Original Article

Head Injury in Children: Has a Change in Circumstances Caused an Increase in Treatment Numbers?

Journal of Child Neurology 2015, Vol. 30(9) 1153-1158 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0883073814554655 jcn.sagepub.com

Andrej Pal’a, MD1, Melanie Kapapa, MD2, Carsten Posovszky, MD3, Go¨tz Ro¨derer, MD, PhD4, Ralph Ko¨nig, MD, PhD1, Dieter Woischneck, MD, PhD5, Christian Rainer Wirtz, MD, PhD1, and Thomas Kapapa, MD, PhD1

Abstract The number of hospitalizations for head injuries in children is rising. The exact causes remain unclear. We analyzed data of children aged between 0 and 18 years who sustained a head injury between 2010 and 2011. The analysis focused on data related to demographics, trauma mechanism, clinical course, results of imaging scans, concomitant injuries, and outcome. A total of 794 inpatient cases of head injury were treated. The leading mechanism of injury was a fall (at home) primarily at the age of 1 to 4 years (46.5%), with the majority of the children sustaining a mild brain injury (764, 96.2%). Neurosurgery was performed in 21 (2.64%) cases; average hospital stay was 2.9 days (range: 0-68 days). This study is not able to confirm that children are increasingly being brought to the hospital by their parents because of new trauma mechanisms or parents’ uncertainty, nor can we confirm that the number of nonaccidental injuries is rising. Keywords computed tomography, concomitant injuries, magnetic resonance imaging (MRI), mechanism of injury, traumatic brain injury Received June 05, 2014. Received revised August 27, 2014. Accepted for publication September 14, 2014.

Traumatic brain injury is the leading cause of death, morbidity, and disability in persons younger than 45 years.1-4 Despite multiple preventive measures and educational programs (Think First 1986 [first implemented by E. Fletcher Eyster, MD, of Pensacola, Florida, and Clark Watts, MD, of Columbia, Missouri]; Safe Kids 1986, United States), mortality from trauma is higher than from any other pediatric diseases combined.5 Moreover, it is becoming a serious economic and social problem with a tremendous impact in terms of the family and loss of human potential. In recent decades, we have gained a better understanding of the mechanism and possible prevention of traumatic brain injuries, especially in adults. This has led to a decrease in the number of traffic accidents and, in turn, fewer severe traumatic brain injuries.6 Children and adolescents often suffer brain injuries, however.7-9 In our previous work, we could clearly demonstrate that in comparison to adults the incidence of traumatic brain injury in children tends to be increasing, especially in those younger than 5 years.10-12 There is no evidence as to the cause for this development and little is known about the incidence of traumatic brain injuries, particularly in infants, children, and adolescents. Prevention is an important tool for protecting neural structures; it includes education and passive protection systems such as airbags, helmets, and safer cars. Primary preventive measures are likely to be

much more effective and save more lives than any improvement in treatment modalities.2,13 The causes for such injuries vary depending on a child’s age: falls are most likely in infants and toddlers, whereas sport-related injuries are common among children of middle school age, and motor vehicle accidents in older children.5 The consequences of traumatic brain injury are difficult to estimate. Mild head injury, accounting for more than 90% of traumatic brain injuries, may have long-lasting sequelae that include learning difficulties, impaired memory, or other behavioral problems that can greatly affect the everyday life of a family.14 Postconcussion syndrome represents a constellation


Department Department 3 Department 4 Department Germany 5 Department 2

of of of of

Neurosurgery, University of Ulm, Ulm, Germany Pediatric Surgery, University of Ulm, Ulm, Germany Pediatrics, University of Ulm, Ulm, Germany Traumatology and Plastic Surgery, University of Ulm, Ulm,

of Neurosurgery, Hospital Landshut, Landshut, Germany

Corresponding Author: Thomas Kapapa, MD, PhD, University of Ulm, Department of Pediatric Surgery, Albert-Einstein-Allee 23, 89081 Ulm, Germany. Email: [email protected]

