Traumatic Brain Injury

Overview

Traumatic brain injury (TBI), a form of acquired brain injury, can result when the head suddenly and violently hits, or is hit by, an object or when an object pierces the skull and enters brain tissue; the latter are called “open” injuries. TBI may result from motor vehicle accidents, sports accidents, falls, assaults (including child abuse), or gunshot wounds. TBI does not include injuries resulting from internal conditions, such as tumor, stroke, primary hypoxia, and degenerative disease.

TBI is often classified as mild, moderate, or severe based on assessments at presentation and during acute recovery over the first few weeks following the injury. Details can be found below under Clinical Classification. The correlation between severity and short- and long-term outcomes is variable, though poorer outcomes are generally associated with greater acute injury severity. Hypoxia secondary to the injury and prolonged post-traumatic amnesia (PTA) are risk factors for more severe longer-term impact.

Sequelae of TBI range from very mild, inconsequential, and transient to severe, debilitating, and life-long. The more serious and persistent sequelae include motor and sensory deficits, cognitive deficits, behavioral and emotional disturbances, and somatic symptoms such as headache, fatigue, sleep disturbance, and chronic pain. See also Mild Traumatic Brain Injury (TBI) and the Post-concussive Syndrome.

Other Names & Coding

Acquired brain injury

Injuries to the head are reported using the ICD-10 S01 thru S09 codes and exclude birth-related injuries. The following focus on brain injuries and their sequelae (indicated by the suffix "S").

ICD-10 coding

S06.xxxS, Intracranial injury (multiple types specified by x’s), sequela

S09.8xxS, Other specified injuries of the head, sequela

Z13.850, Screening for traumatic brain injury

Z87.820, Personal history of traumatic brain injury

See Coding for Head Injuries (icd10data.com). Coding details under S06 for the numerous types of intracranial injury can be found at Coding for Intracranial Injury (icd10data.com).

Prevalence

Inconsistent definitions of TBI and severity and lack of definitive diagnostic criteria make it difficult to determine the true incidence of TBI in children and the prevalence of long-term sequelae. Nevertheless, it is estimated that 145,000 US children (1:564) suffered long-term disability from TBI in 2005. [Zaloshnja: 2008] Using varying estimates across age groups and adjusting for typical age distribution in pediatric practice, the estimated prevalence of children with such sequelae in a pediatric practice is 1:3190 [Bocian: 1999].

The causes of TBI vary by age; most common are inflicted injuries in infants, falls in children 0-4, and motor vehicle accidents in older children and adolescents. Mild TBI accounts for 96.6% of all TBI diagnoses in children and 32% of those hospitalized for TBI. [Graves: 2015] [Bowman: 2008]

A study published in 2008 found the average incidence of TBI in individuals 0-25 years, both hospitalized and non-hospitalized, to be 1.1-2.4 per 100 per year [McKinlay: 2008], higher than previous studies have suggested. [Bowman: 2008]

Impact
Worldwide, TBI is the leading cause of child death and long-term disability and among the most frequent causes of interruption to normal child development. [Dewan: 2016] The median acute hospital cost for children 0-14 with TBI is around $8,000 and higher for older adolescents. [Hu: 2013] When compared with other injuries of similar initial acuity, the long-term care costs for TBI are higher regardless of the level of severity (mild to severe). [Schneier: 2006]

Prognosis

The degree and impact of post-TBI disabilities depend on the extent of the injury, the area of the brain affected, and the age and general health prior to the injury. Recovery after childhood TBI relies on a number of complex and interrelated factors, making outcome difficult to predict and highly variable. [Beauchamp: 2013] Mild injuries generally result in few, if any, impairments. Complicated mild (clinically mild but with skull fracture or intracranial hemorrhage on CT scan), moderate, and severe injuries can cause a variety of cognitive deficits, including in intellectual function, attention, memory and learning, executive function, language, and visual-motor skills. These deficits cause problems with functional skills and can affect educational and vocational abilities, especially in the post-acute period. [Beauchamp: 2013]

Practice Guidelines

No guidelines for management of children with TBI following discharge from the initial hospitalization have been published. The guideline below is for acute care of children with TBI.

Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, Carson S, Chesnut RM, Ghajar J, Goldstein B, Grant GA, Kissoon N, Peterson K, Selden NR, Tasker RC, Tong KA, Vavilala MS, Wainwright MS, Warden CR.
Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition.
Pediatr Crit Care Med. 2012;13 Suppl 1(Jan):S1-82. PubMed abstract

Roles of the Medical Home

Important roles of the medical home for patients with TBI include:
  • Assuring continuity of care by evaluating the needs of the patient and the family before and after discharge from the hospital or rehabilitation facility
  • Coordinating care with multiple providers to optimize the value added by each, minimize duplication of tests and unnecessary treatments, and enhance patient/parent understanding and engagement.
  • Providing prescriptions for medications and therapies. Advise patients/parents to avoid all medications other than those prescribed by you or a referring physician and to make certain all providers have an up-to-date list of current medications, including over-the-counter and other substances (e.g., herbal remedies). Work with the patient's rehab specialist to determine therapy prescription needs and who is responsible for them.
  • Helping the family identify local, state, and national resources
  • Providing letters of medical necessity for resources and referrals
  • Listening to parents and helping them cope with problems as they arise

Clinical Assessment

Overview

Because the initial evaluation and management of the injury usually occur in the inpatient setting and the diagnosis is rarely in question, this section will discuss ongoing assessment and potential secondary sequela. The approach will vary depending on the severity of injury, age of child, and presence of pre-existing and comorbid conditions.

