Mild Traumatic Brain Injury Characteristics and Symptoms in Preschool Children: How Do They Differ to School Age Children? A Multicenter Prospective Observational Study.

OBJECTIVE: To investigate if preschool children differ to school age children with mild traumatic brain injury (TBI) with respect to injury causes, clinical presentation, and medical management. DESIGN: A secondary analysis of a dataset from a large, prospective and multisite cohort study on TBI in children aged 0-18 years, the Australian Paediatric Head Injury Rules Study. SETTING: Nine pediatric emergency departments (ED) and 1 combined adult and pediatric ED located across Australia and New Zealand. PARTICIPANTS: 7080 preschool aged children (2-5 years) were compared with 5251 school-age children (6-12 years) with mild TBI (N= (N=12,331) MAIN OUTCOME MEASURES: Clinical report form on medical symptoms, injury causes, and management. RESULTS: Preschool children were less likely to be injured with a projectile than school age children (P<.001). Preschool children presented with less: loss of consciousness (P<.001), vomiting (P<.001), drowsiness (P=.002), and headache (P<.001), and more irritability and agitation (P=.003), than school-age children in the acute period after mild TBI. Preschool children were less likely to have neuroimaging of any kind (P<.001) or to be admitted for observation than school age children (P<.001). CONCLUSIONS: Our large prospective study has demonstrated that preschool children with mild TBI experience a different acute symptom profile to older children. There are significant clinical implications with symptoms post-TBI used in medical management to aid decisions on neuroimaging and post-acute intervention.

Psychological and Peer Difficulties of Children with Cleft Lip and/or Palate: A Systematic Review and Meta-Analysis.

OBJECTIVES: A systematic review and meta-analysis were conducted to determine if children born with cleft lip and/or palate are at increased risk of psychological and peer difficulties, and if so, which difficulties they develop. METHODS: EMBASE, MEDLINE, and PsycINFO were searched for English language studies published between January 2005 and January 2022 which investigated the psychological outcomes and peer function of children with nonsyndromic cleft lip and palate. Outcomes included internalizing problems, such as anxiety and depression, externalizing problems, such as hyperactivity, conduct disorders, self-concept including self-image and self-esteem, peer problems, resilience, coping, and overall psychological function. A risk of bias assessment was performed using the Newcastle-Ottawa Scale. Random effects models were used in the meta-analysis to compare the outcomes for children born with a cleft and those without. RESULTS: In total 41 studies met inclusion criteria, with 9 included in the meta-analysis. Children born with a cleft appear to have similar psychological outcomes compared to normative controls when using the strengths and difficulties questionnaire. There are some minor differences between self-report and parent report, with parents generally reporting that their child with a cleft has increased emotional, conduct, and hyperactivity problems. The small differences between the study cohort and control cohorts are unlikely to imply any differences on a clinical level. CONCLUSIONS: Overall psychological outcomes appear to be similar between children born with a cleft and the nonaffected population, however, some symptoms such as anxiety and depression appear higher in children with cleft lip and/or palate.

Self-perception and behavioural outcomes of early acquired brain injury.

Acquired brain injury (ABI) occurs commonly in young children. Despite this, the psychosocial implications of ABI in young children are not established, with little understood about the impacts on self-perception and self-esteem. In this study we investigated self-perception, self-esteem and behaviour of children with early ABI. Children with an ABI (n = 47) before six years were compared to 17 typically developing controls (TDCs) matched on demographics. Children were aged 6-12 years and completed the Harter Self-Perception Profile. One parent completed the Child Behavior Checklist. No differences for self-perception and self-esteem were found between the groups. Parents of children with an early ABI reported more internalizing and externalizing behaviours. Children with more externalizing behaviour and social skill problems had more negative self-perceptions. Interaction effects were seen between socioeconomic status (SES) and child self-perception and behaviour. Specifically, children from families of higher SES had a more positive perception of their appearance and children from lower SES backgrounds had more externalizing behaviours and social problems. The study suggests that the relationship between ABI and self-perception and self-esteem is complicated and that children with behavioural problems have lowered feelings of competence. SES has an important role in self-perception and behavioural outcomes.