Downloaded from jcn.sagepub.com at CAMBRIDGE UNIV LIBRARY on August 8, 2015


Journal of Child Neurology 30(9)

of cognitive, behavioral, and neuropsychological disorders that may persist more than 3 months after mild brain injury.14 The financial burden of traumatic brain injuries in childhood is largely unknown.3 Economic development brings with it a change in lifestyle. The main aim of our study was to obtain an accurate estimate of the incidence, grade and mechanism of head injuries suffered by individuals between 0 and 18 years of age. We compiled a summary of the concomitant injuries, courses of treatment, surgeries and outcomes, while at the same time focusing on primary diagnostic steps in terms of the number of scans performed with ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI). These procedures play a crucial role in the diagnosis of traumatic brain injuries. The number of motor vehicles, bicycles, and other wheeled vehicles used for sport and leisure, all of which can lead to accidents and consequently to head injuries, is constantly rising. Hence, our secondary aim was to clarify an influence on the treatment numbers by wheeled toy like 3 wheelers within the age group of 1 to 4 years.

Patients and Methods This study was conducted in 2 cities of southern Germany. The population is estimated at 170 000 inhabitants. Neurosurgical, pediatric, pediatric surgical, and traumatologic departments participated in the study. Our study entailed a prospective review of all patients between 0 and 18 years of age admitted to the hospital with a diagnosis of head injury (International Statistical Classification of Diseases and Related Health Problems 10th Revision [ICD-10]; S06.0-9) between January 1, 2010, and December 31, 2011. Only symptomatic patients suffering from nausea, persisting headaches, or neurologic deficits were admitted to the hospital. Data were collected using standardized clinical notes, transferred to a database, and evaluated. The form was structured to include details of the patient’s age and sex, mechanism of injury, Glasgow Coma Scale score,15 nature and treatment of the injury, concomitant injuries, duration of hospital stay, results of cranial CT and MRI scans, and outcome at discharge according to the Glasgow Outcome Scale and the modified Rankin scale.16-19 To ascertain the severity of the traumatic brain injuries in the patients, we used the modified Frankfurter Glasgow Coma Scale for children and Glasgow Coma Scale score to classify the severity of the head injury. Injuries were classified as severe (traumatic brain injury grade 3) at a Glasgow Coma Scale score of 8 or less, moderate (traumatic brain injury grade 2) at a score between 9 and 12, and mild (traumatic brain injury grade 1) at a score greater than 12. The classification was adapted for children less than 25 months old: severe (traumatic brain injury grade 3) at a Frankfurter Glasgow Coma Scale score of 11 or less, moderate (traumatic brain injury grade 2) at a score between 12 and 16, and mild (traumatic brain injury grade 1) at a score between 12 and 19. We divided the population into 6 groups according to age: under 1 year, 1 to 4 (children learning how to walk, toddlers), 5 to 6 (preschool), 7 to 10 (early school), 11 to 14 (late school), and 15 to 18 (adolescents) years of age.

Results We used the SPSS statistical software (IBM Company, SPSS Inc, Chicago, IL) to analyze the collected data. The t-test was

Figure 1. The age distribution of head injuries among children and adolescents.

used to describe the difference in the number of patients in different years. Differences between groups were calculated by ANOVA and correlations were calculated by (linear od in or binary) regression analysis.

Age and Gender Between January 1, 2010, and December 31, 2011, a total of 794 children were admitted after having sustained a head injury (2010 n ¼ 379; 2011 n ¼ 415, P ¼ .125). A total of 487 (61.3%) of these patients were male. The study population comprised 129 children (16.2%) younger than 1 year, 328 (41.3%) aged 1 to 4 years, 76 (9.6%) aged 5 to 6 years, 115 (14.5%) aged 7 to 10 years, 85 (10.7%) aged 11 to 14 years, and 61 (7.7%) aged 15 to 18 years. The lowest rate of admission was found in the age group 15 to 18 years (7.7%) (Figure 1). Males were consistently more likely to sustain a head injury in all age groups. The age distribution revealed a peak for children between 1 and 4 years (41.3%) of both sexes. The statistical mean duration of the hospital stay in our study was 2.92 days (minimum 0 day, maximum 68 days; standard deviation ¼ 3.651). One (0.13%) child had to remain in hospital for 68 days.