Pearls & Alerts for Assessment

Predicting recovery

Although it is difficult to predict the extent of recovery in a child soon after a TBI, Time to Follow Commands (TFC), a standard measure of injury severity performed during the inpatient stay, was found to predict self-care, mobility, cognitive, and overall function at time of discharge from inpatient rehabilitation. [Suskauer: 2009] The Children's Orientation and Amnesia Test (COAT), also administered as an inpatient, includes assessment of post-traumatic amnesia. [Ewing-Cobbs: 1990]

Repeated concussion

Successive concussions, as well as repetitive sub-concussive blows, have lasting physiological effects. [Choe: 2016] A history of concussion increases an individual’s probability of having a future concussion and prolongs the duration of significantly abnormal cognitive functioning. [Shrey: 2011] Cumulative exposure to sub-concussions, defined as “a cranial impact that does not result in known or diagnosed concussion,” can lead to neurocognitive deficits and structural and functional brain abnormalities detected on advanced neuroimaging studies. [Ellis: 2016] [Bailes: 2013]

Children under 2 years

While most mild injuries result in relatively few impairments, the impact of brain injury in children under 2 years of age may be difficult to appreciate at the time of injury. It should be looked for later in the toddler years by screening prior to school entry. [Pomerleau: 2012]

Screening

For Complications

Standard Developmental Screening Tools (AAP) for deficits in development, learning, problem-solving, and general functioning may identify subtle sequelae/deficits.

Standard mental health screening tools should augment the general clinical assessment and focused surveillance questions. [Beauchamp: 2013] Information and tools related to screening and assessment for these concerns can be found on these Portal pages:

Clinical Classification

Acutely, TBI is often classified as mild, moderate, or severe, based on assessments in the first days or weeks following the injury. The Glasgow Coma Scale (GCS), based on level of consciousness, is the gold standard for primary assessment. Duration of loss of consciousness/coma and the severity of symptoms also contribute to the severity assessment. Duration of post-traumatic amnesia (PTA), characterized by a loss of memory for events surrounding the injury, disorientation, confusion, and significant cognitive impairment, offers further assessment of severity. Resolution of PTA in the pediatric patient is defined as achieving two consecutive passing scores on the Children’s Orientation and Amnesia Test (COAT). (See [Ewing-Cobbs: 1990] and [Iverson: 2002]; the latter includes the COAT questions and response norms by age).

Table 1 below integrates the several factors used to determine severity of brain injury. Mild TBI can be further classified as uncomplicated or complicated, the latter having skull fracture or intracranial hemorrhage on CT scan. A diagnosis of mild TBI does NOT require loss of consciousness. [Management: 2009]

The World Health Organization (WHO) Collaborating Centre Task Force on Mild TBI states that key criteria for identifying persons with a mild TBI include at least 1 of: confusion, disorientation, loss of consciousness less than 30 minutes, post-traumatic amnesia (PTA) for less than 24 hours or other transient focal neurologic abnormalities, and a GCS score of 13 to 15 after 30 minutes of presentation to a health care facility. [Centers: 2015]

Most patients with a TBI will experience resolution of symptoms over time; however, a subset of patients will have persistent somatic, cognitive, sleep, and emotional symptoms classified as post-concussion syndrome and may require outpatient follow-up. [Morgan: 2015] See Mild Traumatic Brain Injury (TBI) and the Post-concussive Syndrome

Table 1: The Management of Concussion Adapted from VA/DoD Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain Injury
The Management of Concussion Adapted from VA/DoD Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain Injury
Source: [Management: 2009]

Comorbid & Secondary Conditions

Hemiplegia or other motor disorder, muscle spasms, seizures/epilepsy (see Seizures/Epilepsy), cognitive dysfunction, mood disorders/anxiety (Depression and Anxiety Disorders), ADHD (see Attention-Deficit/Hyperactivity Disorder (ADHD)), and behavioral problems, such as conduct disorder, are known sequelae of TBI and may persist indefinitely. In general, these disorders should be managed as they would from any cause, with consideration of cognitive abilities and executive functions.

Specific cognitive deficits to address include:
  • Attention
  • Learning and memory
  • Executive functions, such as planning and decision-making
  • Language and communication
  • Reaction time
  • Reasoning and judgment
Seizures following brain injury are correlated with more severe brain injury and younger age at the time of the injury. [Hazama: 2018] [Wilson: 2018] Although there is no compelling evidence that prophylactic medications prevent seizures post injury, they are used frequently. [Mee: 2019] Evidence is clearer that early prophylactic seizure medications do not prevent post-traumatic epilepsy, which occurs in 10-20% of children who have had a TBI. [Park: 2015] Generally, a concern for seizures should provoke an EEG. Then, if evidence for seizures exists, start medication in the same manner as other symptomatic causes of epilepsy. See the Seizures/Epilepsy and Pediatric Neurology (see NM providers [31]).

Behavioral changes may also be noted and particularly troublesome during transitions and special occasions. Behavior changes may involve problems with executive function, fatigue, distractibility, poor organization, sexual inappropriateness, social immaturity, and depression. Changing these difficult behaviors can be a long and slow process that requires trial and error and consultation with experts such as neuropsychologists. Medication may be needed. See Neuropsychiatry/Neuropsychology (see NM providers [0]).

History & Examination

The post-discharge assessment aims to determine the extent of the trauma, obtain details about the inpatient course, evaluate current problems and functioning, and develop a plan for management. This can take some time, particularly if the primary care clinician was not involved in the inpatient stay.

Current & Past Medical History

Background: Explore pre-existing problems, particularly previous brain injury and/or seizures. Did the child have developmental delay, psychiatric or behavioral problems, or cognitive problems before the injury? Did the child have a baseline ImPACT assessment prior to the injury?