Characteristics of concussion based on patient age and sex: a multicenter prospective observational study.

OBJECTIVE: Children with concussion frequently present to emergency departments (EDs). There is limited understanding of the differences in signs, symptoms, and epidemiology of concussion based on patient age. Here, the authors set out to assess the association between age and acute concussion presentations. METHODS: The authors conducted a multicenter prospective observational study of head injuries at 10 EDs in Australia and New Zealand. They identified children aged 5 to < 18 years, presenting with a Glasgow Coma Scale score of 13-15, presenting < 24 hours postinjury, with no abnormalities on CT if performed, and one or more signs or symptoms of concussion. They extracted demographic, injury-related, and signs and symptoms information and stratified it by age group (5-8, 9-12, 13 to < 18 years). RESULTS: Of 8857 children aged 5 to < 18 years, 4709 patients met the defined concussion criteria (5-8 years, n = 1546; 9-12 years, n = 1617; 13 to < 18 years, n = 1546). The mean age of the cohort was 10.9 years, and approximately 70% of the patients were male. Sport-related concussion accounted for 43.7% of concussions overall, increasing from 19.1% to 48.9% to 63.0% in the 5-8, 9-12, and 13 to < 18 years age groups. The most common acute symptoms postinjury were headache (64.6%), disorientation (36.2%), amnesia (30.0%), and vomiting (27.2%). Vomiting decreased with increasing age and was observed in 41.7% of the 5-8 years group, 24.7% of the 9-12 years group, and 15.4% of the 13 to < 18 years group, whereas reported loss of consciousness (LOC) increased with increasing age, occurring in 9.6% in the 5-8 years group, 21.0% in the 9-12 years group, 36.7% in the 13 to < 18 years group, and 22.4% in the entire study cohort. Headache, amnesia, and disorientation followed the latter trajectory. Symptom profiles were broadly similar between males and females. CONCLUSIONS: Concussions presenting to EDs were more sports-related as age increased. Signs and symptoms differed markedly across age groups, with vomiting decreasing and headache, LOC, amnesia, and disorientation increasing with increasing age.

Sexual function, intimate relationships and Friedreich ataxia.

BACKGROUND: Sexual dysfunction (SD) is reported in neurological conditions similar to Friedreich ataxia (FRDA). Anecdotally individuals with FRDA report SD including erectile dysfunction and altered genital sensation. Understanding SD in FRDA assists health professionals identify SD issues and improve healthcare for individuals with FRDA. OBJECTIVE: To quantify if, and to what extent, people with FRDA experience challenges with sexual function and intimate relationships as a result of primary (genital function), secondary (physical) and tertiary (psychosocial) dysfunction. METHODS: An online purpose designed anonymous questionnaire explored SD and intimate relationships. Invitations to participate were sent to individuals with FRDA aged 18 years and over on the Ataxia UK and Friedreich Ataxia Research Alliance databases. Date collection occurred between January and July, 2017. RESULTS: One-hundred-and-seventy-nine adults with FRDA participated, of which 107 reported current or previous sexual activity. Erectile dysfunction was reported in 57% (20/35) of males, inadequate vaginal lubrication interfering with sexual responsiveness was reported in 57.7% (26/45) of females, and 47% (51/107) reported reduced genital sensation. In addition, 88% (94/107) reported problems moving their body during sexual activity and 73% (78/107) reported reduced confidence about their sexuality due to FRDA. A significant negative relationship was shown between younger age of disease onset and SD. CONCLUSION: This study confirmed FRDA impacts sexual functioning, sexual satisfaction and the capacity to form intimate relationships. Understanding the nature and extent of SD is critical to developing interventions and recommendations designed to enhance sexual function, sexuality, and intimate relationships for individuals with FRDA.

