Pediatric TBI: An Introduction

This article is a written transcript of the course, “Pediatric TBI: An Introduction”, presented by Victoria Harding on April 14, 2011.

>> Amy Natho:  Welcome, everybody.  I would like to welcome you to the E-learning Expert Seminar entitled “Pediatric TBI: An Introduction.”  My name is Amy Natho and I'll be your moderator for this online course.  At this time it is my great pleasure and honor to introduce Victoria Harding.  Tori Harding provides specialized program and location development for Neurorestorative and acts as the Clinical Projects Coordinator for Virginia NeuroCare, a Defense and Veterans Brain Injury Center program in Charlottesville, Virginia.  Tori's primary research and clinical interest areas include outcome measurements in post-acute settings, the self-efficacy mechanism in post-acute brain injury, neurogenic communication disorders, and family training for long-term success and advocacy. As a Speech-Language Pathologist, she works as a clinician and an educator and as a Certified Brain Injury Trainer.  She teaches through the Academy of Brain Injury Specialists. Currently a Ph.D. candidate at James Madison University, Tori received her Master’s degree of Business Administration at Plymouth State University and completed her Master of Science in Speech-Language Pathology at Dalhousie University, Nova Scotia, Canada.  So welcome, Tori.  Thank you for coming back and sharing your expertise with us again today.
>> Tori:  Well, sure thing.  Thank you so much for the opportunity to be here and for folks participating, the time that you have given here to huddle up to discuss the topic of pediatric TBI in this introductory format. 
I wanted to speak briefly about the flow of the presentation. The intent is to look at models of outcome of childhood TBI.  I think that is important because you need to know where you're going and what some of the multifactorial inclusions of an outcome model for childhood TBI treatment are.  We will also look at some of the recovery process, and the concept of children who “grow into” their traumatic brain injury, as opposed to an adult model.  We’ll talk about some of the persistent cognitive and linguistic deficits that children may present with, and some interventions and support challenges, including some examples for the child who is now in school who experienced a TBI earlier in life.  So thanks again for being here. 
I just wanted to go over a quick “411” that is probably not news to those of you attending, and that is the idea that traumatic brain injury in childhood is the most prevalent cause of death and long-term disability in children, and it affects all socio-economic levels.  Let's just sit with that for a moment.  This is talking about traumatic brain injury specifically, so not progressive neurological disorders or developmental diagnoses or a brain injury that is due to a birthing complication or acquired brain injury like an anoxic event (e.g., a near drowning).  These are truly traumatic events and I think there is a lot of inconsistency with the definitions of TBI.  It seems to vary according to specialties and circumstances.  Often the term “brain injury” is used synonymously with “head injury,” which may not be associated with a neurological deficit.  There are some problems with inclusion criteria, and we can probably spend about an hour talking about what traumatic brain injury is, within the scope of an acquired brain injury.  But for today we're going to talk about a traumatic brain injury as a non-degenerative, non-congenital insult to the brain from an external mechanism or force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions with an associated diminished or altered state of consciousness.  We're talking about a TBI that is caused by a bump, blow or jolt to the head or penetrating injury that disrupts the normal functions of the brain. 
Challenges of Pediatric TBI
Some of the challenges of pediatric TBI are, of course, that it is the leading form of acquired brain injury in children.  To me, that seems like an epidemic if we're talking about the leading form of acquired brain injury.  The costs of childhood TBI are certainly considerable to the child.  There is pain and suffering.  Certainly, there are personality changes; that is something that families reliably report is consistent.  There is compromise of ability to learn, and some poor peer relations as a result of the neural changes and social dysfunction.  To the family, there is the loss of their child, and increased burden of parenting now that there is a child with special needs, including health needs and education needs.  To educators, there is the challenge of teaching children who do not fit that traditional learning disability profile – somehow, it is qualitatively different.  And for society, there is a cohort of individuals who may be marginally employable, or, in a worst case scenario, lacking in social judgment.  These are all some of the changes that we want to address when working with a child with traumatic brain injury. 
 The costs of childhood TBI are largely hidden.  By that, we mean in comparison to an adult.  The costs for adults are evident around the time of injury.  An adult has met their developmental milestones and it is clear some of the presenting challenges an adult who experiences a traumatic brain injury may have.  However, for children, the costs may escalate from the time of injury.  Children have not yet developed those cognitive-linguistic skills that adults possess.  We may be able to note some motor and balance and strength and health changes following a brain injury.  But some of those cognitive, linguistic, pragmatic, and psychosocial deficits may not be apparent, because they have not developed them yet.  They're not expected to have developed them yet. 
Etiology of TBI
This is just a little quick note about etiology of TBI.  Birth to two, the primary causes of traumatic brain injury are falls, abuse, motor vehicle accidents, delivery, and accidents (other forms of accidents that don't fall into those above mentioned categories). 
Shaken Baby Syndrome (SBS)
I receive Google alerts daily on the topic of brain injury. One particular type of abuse that we are unfortunately seeing, and at least daily there are reports of the phenomena, is Shaken Baby Syndrome.  Just a little bit specifically about that form of abuse; it certainly creates a traumatic brain injury.  This motion of anterior/posterior rapid shaking creates permanent brain damage.  It is similar to a motor vehicle accident occurring repeatedly  - back and forth, back and forth.  Often, because babies are shaken anterior to posterior, we see this coup-contracoup injury.  The site of injury is at the frontal lobe and then immediately at the opposite direction in the occipital and the cerebellar areas.  Oftentimes with these children, we may see some frontal lobe challenge of execution, the occipital changes in vision, and certainly some of the motor planning changes because of the cerebellar involvement.  These babies have smaller frontal lobes, smaller brains.  That violent shaking is going to have a greater impact than it may have on a brain that has had the chance to more fully form those frontal lobes. 
Certainly, there are a number of characteristic injuries that we see when children present emergently to hospitals.  Retinal hemorrhaging is very common because of the involvement of the ocular portions of the head.  There are multiple fractures of the long bones because they have been shaken so violently.  Subdural hematoma is anticipated.  There is diffuse axonal injury, and those neurons are stretched and pulled and sometimes ripped as a result of the shaking.  There may be a hypoxic event where an infant or child has not received adequate oxygen as a result of the event, and has been unconscious and not breathing.  There can be edema and swelling and intracranial pressure, and sometimes a surgical intervention is needed to relieve it.  Well past their initial recovery, victims of Shaken Baby Syndrome may show irritability, failure to thrive, alterations in their eating patterns, lethargy, vomiting, and this phase can pass through surgery.  There may be seizures.  There may be bulging or tense fontanels -- that is a hallmark when you see a child with bulging or tense fontanels.  The size of the head is increased because of that intracranial pressure.  There can be altered breathing and dilated pupils.  Fractured vertebrae or long bones or ribs may also be associated with shaken baby syndrome. 
It is in the news quite a bit now because it is a criminal offense, and people do go to jail for the offense of shaken baby syndrome.  If the child, even later in life, is unable to make gains and eventually dies, that charge can be changed to murder for the individual who perpetrated the crime of shaking the baby. 
 What Do You Want to Know?
What do we want to know for all children that experience traumatic brain injury, regardless of the...