Time Points of Injury The most accidents occurred on a Friday (n ¼ 130, 16.4%). The most admissions due to traumatic brain injury occurred on Wednesday between 7 and 8 PM (n ¼ 17, 15.2% of the day) and Friday between 6 and 7 PM (n ¼ 17, 13.1% of the day). The largest number of cases of severe traumatic brain injury occurred on Saturday (n ¼ 4) (Figure 2).

Downloaded from jcn.sagepub.com at CAMBRIDGE UNIV LIBRARY on August 8, 2015

Pal’a et al


Figure 2. Number and distribution of admissions due to traumatic brain injury (grades) on the days of the week.

Figure 4. Overview of the most frequent pathologies resulting from head injury.

Figure 3. Age dependency of the grade of traumatic brain injury (grade 1 ¼ Glasgow Coma Scale score 15-13, grade 2 ¼ Glasgow Coma Scale score 12-9, grade 3  8).

Figure 5. Overview of different causes for falls among children and adolescents.

Severity of Injury A total of 764 (96.2%) children were admitted with mild traumatic brain injury, 15 children (1.9%) with moderate traumatic brain injury, and 14 children (1.8%) with severe brain injury. The proportion of mild brain injuries among admitted older children was lower (P ¼ .009). Mild brain injuries were typically the reason for admission in the younger age groups (P ¼ .013) (Figure 3).

Fractures and Intracranial Injuries Forty-one children (5.16%) sustained skull fractures. Parietal fracture was detected in 2% of all cases. Acute subdural hematoma was diagnosed in 8 patients (1%), epidural hematoma in 7 (0.88%), and cerebral contusion in 10 children (1.26%) (Figure 4).

Mechanism Injuries and Multiple Injuries A total of 284 (35.77%) of the injuries were sustained at home and 69 (8.69%) in the playground. The most common mechanism of injury was a fall (544, 68.51%), though the causes

differed between the age groups. In children under 1 year falls at home were predominant (Figure 5). Wheeled toys like 3wheelers or scooters were seldom the cause of injury (n ¼ 67, 8.4%). Admissions due to only bicycle accidents (n ¼ 48, 6%), accidents with a bicycle versus car (n ¼ 7, 0.88%), motor-scooter versus car (n ¼ 2, 0.25%), or motor-bike versus car (n ¼ 1, 0.12%) were relatively seldom. Multiple injuries were noted in 157 cases (19.8%) and isolated head trauma in 637 (80.2%) cases. Sixty-six (8.31%) patients suffered injury to the limbs, 66 (8.31%) had a concomitant facial injury, 11 (1.39%) children were admitted with a concomitant thoracic injury, 33 (4.16%) had a spinal injury, and 21 (2.64%) had suffered pelvic and abdominal injury (Table 1).

Surgical Intervention Neurosurgery was performed only in 21 (2.64%) cases. Seven (0.88%) patients required cranial decompression and evacuation of intracranial hematoma. Evacuation of intracranial hematoma without cranial decompression was performed in 4 (0.5%) cases. Intracranial pressure monitoring was necessary

Downloaded from jcn.sagepub.com at CAMBRIDGE UNIV LIBRARY on August 8, 2015


Journal of Child Neurology 30(9)

Table 1. Distribution of Concomitant Injuries in Different Age Groups. Age (y)

Head Injury in Children: Has a Change in Circumstances Caused an Increase in Treatment Numbers?

The number of hospitalizations for head injuries in children is rising. The exact causes remain unclear. We analyzed data of children aged between 0 a...
252KB Sizes 0 Downloads 5 Views