Long-Term Intellectual Function After Traumatic Brain Injury in Very Young Children.

OBJECTIVE: To investigate long-term intellectual function following a traumatic brain injury (TBI) in early childhood and to identify the contribution of injury and environment to outcome. PARTICIPANTS: Fifty children younger than 3 years with a diagnosis of accidental TBI were recruited through a pediatric hospital emergency department. Children with TBI were compared with a group (n = 33) of typically developing children (TDC) matched on demographics. DESIGN: Longitudinal, single-site, case-control study. MEASURES: Children completed intellectual assessments (IQ) at 4.5 to 5.5 years of age (average 3.5 years after TBI) and at 7.5 to 9 years of age (average 6.5 years after TBI). Information on injury and environmental predictors of outcome was collected. RESULTS: IQ scores for all groups were in the average range; however, children with TBI of any severity had lower scores than TDC at both time points. There was some suggestion of children with TBI achieving lower verbal IQ scores over time than TDC. IQ scores were predicted by family environment, not injury characteristics. CONCLUSIONS: A TBI in early childhood is associated with lower IQ scores that persist several years postinjury. Socioeconomic status is an influential factor on IQ at 6.5 years post-TBI.

Validation of the PredAHT-2 prediction tool for abusive head trauma.

OBJECTIVE: The validated Predicting Abusive Head Trauma (PredAHT) clinical prediction tool calculates the probability of abusive head trauma (AHT) in children <3 years of age who have sustained intracranial injuries (ICIs) identified on neuroimaging, based on combinations of six clinical features: head/neck bruising, seizures, apnoea, rib fracture, long bone fracture and retinal haemorrhages. PredAHT version 2 enables a probability calculation when information regarding any of the six features is absent. We aimed to externally validate PredAHT-2 in an Australian/New Zealand population. METHODS: This is a secondary analysis of a prospective multicentre study of paediatric head injuries conducted between April 2011 and November 2014. We extracted data on patients with possible AHT at five tertiary paediatric centres and included all children <3 years of age admitted to hospital who had sustained ICI identified on neuroimaging. We assigned cases as positive for AHT, negative for AHT or having indeterminate outcome following multidisciplinary review. The estimated probability of AHT for each case was calculated using PredAHT-2, blinded to outcome. Tool performance measures were calculated, with 95% CIs. RESULTS: Of 87 ICI cases, 27 (31%) were positive for AHT; 45 (52%) were negative for AHT and 15 (17%) had indeterminate outcome. Using a probability cut-off of 50%, excluding indeterminate cases, PredAHT-2 had a sensitivity of 74% (95% CI 54% t o89%) and a specificity of 87% (95% CI 73% to 95%) for AHT. Positive predictive value was 77% (95% CI 56% to 91%), negative predictive value was 85% (95% CI 71% to 94%) and the area under the curve was 0.80 (95% CI 0.68 to 0.92). CONCLUSION: PredAHT-2 demonstrated reasonably high point sensitivity and specificity when externally validated in an Australian/New Zealand population. Performance was similar to that in the original validation study. TRIAL REGISTRATION NUMBER: ACTRN12614000463673.

Accuracy of NEXUS II head injury decision rule in children: a prospective PREDICT cohort study.

