Sibling adjustment to pediatric traumatic brain injury: a case-controlled pilot study.

OBJECTIVE: To assess depressive symptoms, self-concept, and behavior in non-affected siblings of children with severe pediatric traumatic brain injury (TBI). DESIGN: Cross-sectional study with case controls. SETTING: Children's hospital tertiary care center. PARTICIPANTS: Twelve siblings of children consecutively admitted to an inpatient rehabilitation unit after a severe TBI. Case controls were randomly selected from the sibling's classmates. MAIN OUTCOME MEASURES: The Child Behavior Checklist (CBCL), the Teacher's Report Form of the CBCL (TRF-CBCL), the Self-Perception Profile for Children and the Children's Depression Inventory (CDI). RESULTS: No statistical differences were found in depressive symptoms, self-concept, or behavior between the siblings and their classmates 3 to 18 months after injury. Poorer functional outcomes in the child with a TBI were found to correlate significantly with lower self-concept and more symptoms of depression in the siblings. CONCLUSIONS: Further research is needed to evaluate the potential impact on sibling adjustment after pediatric TBI.

Association between injury indices and outcome after severe traumatic brain injury in children.

OBJECTIVES: (1) To determine whether indices of traumatic brain injury (TBI) in children are associated with outcome at hospital discharge and 5 to 7 years later; (2) to describe persisting disabilities. DESIGN: Retrospective, uncontrolled study of a cohort of children with severe, nonpenetrating TBI. SETTING: Consecutive admissions to a level 1 trauma center over 2 years. SUBJECTS: Seventy-five children younger than 17 years old were previously studied to identify predictors of disability at acute care discharge. Thirty-three of the 50 survivors (66%) were enrolled. MAIN OUTCOME MEASURES: A database of variables abstracted from medical records was available from the previous study. Subjects were surveyed about premorbid problems, school, employment, and current function, and school records were reviewed. Using all information, a Glasgow Outcome Scale (GOS) score was assigned 5 to 7 years after TBI. Associations between database variables and GOS score at discharge and follow-up were examined using nonparametric analyses. The odds ratio for good recovery was calculated for all significant associations. RESULTS: Late GOS was good recovery for 27%, moderate disability for 55%, and severe disability for 18%. Discharge GOS scores were related (p < or = .01) to the head Abbreviated Injury Scale score, Injury Severity Scale score, Glasgow Coma Scale (GCS) score measured in the field and at 6, 24, and 72 hours, the length of coma, and initial discharge site. Late GOS scores were related (p < or = .01) to the same variables except the field and 6-hour GCS scores, as well as pupillary responses in the field and the discharge GOS. At follow-up, 64% were independent in mobility, 70% in self-care, and 24% in cognitive items on the Functional Independence Measure. Seventy percent of children received special education services. Employment histories were poor. Most subjects were not receiving neurological or rehabilitation follow-up. CONCLUSIONS: Early and late outcome after severe TBI are related to variables measured at and after injury. Subjects had long-term educational and vocational problems but often did not utilize the medical model of neurorehabilitation.

Traumatic brain injury in children.

Head trauma is a common occurrence in childhood, and the spectrum of its consequences is broad. Depending on the severity, type, and location of the injury, outcome may range from complete recovery in children with mild injuries to severe disability in children with more serious injuries. Potential deficits are multiple and include motor, communicative, cognitive, sensory, behavioral, and emotional problems. Optimizing function in those areas is the goal of neurorehabilitation, and this may require medical, therapeutic, and educational interventions. An even more important goal is prevention, and here, too, the pediatrician can play an essential role.

Traumatic brain injury as a risk factor for behavioral disorders in children.

The most common behavioral problems that are associated with traumatic brain injury in children are the same behaviors that prompt referral to special education for behavioral disorder. The purpose of this study was to determine whether there is an association between traumatic head injury in children and subsequent behavioral disorders for which special educational services are provided. A case-control design was used to compare occurrences of prior head injury in children receiving special educational services for behavioral disorders (cases) to similar occurrences in children in regular education (controls). Subjects included 170 case and 197 control students in grades 1 through 5 in a single large school district during 1988-1989. Data were collected by parent questionnaire and school record review. The odds ratio (OR) of a history of head injury among children with behavioral disorders relative to controls was 3.3 (95% confidence interval [CI] 1.3-8.3); the OR of a history of head injury sustained during the preschool years was 8.7 (95% CI 2.5-30.7) in cases relative to controls. Mean IQ scores were significantly lower for cases injured at two years of age or less in comparison with cases injured later. Full scale IQs (+/- SD) were 88 +/- 5 versus 107 +/- 14 (t = 3.5, p = .008), performance IQs 91 +/- 9 versus 108 +/- 12 (t = 3.0, p = .012), and verbal IQs 86 +/- 7 versus 106 +/- 15 (t = 3.2, p = .008). Achievement test results did not differ between cases with and those without histories of head injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Rehabilitation of children with brain tumors.

Brain tumors are the most common type of solid tumors in childhood. It has only been over the past 20 years that the majority of children with intracranial tumors are surviving. Children who survive their tumors may do so with significant disabilities resulting from the tumor or its treatment, and are presenting a new challenge in pediatric rehabilitation. In this article, we will discuss the epidemiology and characteristics of the major types of brain tumors that occur in children, the multimodality approach to tumor treatment along with the major complications of the interventions that have implications for the quality of survival, the types of deficits in function that occur most commonly in children who survive their tumors, and the team approach to rehabilitation of children with disabilities due to brain tumors.

