Precocious puberty is defined as the onset of puberty in girls before the age of 8 years and in boys before the age of 10 years. It can occur following TBI in children, with signs developing from 2 to 17 months after the initial injury. There is a positive correlation between increased ventricular size secondary to cerebral atrophy and the development of precocious puberty, and girls are affected much more frequently than boys (54.5% in girls to 4.5% in boys) (173). The signs of precocious puberty include onset of secondary sexual development prior to the predicted age and accelerated linear growth. These children demonstrate advanced bone age and premature closure of the epiphyseal plates. Because precocious puberty places a social and emotional burden on the patient and family, and because of the development of short stature secondary to premature epiphyseal plate closure, it is essential that the physician have a watchful eye for precocious puberty and be prepared to evaluate for it and treat it if indicated.


Recommendations for the treatment of children with TBI include transitioning from endotracheal intubation to tracheostomy for ventilatory support around the time

the patient is 7 to 10 days postinjury. The tracheostomy allows for pulmonary support, easier secretion clearance, and better long-term airway management. The tracheostomy is not without complications, though, including, the potential for vocal cord paralysis, tracheal stenosis, subglottic and glottic stenosis, and tracheomalacia (174). The ultimate goal is to move toward decannulation once controlled ventilation is no longer needed and when the patient is able to manage his own secretions. Another reason to move toward decannulation is to avoid the increased nursing and respiratory care requirements when the tracheostomy tube is in place. These increased needs can complicate discharge, as some long-term care facilities are unwilling to provide care for patients with tracheostomies and family members may be anxious and apprehensive about caring for a child who has one (175). The stepwise fashion moving toward decannulation has been described by Klingbeil (176). The process begins with downsizing the tracheostomy tube sequentially until, ultimately, an uncuffed small tube is tolerated. Then capping of the tracheostomy tube is recommended as the clinician evaluates the patienf s tolerance. If the patient is able to maintain oxygen saturations with a comfortable breathing effort and demonstrate effective cough with good management of secretions, the tube is removed and an occlusive dressing is placed to allow the site to heal. If the patient is demonstrating difficulty during the process of decannulation with worsening respiratory function or distress, it is recommended that the patient undergo direct laryngoscopy prior to decannulation in order to evaluate for concerns such as tracheal granuloma.


Very early after severe TBI, it is important for the primary team to place emphasis on the child's nutritional status. Guidelines have been established for achieving adequate nutritional management in this population (177). These guidelines are mostly from the adult TBI literature, as there is quite limited pediatric research regarding nutrition after TBI. Metabolism is reported to be increased after severe TBI in children, causing increased nutritional requirement. Phillips and colleagues (178) studied pediatric TBI survivors who had initial GCS between 3 and 8. Overall, the energy expenditure in those patients was 130% of their expected metabolism. Phillips also found that weight loss ranged between 2 and 26 pounds during their 2-week postinjury evaluation despite aggressive nutritional support. Moore and colleagues (179) identified metabolic profiles of pediatric TBI survivors who had initial GCS of less than 7. They found that the increased energy expenditure in that group averaged 180%. In adult literature, hypermetabolism in TBI survivors is well established. The guidelines for the adult population include the following recommendations: (a) full nutritional replacement should be initiated by day 7 postinjury; (b) enteral nutrition should be started no later than 72 hours postinjury; and (c) tight control of serum glucose is necessary to avoid hyperglycemia, which is associated with worsening ischemic injury and worse outcome. Parenteral nutrition should be started if enteral nutrition is not full and complete by day 7.

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