The following details related to the acute injury may help you understand the injury and its impact on the child and family:
  • What were the circumstances surrounding the trauma?
  • What was the nature of the injury?
  • Was the injury witnessed?
  • Did the child lose consciousness? For how long?
  • What was the initial Glascow Coma Scale?
  • What, if any, other injuries did the patient suffer?
  • Did the patient have any seizures at the time of injury?
  • What treatment was given post-injury?
  • Was a CAT scan or MRI performed?
  • Were C-spine films done?
  • Was the child admitted to an ICU? If so, for how long?
  • Was the child intubated? If so, for how long?
  • Did the child receive inpatient rehabilitation? If so, for how long?
  • What is the first thing the child remembers after the accident?
  • Did the child receive a cognitive evaluation (usually by a Speech/Cognitive Therapist)?
Since discharge from the hospital:
  • What medications is the child taking?
  • Ask the child and then the parent by what percentage has the individual returned to pre-injury status? What is hindering the child from being 100%?
  • Ask them to prioritize the top three challenges and delve into each for clarification.
ImPACT (Immediate Post-Concussion Assessment and Cognitive Test) is a computerized test administered by a licensed professional and is commonly used in sport-related concussion. Although you may not be able to administer the full ImPACT, the following questions will assist in focusing the assessment and developing the treatment plan:
Is the child having
  • Headaches (if present, consider evaluation by an optometrist with experience in TBI)
  • Nausea
  • Vomiting
  • Balance problems
  • Dizziness
  • Trouble falling asleep
  • Fatigue
  • Sleeping too much
  • Sleeping too little
  • Drowsiness
  • Light sensitivity
  • Noise sensitivity
  • Irritability and agitation
  • Sadness
  • Feeling nervous
  • Feeling more emotional
  • Numbness or tingling
  • Feeling too slow
  • Mentally “foggy”
  • Difficulty concentrating
  • Memory problems
  • Visual or reading problems (if present, consider evaluation by an optometrist with experience in TBI)
Functional status (assess relative to child's age and condition):
  • Eating; is the child having difficulty maintaining or gaining weight?
  • Bathing
  • Dressing
  • Bowel/bladder function
  • Fine motor skills
  • Mobility
  • Communication and comprehension
  • School and developmental milestones
  • Which therapies is the child receiving?

Periodic screening for mental health problems may be very useful. (See Depression , Initial Diagnosis and Anxiety Disorders, Initial Diagnosis for screening tools.)

Family History

Is there a family history of neurological conditions? Any family members who have experienced TBI? This may offer insight into prior knowledge and understanding of the condition and may elicit fears or optimism to guide ongoing education and communication.

Pregnancy/Perinatal History

Primarily, this is relevant to help identify possible pre-existing neurologic or neuro-behavioral deficits.

Developmental & Educational Progress

Assess educational status before and after injury for:
  • Grade/school/academic program
  • Presence of physical, emotional, or learning challenges
  • Receiving special accommodations or modifications (504, IEP plans)
  • Level of academic performance. Assess for changes.

Maturational Progress

Assessment of pubertal status is important, particularly for understanding the social impact of any resulting disabilities. [Webb: 2014] [Casano-Sancho: 2017]
  • Have menses begun or resumed since accident?
  • Was the adolescent sexually active prior to injury?
  • Is the adolescent sexually active now? Is birth control/protection being used?

Social & Family Functioning

Psychiatric disorders after TBI are correlated with pre-injury family functioning, family socio-economic class and functioning, and a family history of psychiatric problems. [Rashid: 2014] A family history of mood disorder and other psychiatric illness increases the likelihood of post-concussion syndrome. [Morgan: 2015]

Are there medical or social challenges that may hinder the parent in providing for the ongoing needs of the child? Is there a history of depression, alcoholism, etc. in the child or family that might hamper recovery? Is there family support available? Ask about school and relationship problems (within the family and with peers).

Physical Exam

General

Assess mental status, including wakefulness, alertness, interaction, ability to follow commands in an age-appropriate manner, attention span for age, and memory. Assess speech and language. Are expressions of wants and needs and responses to circumstances age-appropriate? Compare current exam with previous exam. Except as related to associated injuries, aspects of the exam not mentioned below should be normal.

Vital Signs

Blood pressure

Growth Parameters

Ht | Wt | BMI

Extremities/Musculoskeletal

Look for contractures, assess range of motion.

Neurologic Exam

Perform developmentally-appropriate exam with special attention to:
  • Tone, especially spasticity
  • Strength
  • Reflexes
  • Gait/posture
  • Balance and coordination

Testing

Sensory Testing

Obtain or review hearing and vision screens. Repeat if concerns arise.
  • Vision: Monitor for decreased visual acuity, diplopia, strabismus, visual field deficits. Visual changes may also be due to cortical injury and resulting in decreased convergence. Vision therapy, with a specialized OT or optometrist with training in neuro-vision services, may be useful. Review hospital/clinic records for previous screening.
  • Hearing: Refer to an audiologist for concerns about conductive or sensorineural hearing loss. Review hospital records for audiology screening.

Imaging

Review previous scans. Although a non-contrast CT scan indicates the presence of hemorrhage or edema, MRI provides a much clearer picture and shows subtle changes. Imaging needn't be repeated unless the patient has acute changes in mental status. Note: MRI/CT scans look at the structural anatomy of the brain and spinal cord. Subtle and/or chemical changes may not be radiographically evident, and functional changes may not be reflected on the MRI/CT. Focus should be on functional status, which may evolve with time. In general, imaging results will not alter the treatment plan. [Haghbayan: 2016]

Other Testing

Consider EEG if seizures are suspected after the first week post-injury (the longer the patient goes without a seizure, the less likely post-traumatic seizures develop).

Specialty Collaborations & Other Services

Pediatric Physical Medicine & Rehabilitation (see NM providers [4])

Key to devising and implementing a rehabilitation plan. Often helpful in monitoring physical, emotional, and behavioral issues, and spasticity.