OBJECTIVE: The National Emergency X-Radiography Utilisation Study II (NEXUS II) clinical decision rule (CDR) can be used to optimise the use of CT in children with head trauma. We set out to externally validate this CDR in a large cohort. METHODS: We performed a prospective observational study of patients aged <18 years presenting with head trauma of any severity to 10 Australian/New Zealand EDs. In a planned secondary analysis, we assessed the accuracy of the NEXUS II CDR (with 95% CI) to detect clinically important intracranial injury (ICI). We also assessed clinician accuracy without the rule. RESULTS: Of 20 137 total patients, we excluded 28 with suspected penetrating injury. Median age was 4.2 years. CTs were obtained in ED for 1962 (9.8%), of whom 377 (19.2%) had ICI as defined by NEXUS II. 74 (19.6% of ICI) patients underwent neurosurgery.Sensitivity for ICI based on the NEXUS II CDR was 379/383 (99.0 (95% CI 97.3% to 99.7%)) and specificity was 9320/19 726 (47.2% (95% CI 46.5% to 47.9%)) for the total cohort. Sensitivity in the CT-only cohort was similar. Of the 18 022 children without CT in ED, 49.4% had at least one NEXUS II risk criterion. Sensitivity for ICI by the clinicians without the rule was 377/377 (100.0% (95% CI 99.0% to 100.0%)) and specificity was 18 147/19 732 (92.0% (95% CI 91.6% to 92.3%)). CONCLUSIONS: NEXUS II had high sensitivity, similar to the derivation study. However, approximately half of unimaged patients were positive for NEXUS II risk criteria; this may result in an increased CT rate in a setting with high clinician accuracy.

Investigating the Variability in Mild Traumatic Brain Injury Definitions: A Prospective Cohort Study.

OBJECTIVE: To prospectively compare the proportion of traumatic brain injuries (TBIs) that would be classified as mild by applying different published definitions of mild TBI to a large prospectively collected dataset, and to examine the variability in the proportions included by various definitions. DESIGN: Prospective observational study. SETTING: Hospital emergency departments. PARTICIPANTS: Children (N=11,907) aged 3 to 16 years (mean age, 8.2±3.9y). Of the participants, 3868 (32.5%) were girls, and 7374 (61.9%) of the TBIs were the result of a fall. Median Glasgow Coma Scale score was 15. MAIN OUTCOME MEASURES: We applied 17 different definitions of mild TBI, identified through a published systematic review, to children aged 3 to 16 years. Adjustments and clarifications were made to some definitions. The number and percentage identified for each definition is presented. RESULTS: Adjustments had to be made to the 17 definitions to apply to the dataset: none in 7, minor to substantial in 10. The percentage classified as mild TBI across definitions varied from 7.1% (n=841) to 98.7% (n=11,756) and varied by age group. CONCLUSIONS: When applying the 17 definitions of mild TBI to a large prospective multicenter dataset of TBI, there was wide variability in the number of cases classified. Clinicians and researchers need to be aware of this variability when examining literature concerning children with mild TBI.

Developmental Trajectory of Information-Processing Skills in Children: Computer-Based Assessment.

There are significant merits to a comprehensive cognitive assessment, but they are also time-consuming, costly, and susceptible to practice effects and may not detect change in the context of medical interventions or minor brain disruptions. Brief computer-based assessments focused on "fluid" cognitive domains (e.g., information-processing skills), which are vulnerable to disruption as a result of a brain injury, may provide an alternative assessment option. This study sought to: (a) examine the utility of a well-established, adult-based computerized tool, CogSport for Kids (CogState), for evaluating information-processing skills in children and adolescents; and (b) to report normative data for healthy children and adolescents. The study was a cross-sectional, community-based observational study of typically developing children aged 9 to 17 years old (N = 832). Participants completed the CogSport for Kids test battery, which includes six brief computerized tasks that assess cognitive functions including processing speed, attention, and working memory. Results showed an improvement with age for response speed and accuracy. The greatest change occurred between 9 and 12 years with performance stabilizing at 15 years. This brief screening tool is appropriate for clinical and research use in children aged 9 years and older and may be used to track cognitive development from childhood into adulthood and to identify children who deviate from normal expectations.

Sequelae in children: developmental consequences.

