TRAUMATIC BRAIN INJURY
Linda E. Krach, Mark E. Gormley, Jr., and Marcie Ward
Traumatic brain injury (TBI) is a major cause of death and disability in children. It is the leading cause of death in children over 1 year of age. In 2009 to 2010, the Centers for Disease Control (CDC) reported that TBI resulted in a rate of 2,193.8 /100,000 emergency department (ED) visits, 57/100,000 hospitalizations, and 4.3/100,000 deaths in the 0 to 4 age group and a rate of 888.7/100,000 ED visits, 23.1/100,000 hospitalizations, and 1.9/10,000 deaths for those between the ages of 5 and 14 years of age (1). The incidence of pediatric TBI peaks at two separate periods: below age 5 and in mid-to-late adolescence. The incidence of hospitalization for TBI has been reported to be 125 per 100,000 children per year in the 15- to 17-year age group (2,3). Males are more likely to sustain TBI than females, at a ratio of approximately 60% to 40% (4). Falls are the leading cause of injury in all those aged 0 to 14, but motor-vehicle-related causes increase over age 4 (5). From 2001 to 2009, the rate of reported concussion among those under 19 years of age rose 5% and in 2009, an estimated 248,418 children (age 19 or younger) were treated in U.S. EDs for sports- and recreation-related injuries that included a diagnosis of concussion or TBI (5). The leading cause of TBI-related death for children under age 4 was nonaccidental trauma (5).
Children with a history of attention deficit hyperactivity disorder (ADHD) are at a greater risk to sustain TBI than those without it. ADHD affects approximately 6% of children, has a male predominance, and a hereditary tendency. Of children who sustain TBI, prevalence of preinjury ADHD is noted to be between 10% and 20% (6).
Some authors have also evaluated the incidence of TBI in the United States by race. Langlois and colleagues (7) evaluated information from the National Center for Health Statistics. They reported a significantly higher rate of both hospitalization and death due to traffic/ motor-vehicle-related causes in children aged 0 to 9 in Blacks compared to Whites. Another group reported their experience in a regional trauma center and concurred that traffic/motor-vehicle-related accidents were more frequently seen in minority children; however, there was no difference in death rates or the severity of brain injury (7).
A recent report of the prevalence of TBI from a birth cohort of individuals between the ages of birth and 25 years in New Zealand indicated that the average incidence was from 1.10 to 2.36 per 100 per year with an overall prevalence of approximately 30% with 10% meeting criteria for moderate to severe injury (8).
COSTS OF INJURY
The costs associated with pediatric TBI are significant. In a study of hospital resource utilization for pediatric TBI in the year 2000, Schneier and colleagues (3) reported that more than $1 billion in hospital charges was generated for TBI patients less than 17 years of age. A survey study of needs after hospitalization reported that at 3 months after injury, 62% of children hospitalized for at least one night after TBI received at least one outpatient health care service during the interval since injury and 26% had unmet needs. At 12 months, 31% were reported to have unmet needs (9). The cost of TBI to families is something that is difficult to quantitate. However, Hawley and colleagues (10) published a report concerning parental stress after TBI in children and adolescents. The Parenting Stress Index and General Health Questionnaire results of parents of children with hospitalization of greater than 24 hours for TBI were compared to the same measures administered to a control group of parents that was identified by the subject parents. Loss of income due to the TBI was reported by 44.3% of families. For those with a child with a severe TBI, it was 69%. Also, parents of children with TBI were found to have significantly greater stress and poorer psychological health than the comparison parents. Parents of children with TBI were noted to have clinically significant levels of stress in 41% of the cases (10).
CAUSES OF INJURY
The cause of injury differs by age. Nonaccidental trauma is responsible for 17% of brain injuries in infants and 5% in those aged 1 to 4. It causes a disproportionate percentage of severe TBI, resulting in 56% and 90% of severe injury in these two age groups (11). Motor-vehicle-related injuries are more common in adolescents than young children, accounting for 66% and 20% of TBIs in the respective age ranges (2). Falls cause 39% of TBI in those under age 14, and are especially common in those under age 5 (4). Falls are the leading cause of injury in children under age 4 (5).
ASSOCIATION WITH OTHER INJURIES
It is common for TBI to occur in association with other injuries. Children with more severe injury are more likely to have been injured in a traffic-related accident and to have associated injuries (9). It has been reported that about 50% of children with TBI have other injuries as well (12). The presence of chest and abdominal injuries has been associated with decreased survival (13,14). In one study, undetected fractures during the acute care stay were found in 16 of 60 children with TBI, some having more than one fracture (13,14).