Pediatric Neurology (see NM providers [31])

Refer as needed for the treatment of seizures. Pediatric neurology may also follow patients with traumatic brain injury, depending on local expertise.

Pediatric Orthopedics (see NM providers [13])

Refer as needed for orthopedic issues relating to spasticity or injuries.

Pediatric Gastroenterology (see NM providers [8])

Refer as needed for problems related to feeding.

Speech - Language Pathologists (see NM providers [377])

Refer to evaluate language, content, memory, speech, and feeding-related functions.

Occupational Therapy (see NM providers [298])

Refer to evaluate visual perception and processing, handwriting, upper extremity strength and coordination, activities of daily living, and fine motor skills.

Physical Therapy (see NM providers [321])

Refer to evaluate gross motor function, balance, lower extremity strength, and coordination.

Educational Advocacy (see NM providers [31])

Refer to assess learning disabilities and develop a plan for re-integration into school.

Neuropsychiatry/Neuropsychology (see NM providers [0])

Refer to assess cognitive abilities. The assessment sometimes is available during the initial hospitalization, but usually it is not done until 3 to 6 months post-traumatic injury and then repeated every 2 to 3 years as needed.

Pediatric Ophthalmology (see NM providers [9])

Refer to an ophthalmologist or optometrist with experience in evaluating children with TBI if headaches, reading, or vision are identified as problems.

Treatment & Management

Overview

The focus of care for children following TBI is to restore independence in mobility, communication, and self-care (feeding, grooming, toileting) through rehabilitation. Rehabilitation should be consulted early (even while the patient is in the intensive care unit) to begin planning care based on the extent of injury, family situation, and available resources. Early and regular communication between the rehab team and the primary care physician can optimize follow-up and outcomes. Follow-up with primary care should occur 1-2 weeks after discharge from the hospital.

The need for intervention (physical, emotional, cognitive, educational) in children with TBI should be reassessed periodically as the patient recovers cognitively, physically, and from other post-injury problems, such as headaches and attention deficits. Pediatric Physical Medicine & Rehabilitation (see NM providers [4]) can help coordinate a multi-disciplinary team.

Pearls & Alerts for Treatment & Management

Mild TBI

In the emergency room, the focus for children with concussion or mild TBI is often ruling out more serious injuries. If none are found, children and families may be discharged with education about mild TBI, such as changes in mood and/or concentration, learning problems, headaches, and sleep problems. Follow-up with a physiatrist or neurologist, depending on local expertise, can be helpful. [Yeates: 2009] [Taylor: 2015] [Scholten: 2015]

Depression is common after TBI

Up to 50% of brain-injured children present with behavioral problems and disorders. These can emerge either immediately after the injury or several years later. and they often persist and even worsen with time. [Li: 2013] The frequency varies with age at brain injury and the degree of injury. [Beauchamp: 2013] Depression following TBI may appear as a deterioration in ability and should be considered in follow-up visits by the medical home. A child with previous mental health issues will likely have greater need for mental health services than before the injury. [Max: 2015]

Return to driving

If the adolescent has a driver’s license or learner’s permit, the return to driving needs to be discussed with the adolescent and family. Visual deficits need to be addressed; if the patient has seizures treated by an antiepileptic, state guidelines need to be followed. Depending on the degree of injury, a driving evaluation from a specialized occupational therapist may be necessary.

How should common problems be managed differently in children with Traumatic Brain Injury?

Growth or Weight Gain

Monitor for weight gain/status in the child with any mobility impairments. While Childhood Obesity Screening & Prevention are helpful, it is also important to look at endocrine function as a factor for weight gain.

Development (Cognitive, Motor, Language, Social-Emotional)

Ongoing developmental assessment is important because brain injury deficits may not be apparent until the child reaches a new developmental level and new skills are expected.

Systems

Neurology

Headaches are common following a head injury. While the duration of headaches is unknown, it is a potential symptom of post-concussive syndrome, which can last 12-24 months and is the most common acute post-injury symptom. The SAFE (Sleep, Activity, Food/Fluid, Environment) guidelines are a conservative but effective treatment for headaches. These include ensuring proper sleep hygiene, limiting screen time, encouraging activity, ensuring hydration, and eating healthy food. While exposure to light and noise can trigger or exacerbate headaches, a plan for progressive tolerance to these stimuli needs to be established. [Starkey: 2018] For more information, see Headache (Migraine & Chronic).

For seizures, anticonvulsants are generally discontinued 1 week after injury if no new seizures are noted. The risk of post-traumatic epilepsy is 7-12% for up to 10 years following TBI. [Krach: 2015] The more severe the injury, the more likely the patient will develop seizures. For detailed information, see Seizures/Epilepsy.

Specialty Collaborations & Other Services

Pediatric Neurology (see NM providers [31])

Children with epilepsy and intractable headaches after TBI may benefit from evaluation by pediatric neurology.

Musculoskeletal

The management of spasticity includes both surgical and non-surgical interventions. Severe spasticity, secondary contractures, and pressure sores interfere with the child's functional abilities, make hygiene difficult, and cause discomfort. Spasticity may worsen when the patient is ill or upset. Treatment, generally provided by a physiatrist-led team, includes therapies and orthopedics. Realistic expectations are key to successful therapy.