Child traumatic brain injury (TBI) is a major cause of disability in early life. Unlike in adults, a TBI in childhood causes an insult to a brain that is developing, potentially affecting future brain maturation, neural connectivity, and the acquisition of new skills. This review considers how such early brain insult may impact children's functional abilities, and how these processes may link with differential patterns of recovery across infancy, childhood, and adolescence. We also review evidence for cognitive impairment across a range of domains (IQ, attention, processing, memory executive function) and common educational, behavioral, and social consequences associated with child TBI. While impairments in all of these domains have been reported, in fact outcomes from child TBI are surprisingly varied and difficult to predict. To assist in understanding what may contribute to outcomes, we discuss predictive factors (injury severity, child and environment status) and research reporting on their individual and combined effect on recovery. The identification of such outcome predicators has led to an emerging literature in the area of intervention and rehabilitation that we also summarize. Finally, it concludes with discussion of the future direction of pediatric TBI research.

Verbal ability and language outcome following traumatic brain injury in early childhood.

OBJECTIVE: To investigate language outcomes of TBI in preschool-aged children. Competent early language skills are pivotal for the future development of literacy skills. While previous research has reported that traumatic brain injury (TBI) places children at risk of language impairments, the majority of these studies have been conducted with school-aged children. SETTING: Royal Children's Hospital, Melbourne, Australia. PARTICIPANTS: Children aged 4 to 6 years who had sustained a mild (N = 19) or moderate/severe (N = 16) TBI prior to 3 years of age and a control group (N = 20) of typically developing children matched for age, gender, and socioeconomic status. MAIN MEASURES: The Wechsler Preschool and Primary School Scale of Intelligence, Third Edition, measured Verbal IQ. The Clinical Evaluation of Language Fundamentals-Preschool version and the Bus Story Test measured language skills. RESULTS: More severely injured children displayed greater impairments in verbal intellectual abilities and language skills compared with children with mild TBI and uninjured children. Children with mild TBI performed similarly to children in the control group. CONCLUSION: Language appears vulnerable to TBI and should be investigated as a matter of course in clinical assessments of TBI recovery.

Does the presence of posttraumatic anosmia mean that you will be disinhibited?

Dispute has surrounded the issue of whether the relationship between anosmia and executive dysfunction in traumatic brain injury (TBI) may be artefactual due to poor ascertainment. Three groups matched for age, gender, education, Full Scale IQ, and the Wechsler Working Memory Index and showing adequate symptom validity were compared: 30 anosmic TBIs (TBI-A) matched for posttraumatic amnesia (PTA) and working memory functioning with 36 nonanosmic TBIs (TBI-NA) and 51 controls. The groups performed the FAS test, the Animal Fluency test, the Stroop Neurological Screening Test (SNST), the Wisconsin Card Sorting Test-64 (WCST-64) and the Trail Making Test (TMT-B) as well as tests of emotional functioning and return to work outcome. After adjusting for the covariates (i.e., gender; Wechsler Test of Adult Reading, WTAR; and years of education), a significant effect was found for items successfully completed on the SNST, the FAS task, the Animal Fluency task, and the WCST-64 categories completed. After adjusting for the covariates, a significant difference was found for number of errors on the SNST and for the number and type of errors on TMT-B. The two groups did not differ in terms of their affective functioning (i.e., Beck Depression Inventory or Beck Anxiety Inventory), or in terms of their outcome with regard to return to work. The findings support the notion that the TBI-A group demonstrated considerably weaker performance on executive tasks than did the nonanosmic TBIs. These patients were not, however, more prone to an error-prone pattern of performance, and, if anything, their executive deficit was more likely attributable to a reduced productivity of response.

Executive function outcomes of children with traumatic brain injury sustained before three years.

Traumatic brain injury (TBI) is a common cause of disability in childhood. While the outcomes of TBI sustained in school years has been heavily researched, very little is known about the impact of TBI in infants and young children. The aim of this study was to investigate the impact of TBI on executive function (EF) in children who sustained a TBI before 3 years of age. A group of 55 children, 19 with a mild TBI, 16 children with a moderate-severe TBI, and 20 uninjured comparison children participated. The EF of children aged 3 to 6 years were compared using child-based measures of attentional control and information processing. Parents completed questionnaires rating their child's EF. Severity groups differed on the child-based EF measure of attentional control with children with TBI performing below the control group. There were no significant group differences for information processing or parent-rated EF. It appears that children who sustain a TBI before the age of 3 years display impairments in some areas of attentional control 3-4 years postinjury. The findings fit with the existing EF literature for older children.