Predictors of survival and severity of disability after severe brain injury in children.

Seventy-five children, 16 years of age or younger, consecutively admitted to a level I trauma center over a 2-year period with severe nonpenetrating traumatic brain injuries were studied to assess factors predictive of survival and level of disability. The mortality rate was 33%; 31% had good recovery, 12% had moderate disability, 19% had severe disability, and 5% remained in a vegetative state. Factors were analyzed separately for potential effects on survival and, with fatalities excluded, for potential effects on the level of disability in survivors. Clinical status in the field and emergency room, although highly associated with survival, was less predictive of the level of disability in survivors. Glasgow Coma Scale scores 72 hours after injury, especially the motor component, were significantly better predictors of quality of survival. The severity of the brain injury and the presence and severity of extracranial injuries were strongly related both to survival and quality of survival. Chest injuries, in particular, were associated with increased mortality and morbidity, as was level of oxygenation; these factors were highly correlated. Factors most significantly predictive of survival were severity of total injuries as assessed with the Injury Severity Score and pupillary responses in the emergency room; factors most predictive of disability were Glasgow Coma Scale motor responses 72 hours after injury and level of oxygenation in the emergency room. These findings of differential predictive factors for outcomes of survival versus quality of survival have implications relevant both to clinical care and to research involving severely brain-injured children.

Elevated initial blood glucose levels and poor outcome following severe brain injuries in children.

To determine whether elevations in blood glucose levels were related to neurologic outcomes following severe brain injuries in children, 54 patients 16 years of age or younger admitted to a regional trauma center with a Glasgow Coma Scale score of 8 or less over a 2-year period were retrospectively reviewed. The mean initial blood glucose level on hospital admission was significantly higher in the 16 patients with outcomes of death or vegetative state in comparison with that of the 38 patients with outcomes of good recovery, moderate disability,or severe disability (288 mg/100 mL vs. 194 mg/100 mL, t = -2.74, p = 0.01). Blood glucose levels correlated significantly with indicators of the severity of the brain injury, which were also related to outcome. In contrast, blood glucose levels did not correlate with indicators of the severity of the extracranial injuries, although the latter were significantly related to outcome. Logistic regression analysis resulted in a model for prediction of outcome which included the Glasgow Coma Scale score on admission and the initial blood glucose level. The odds ratio of a poor outcome in this model in patients with blood glucose levels greater than or equal to 250 mg/100 mL relative to those with lower levels was 8.3 (95% confidence interval 1.3-53.6). A simple prognostic score was derived from the logistic regression which improved upon the prediction of outcome using the Glasgow Coma Scale score alone in those patients with initial blood glucose levels greater than or equal to 250 mg/100 mL.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital carpal tunnel syndrome: case report of autosomal dominant inheritance and review of the literature.

Carpal tunnel syndrome (CTS) is unusual in childhood, and familial occurrence has been reported infrequently. A case of CTS in a seven-year-old boy, associated with abnormal thickening of the transverse carpal ligament and aplasia of the median nerve distal to this ligament, is described. Clinical, electrodiagnostic, and surgical findings are presented: all were consistent with absence of the median nerve distal to the transverse carpal ligament. Family history of CTS was positive in a pattern consistent with autosomal dominant transmission in three generations. Thickening of the transverse carpal ligament has been described, although infrequently, in childhood and familial CTS. Aplasia of the median nerve distally has not been reported in association with this anatomic abnormality. Case reports of familial CTS are reviewed, and other congenital anomalies which should be considered in the differential diagnosis of CTS in children and adults are discussed.

Hemangioblastoma of the conus medullaris associated with cutaneous hemangioma.

A 6-month-old infant is reported with a spinal cord hemangioblastoma located in the conus medullaris associated with an overlying congenital dermal sinus and cutaneous capillary hemangioma. There were no neurologic deficits either preoperatively or following removal of the tumor. The skin and spinal cord lesions were believed to represent an isolated vascular malformation. This spinal cord hemangioblastoma is unusual because of the age of the patient, manner of clinical presentation, location in the caudal spinal cord, and pathologic characteristics. We review the literature and discuss the associations of spinal cord hemangioblastomas with cutaneous and other lesions.

Neonatal myasthenia gravis: specific advantages of repetitive stimulation over edrophonium testing.

A premature infant with neonatal myasthenia gravis is presented to illustrate the utility of electrodiagnosis. The patient, born to a mother with myasthenia gravis, suffered additional problems, including hypoxia and subependymal hemorrhage which potentially contributed to hypotonia and poor respiratory effort, thus complicating the diagnosis. Standard testing with edrophonium originally was negative which cast doubt on the diagnosis; however, a repetitive motor nerve stimulation test demonstrated a significant decremental response which was consistent with neonatal myasthenia gravis. This decremental response was corrected following intravenous infusion of edrophonium. In the newborn with suspected myasthenia gravis, repetitive motor nerve stimulation may be a more reliable diagnostic procedure than the more frequently recommended pharmacologic tests. Use of this electrodiagnostic procedure in combination with pharmacologic testing may improve diagnostic accuracy in the premature infant and lead to earlier treatment.