Non-surgical interventions include:
  • Therapies - physical and occupational
  • Positioning aids (to help the child sit, lie, or stand) - If the child isn't sitting independently, a corner chair, tumble form, wheelchair, or other positioning aids enable a seated position for feeding and optimal hand use during play and activities of daily living (ADLs).
  • Braces and splints - These prevent deformity and provide support and protection. They may be used during the day or night to provide a stretch and optimal positioning across joints.
  • Wheelchairs, either manual or power, may be needed for mobility.
  • Standers/walkers allow standing and walking for those needing help with balance and support for walking. Weight-bearing also helps prevent osteoporosis, allow full lung expansion, stretch hamstrings, and enable children to be on-level with peers.
  • Medications:
    • Oral - Although oral antispasmodic agents may cause excessive sleepiness, they are often tried because they are non-invasive. Examples are baclofen (Lioresal), tizanidine, diazepam (Valium), and clonazepam (Klonopin). Valium before sleep is helpful in some patients and may not cause daytime drowsiness. [Mathew: 2005] Despite limited studies in pediatrics, modafinil (Provigil)  and tizanidine (Zanaflex) may improve function in children with spasticity. Doses should be titrated to avoid weakness and excessive hypotonia. [Murphy: 2008]
    • Injections - Botulinum toxin (Botox) or (Dysport) and phenol injections are used to treat and prevent contractures that lead to tight ankles (difficulty walking) and hygiene problems (hip adduction contractures). To optimize impact, injections are usually combined with physical therapy, splinting, or casting. [Pattuwage: 2017]
Surgical interventions used to manage the severe spasticity and/or dystonia include:
  • Orthopedic surgery for scoliosis, hip dislocations, muscle contractures, and ankle, foot, and hand deformities
  • A programmable baclofen pump placed in the abdominal wall with a catheter in the intrathecal space. Complications include infection, catheter breakage (resulting in withdrawal), and a possible increase in scoliosis. Baclofen pumps are used in children weighing more than 30 lbs.
  • Selective dorsal rhizotomy is a neurosurgical procedure that reduces spasticity by severing parts of sensory nerves in the spinal cord.

Specialty Collaborations & Other Services

Pediatric Physical Medicine & Rehabilitation (see NM providers [4])

Physiatry will manage the different treatment options available for spasticity after TBI, including initial evaluation and management of a baclofen pump.

Pediatric Orthopedics (see NM providers [13])

Children with spasticity should be referred to orthopedics for management and related orthopedic complications.

Pediatric Neurosurgery (see NM providers [1])

Neurosurgery, in conjunction with Pediatric Physical Medicine & Rehabilitation, performs a baclofen trial and the pump insertion surgery.

Nose/Throat/Mouth/Swallowing

Swallowing dysfunction (dysphasia) may manifest as drooling, salivary pooling (with malodorous breath and increased risk of dental caries), malnutrition, choking, coughing after drinking, and/or frequent pneumonias. Children with swallowing problems should receive therapy from a speech therapist (or, in some locations, an occupational therapist) who can evaluate swallowing function and safety, determine if interventions (e.g., oral therapy, special feeding techniques, improved feeding position) might lead to improvements, and determine the safest and most efficient textures for eating. If dysphagia is a problem, diets using pureed foods and thickened liquids may be necessary to prevent aspiration. See Power Packing, Thickening Liquids & Pureeing Foods, and Aspiration/Chronic Lung Disease.

Many parents will choose not to treat drooling due to concerns about the side effects of medication or surgery. Drooling in the older, socially-aware child can be very embarrassing and create barriers to important social interactions. Let's Talk About... Series for Pediatric Brain Injury and Associated Issues (Spanish & English) resources and information for patients and families about specific treatments.

Specialty Collaborations & Other Services

Speech - Language Pathologists (see NM providers [377])

Refer for swallowing and feeding issues.

Occupational Therapy (see NM providers [298])

In some locations, OTs may have the most expertise in swallowing and feeding issues.

Pediatric Gastroenterology (see NM providers [8])

Refer to evaluate and manage gastric tubes and nutrition. Gastroenterologists may collaborate with dietician to monitor caloric needs related to growth.

Pediatric Otolaryngology (see NM providers [2])

Refer as needed to assess anatomic and functional disturbances in swallowing; may perform surgical treatments and interventions for excessive drooling.

Mental Health/Behavior

Children with a TBI may have behavioral problems, such as sustaining attention, mood stability, depression, and anxiety, that interfere with social and emotional development. These behavioral problems may be challenging to address and lead to social difficulties, particularly in the school setting. Behavior problems are exacerbated by fatigue, stress, frustration, and external stimuli, such as bright lights and loud noises. For more information, see Traumatic Brain Injury Survival Guide (Dr. Glen Johnson).

Evaluation and treatment by physiatrists, neuropsychologists, psychiatrists, or psychologists with experience with TBI can be helpful. Ask parents, the patient (if appropriate), teachers, care providers, and therapists to complete the Behavioral Checklist for Patients with TBI (PDF Document 50 KB) to identify specific problems. When working with the families of children with TBI, the medical home should help families prioritize the issues on which to focus.

Patients may be discharged on stimulant medications for attention and memory problems. Their efficacy is still unclear, but they may be helpful in selected patients, particularly those who had ADHD before the injury. [Huang: 2016] [Spritzer: 2015] Other psychotropic drugs may be prescribed to address problems with behavior, attention, and learning. [Williamson: 2016] Behavior modification has also been used to address the personality and behavioral effects of TBI. [1998 Consensus Statement - Rehabilitation after TBI (NIH Conference) (PDF Document 920 KB)] Depression is common after TBI and should be watched for by families and screened for in the medical home. See Depression for screening tools and management information.

The medical home should work with the family to monitor how the child functions in the community and the family is coping. Children may have behavior problems after a TBI and act-out. They may have anxiety and/or post-traumatic stress disorder. Sometimes a child who is functioning well at first presents with behavior or adjustment problems later. Pre-injury function, injury severity, parent mental health, and child self-esteem all contribute significantly to predicting social and behavioral outcomes. [Catroppa: 2017]

Specialty Collaborations & Other Services

Psychiatry/Medication Management (see NM providers [14])

Refer for the treatment of behavioral problems and mood disorders following TBI.