Head injuries in children under 3 years.

BACKGROUND: A significant number of children under 3 years sustain a head injury every year. Despite this few studies have provided detailed information about these injuries. METHODS: A retrospective review of the medical files all children aged 0-3 years who attended a paediatric emergency department for treatment over a 2-year period. RESULTS: Children aged 0-6 months had the highest rate of moderate head injury. Children under 12 months were at the greatest risk of injury. Falls were the most common cause of injury including falls from caregiver's arms. CONCLUSIONS: Children under 12 months are at significant risk of head injury, many of these injuries could be prevented by increased parental supervision or improved home safety.

Timing of traumatic brain injury in childhood and intellectual outcome.

OBJECTIVE: Typically, studies on outcomes after traumatic brain injury (TBI) have investigated whether a younger age at injury is associated with poorer recovery by comparing 2 age groups rather than participants injured across childhood. This study extended previous research by examining whether the influence of age on recovery fits an early vulnerability or critical developmental periods model. METHODS: Children with a TBI (n = 181) were categorized into 4 age-at-injury groups-infant, preschool, middle childhood, and late childhood--and were evaluated at least 2-years post-TBI on IQ. RESULTS: Overall, the middle childhood group had lower IQ scores across all domains. Infant and preschool groups performed below the late childhood group on nonverbal and processing speed domains. CONCLUSIONS: Contrary to expectations, children injured in middle childhood demonstrated the poorest outcomes; this age potentially coincides with a critical period of brain and cognitive development.

Intellectual, behavioral, and social outcomes of accidental traumatic brain injury in early childhood.

OBJECTIVE: The intellectual, behavioral, and social function of children who sustained traumatic brain injury (TBI) before 3 years of age were compared with a group of uninjured children. The role of injury and environmental factors in recovery was examined. METHODS: A group of 53 children who sustained a TBI before 3 years of age (20 mild and 33 moderate/severe) and 27 uninjured children (control group) were assessed on an IQ measure and parent measures of behavior and social skills. Children were aged 4 to 6 years and were an average of 40 months since sustaining their injury. RESULTS: There were no demographic differences between the groups. Although all group scores were in the average range, children with moderate/severe TBI performed significantly below uninjured children on an IQ measure. No significant differences were found on parent behavior ratings, although effect sizes between groups were medium to large. No differences were found for social skills. All outcomes were significantly influenced by environmental but not injury factors. CONCLUSIONS: Moderate/severe TBI at an early age appears to be associated with lowered intellectual function and possibly behavior problems. A child's environment influences cognitive and behavior function after TBI.

Head injuries related to sports and recreation activities in school-age children and adolescents: data from a referral centre in Victoria, Australia.

OBJECTIVES: Head injuries (HI) in children are common and even mild HI can lead to ongoing cognitive and behavioural changes. We set out to determine the causes of sport-related HI in school-age children presenting to a large urban ED as a basis for future interventions. METHOD: Identification and medical record review of all sport-related HI in children aged 6-16 years at a tertiary children's hospital ED in Victoria, Australia, over a 1 year period. Information was collected on demographics, injury variables and radiology findings. HI were classified as mild, moderate and severe based on GCS and radiography reports. RESULTS: Over 12 months there were 406 HI in school-age children. Seventy per cent were male. A large number of HI (129; 33%) were related to sports. Of these, most were classified as mild and 13% were classified as moderate or severe. Among a range of sports, Australian Rules football was associated with more than 30% of all HI attributable to a sport and recreation cause. Equestrian activities were the main cause of moderate HI. CONCLUSION: The present study identified sports as a major cause of HI in the Victorian paediatric emergency setting with Australian Rules football the most commonly involved sport. Further prevention initiatives should consider targeting Australian Rules football and equestrian activities.