional lability may be exhibited as depression, anxiety, irritability, and even aggression, leading to safety concerns for the child and others around him or her.

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