Neuropsychiatry/Neuropsychology (see NM providers [0])

Refer for behavioral evaluation and management, including cognitive problems after TBI.

Sleep

Lack of sleep interferes with the healing process, affects memory, causes irritability, and generally makes head injury symptoms worse. It can also contribute to depression and anxiety. The child may:
  • Go to sleep easily but wake up often
  • Have difficulty falling asleep
  • Suffer from fatigue during the day
  • Have disruption of day/night sleep cycles
  • Be awakened easily by minimal stimuli, such as soft noises
Complete a sleep assessment to assess severity and potential approaches:
  • When do you lie down to sleep?
  • How long does it take you to fall asleep?
  • How many times do you wake up during the night?
  • What time do you get up?
  • Do you feel rested upon awakening in the morning?
  • How often/how long do you nap?
See Screening for Sleep Problems.

First, ensure that families are following good sleep hygiene measures, including having the child:
  • Go to bed at the same time every night, even on weekends.
  • Avoid caffeine and chocolate, especially in the evening.
  • Avoid exercise or stimulating activity late in the evening.
  • Keep the bedroom at an even, moderate temperature and dark and quiet.
  • Avoid napping during the day.
  • No screen time 1-2 hours prior to bedtime.
  • Establish a routine for bedtime, which may include: bath, stories, reading, journaling, and if using medications, administer as part of the “winding down” routine, stimulation should be avoided after medications have been given.
If hygiene measures are insufficient, medications for short- or long-term may be helpful. See Sleep Medications.

Specialty Collaborations & Other Services

Pediatric Sleep Medicine (see NM providers [1])

Refer as needed for the assessment and management of sleep problems following TBI.

Gastro-Intestinal & Bowel Function

Constipation is common in children with impaired mobility. Symptoms may include unexplained irritability, vague abdominal pain, loss of appetite, and/or intolerance of feeds. Encourage a healthy diet including fruits, vegetables, lean protein, whole grains, and adequate water intake. If the child receives feedings via G-tube, consider prescribing a formula with added fiber. For medical management of constipation, see the Portal’s Constipation, Treatment & Management module.

Specialty Collaborations & Other Services

Pediatric Gastroenterology (see NM providers [8])

Helpful for patients with intestinal motility problems or constipation that do not respond to typical measures implemented in the medical home.

Learning/Education/Schools

The medical home should assist the family in planning and negotiating for educational needs following TBI. An education consult may have been obtained during the child’s hospitalization. His/her school may have been contacted regarding severity of the brain injury.

It may be appropriate to order a neuropsychological evaluation at least 6 months after the event to assess the child’s learning style and abilities. This information can be used in collaboration with the school to make the most appropriate accommodations or modifications to the school program.

The medical home should advocate for early involvement of the education team for evaluation for needed services. Returning to school may provoke anxiety. The medical home can assist the child/parent in setting a plan for gradual reintegration into the school community.

The school may request a letter from the medical provider specifying modification/accommodations needed for the child. See Traumatic Brain Injury: A Guidebook for Educators (University of the State of New York).

Other helpful resources include:
  • Schools Information Release Form (PDF Document 49 KB): Sample form for schools that authorizes the exchange of information between the student’s health care provider and school professionals as it relates to the diagnosis/condition listed.
  • Medical Home to School Summary Form (PDF Document 40 KB): Sample form to facilitate communication between health care providers and school professionals relating to health concerns that impact a student's education.
  • TBI Resources for Educators (USOE): Presentations, reports, and guides to provide strategies in working with students with traumatic brain injury; Utah State Office of Education.

Specialty Collaborations & Other Services

Pediatric Physical Medicine & Rehabilitation (see NM providers [4])

Generally well-connected with local school systems and able to advise families regarding options and the most efficient and effective approaches to seeking accommodations and assistance.

Family

It is important to understand the stressors that affected children and their families may face after leaving the hospital. The transition home can be overwhelming and include:
  • Adequate insurance coverage for required medical/therapeutic services
  • Providing constant supervision as needed for the child
  • Transportation to appointments/therapies
  • Managing the child’s medical needs such as medication, nutrition, and daily cares
  • Adjustments/home modification, as needed
  • Coordinating with the school for modifications/accommodations
  • Changes in lifestyle, work routine, and leisure activities
  • Changes in family/marital roles and responsibilities
  • Emotional adjustments and changes in expectations/hopes
The medical home should help the family by suggesting financial resources, support groups, counseling and/or psychotherapy for the patient and/or family. Local brain injury associations and support groups can be a resource for the patient and family. They help with education, resource allocation, and can connect the patient and family with support groups.

Complementary & Alternative Medicine

There is strong evidence that combining complementary and integrative medicine with conventional medical care is safe and effective in treating traumatic brain injury, and in some circumstances, a multi-disciplinary approach may be necessary for optimum recovery. Complementary and integrative medicine includes therapy, such as cognitive-behavioral therapy, traditional Chinese medicine (acupuncture, tai chi, Qigong, yoga), manipulative therapies (e.g., physical and occupational therapies, chiropractic treatment), and mind-body practices (deep breathing, relaxation, meditation). [Drake: 2017] [Hernández: 2016] See Integrative Medicine for CYSHCN.

Issues Related to Traumatic Brain Injury

No Related Issues were found for this diagnosis.

Ask the Specialist

When can the child return to school?

If the child is able to pay attention, sit upright without feeling worse, and participate in therapies and home activities, start with 1-4 hours of school while progressively increasing time in class. Limit screen time, promote 8-10 hours of sleep nightly, and adequate hydration, while monitoring for worsening headaches, tolerance of light, and feelings of being overwhelmed. It may be beneficial to meet with the school counselor/teachers and evaluate the need for 504 accommodations allowing for rest periods and decreased workload (extended due dates, lighter homework assignments, and test-taking accommodations). See Let's Talk About... Brain Injuries: A Guide for Teachers (Spanish & English).

When should I try medications to help manage impaired attention, focus, and impulsivity?

If attending cognitive/speech therapy is not effective in reducing impaired executive functioning deficits, such as decreased attention and focusing abilities, then typical dosing for medications to treat attention/focusing can be initiated and titrated to effect. It is important to monitor changes in appetite and sleep when starting these medications. See Attention-Deficit/Hyperactivity Disorder (ADHD) for more information.

When should I consider ordering a neuropsychological evaluation?

Neuropsychological testing is usually discussed with the parents/child 1-3 months following TBI, but it is not typically completed until after at least 6 months post-injury and/or when the child has plateaued in their recovery. Consider repeating the test every 2-3 years post-injury to allow for changes due to recovery and development to identifies strengths in learning what can be incorporated into 504/IEPs.

When can the child/adolescent return to increased activity (progression from “Two-Feet on the Ground”)?

Although guidelines are listed below, each child needs to be evaluated over time as the child returns to sports and other typical age-appropriate activities.

  • Mild TBI: With normal CT scan and no skull fractures, 2 feet on the ground for 1 month
  • Complicated Mild TBI: Intracerebral bleeding or skull fracture, 2 feet on the ground x2 months
  • Complicated Mild TBI: Intracerebral bleeding and skull fracture, 2 feet on the ground x3 month
  • Moderate/Severe TBI: Two feet on the ground x3-6 months depending on restoration of balance and vestibular function. It may not be recommended to return to high-contact sports, such as football, wrestling, motor cross.
As the child/adolescent returns to activity, promote 8-10 hours sleep nightly and adequate hydration while monitoring for worsening headaches, tolerance of light, and feelings of being overwhelmed, as these may indicate the child needs to return to the last level of tolerated activity.

Emphasize safe activities the child can do while recovering as staying active will promote recovery. See Let's Talk About... Brain Injury Keeping Your Child Safe After a Head Injury (Spanish and English).

Resources for Clinicians

On the Web

Traumatic Brain Injury (CDC)
Facts, statistics, clinical guidelines, publications, reports, videos, and resources for parents and clinicians responding to TBI. Also includes tools to assist with prevention of TBI, recognizing and responding to a concussion and other serious brain injuries, and how to safely return to school and sports; Centers for Disease Control and Prevention.

Brain Trauma Foundation
Education for health care professionals and first responders who treat brain injury. Guidelines for pre-hospital management, surgical management, and acute medical management of severe TBI in infants, children, and adolescents.

Traumatic Brain Injury (NINDS)
Overview and links to publications and relevant organizations - not pediatric-specific; National Institute of Neurological Disorders and Stroke.

Center for Outcome Measurement in Brain Injury (COMBI)
Measurement scales and support for outcome measures of brain injuries. Scales are commonly used in rehabilitation and assessment. Featured instruments often include contact information, background information, scale syllabi, administration and scoring guidelines, training and testing materials, information on scale properties, references, scale forums, and frequently asked questions.

Traumatic Brain Injury Model Systems (National Data and Statistical Center)
Research and dissemination efforts of the Traumatic Brain Injury Model Systems (TBIMS) program; funded by the National Institute on Disability and Rehabilitation Research (NIDRR).

Heads Up to Health Care Providers (CDC)
Provides physicians with information for assessment of mild TBI and helps guide the management and recovery of patients of all ages although some information pertains to very young children; Centers for Disease Control and Prevention.

Helpful Articles

PubMed search on rehabilitation and management of traumatic brain injury in children: articles over the past year

Brands I, Stapert S, Köhler S, Wade D, van Heugten C.
Life goal attainment in the adaptation process after acquired brain injury: the influence of self-efficacy and of flexibility and tenacity in goal pursuit.
Clin Rehabil. 2015;29(6):611-22. PubMed abstract

Dewan MC, Mummareddy N, Wellons JC 3rd, Bonfield CM.
Epidemiology of global pediatric traumatic brain injury: qualitative review.
World Neurosurg. 2016;91:497-509.e1. PubMed abstract

Goldsworthy R.
The effect of traumatic brain injury on caregivers.
Spotlight on Disability Newsletter. 2015; (March). American Psychological Association; http://www.apa.org/pi/disability/resources/publications/newsletter/201...

Rashid M, Goez HR, Mabood N, Damanhoury S, Yager JY, Joyce AS, Newton AS.
The impact of pediatric traumatic brain injury (TBI) on family functioning: a systematic review.
J Pediatr Rehabil Med. 2014;7(3):241-54. PubMed abstract

Clinical Tools

Assessment Tools/Scales

Behavioral Checklist for Patients with TBI (PDF Document 50 KB)
Questionnaire for parents, patient, teachers, and care providers. Assists in identifying key behavioral problems and narrowing the focus of treatment; Primary Children's Rehabilitation Program.

Sleep History Questionnaire (PDF Document 20 KB)
A 14-day sleep tracker and 1-page questionnaire about sleep routines and behavior.

Sleep Log (PDF Document 31 KB)
One-page chart to help parents record a child's sleep status and the effects of sleep interventions.

Glascow Coma Scale (PDF Document 93 KB)
Scoring system used to describe the level of consciousness in a person following a traumatic brain injury.

Rancho Levels of Cognitive Functioning Overview (PCH) (PDF Document 40 KB)
A 2-page summary describing the typical levels of recovery after brain injury; Pediatric Brain Injury series from Primary Children's Hospital.

Toolkits

Heads Up: Brain Injury in Your Practice (CDC)
Practical clinical information and tools, including a booklet on diagnosis and management of a mild TBI; an ACE; a care plan to help guide a patient's recovery; fact sheets in English and Spanish on preventing concussion a palm card for the on-field management of sports-related concussion; and a CD-ROM with downloadable kit materials and additional mild TBI resources.

Patient Education & Instructions

Let's Talk About... Series for Pediatric Brain Injury and Associated Issues (Spanish & English)
Search the patient education library to find PDFs in Spanish and English for topics related to TBI. Examples include: Safety after Brain Injury; Acquired Brain Injury Characteristics; Sleep and Brain Injury; Selective Dorsal Rhizotomy; Mild Traumatic Brain Injury; Dysphagia; Brain Injury Severity and Measurement; Power Packing; Thickening Agents; and Brain Injury and a Healing Environment; Intermountain Healthcare.

Cognitive Functioning Scale: A Guide for Family and Friends (Rancho Los Amigos National Rehabilitation Center) (PDF Document 1.7 MB)
Thirteen-page booklet that explains the cognitive and behavioral levels of recovery after a brain injury.

Let's Talk About... Baclofen Pump (Spanish & English)
Description of the benefits, risk, care, and use of a baclofen pump for spastic muscle relaxation; Intermountain Healthcare.

Let's Talk About... Selective Dorsal Rhizotomy (Spanish & English)
Description of the benefits, risks, and care after a selective dorsal rhizotomy (SDR) procedure for muscle spasticity; Intermountain Healthcare.

Let's Talk About... Brain Injuries: A Guide for Teachers (Spanish & English)
Description of student behavior changes after a traumatic brain injury; Intermountain Healthcare.

Let's Talk About... Brain Injury Keeping Your Child Safe After a Head Injury (Spanish and English)
Description of why a child needs greater supervision after a traumatic brain injury (TBI) and how parents can help the child; Intermountain Healthcare.

Let's Talk About... Brain injury: Creating a Healing Environment (Spanish & English)
Description of how to create a calm environment for a child with a Traumatic Brain Injury (TBI) including triggers, signs of being overwhelmed, and steps to prevent agitation; Intermountain Healthcare.

Let's Talk About... Sleep After a Brain Injury (Spanish & English)
Description sleep problems, signs of those problems, and helping a child with a Traumatic Brain Injury (TBI) sleep better; Intermountain Healthcare.

Resources for Patients & Families

Information on the Web

Traumatic Brain Injury (MedlinePlus)
Offers an overview and an extensive compilation of links to reliable websites and organizations related to TBI; National Library of Medicine and National Institutes of Health.

Traumatic Brain Injury (NINDS)
Information about traumatic brain injury, treatment, prognosis, clinical trials, organizations, and publications; National Institute of Neurological Disorders and Stroke.

TBI Resource Guide (CSN)
Comprehensive list of national , informational, educational, and organizational resources related to traumatic brain injury; Children's Safety Network.

Traumatic Brain Injury (Center for Parent Information & Resources)
Parent-focused page about TBI, includes information about education.

Brainline Kids – Helping Kids with Brain Injury
BrainLine Kids, a feature of Brainline.org, provides information about children ages birth through 22 years who are affected by Traumatic Brain Injury.

Abusive Head Trauma / Shaken Baby Syndrome (Nemours)
Signs, symptoms, outcomes, and prevention of abusive head trauma/shaken baby syndrome; KidsHealth.

Traumatic Brain Injury (CDC)
Facts, statistics, clinical guidelines, publications, reports, videos, and resources for parents and clinicians responding to TBI. Also includes tools to assist with prevention of TBI, recognizing and responding to a concussion and other serious brain injuries, and how to safely return to school and sports; Centers for Disease Control and Prevention.

Types of Memory (PDF Document 59 KB)
A five-page handout developed by Dr. Glen Johnson, Clinical Neuropsychologist, that describes the types of memory, things that affect memory, and tips for improving memory.

Fatigue (PDF Document 41 KB)
Courtesy of Dr. Glen Johnson, Clinical Neuropsychologist, this handout describes fatigue and ways to adjust to the fatigue factor.

The Road to Rehabilitation Series (BIAUSA) (PDF Document 758 KB)
Eight articles (total 80 pages) for TBI patients and families about dealing with pain, headaches, cognition and memory, behavior changes, speech and language, drug therapy, spasticity, and concussion/mild brain injury; Brain Injury Association of America.

National Resource Center for Traumatic Brain Injury
Practical information for professionals, persons with brain injury, and family members.

Pediatric Neuropsychology: A Guide for Parents (PDF Document 456 KB)
Describes pediatric neuropsychology, how it differs from a school psychological assessment, reasons for referral, what is assessed, what it will tell you about your child, and how to prepare for the test.

Easter Seals
Nonprofit organization offering services for individuals with disabilities and their families. Primary services include medical rehabilitation, early intervention, physical and occupational therapy, speech and hearing therapy, child care, recreation, and transition.

Family Functioning Following Pediatric Traumatic Brain Injury (Word Document 80 KB)
Information about family adaption after TBI and characteristics of healthy families, re-entry into community and school, role of the pediatrician, and family functioning research; Brain Injury Association of Washington.

When your Child is in the Hospital
Information about TBI specific to the Boston area. Good tools/resources for families in any state; Brain Injury Center at Children’s Hospital, Boston.

Traumatic Brain Injury: Hope Through Research (NINDS)
Research and clinical trials that are funded by the National Institute of Neurological Disorders and Stroke.

National Resource Center for TBI (Virginia Commonwealth University)
Answers basic questions for parents and teachers, provides lists of links that address a multitude of topics such as medication, education, family support, legal issues, rehab resources and more.

National & Local Support

Brain Injury Association of America
Links to resources, publications, and information about policy/legislation and state chapters.

Services for Patients & Families in New Mexico (NM)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: June 2009; last update/revision: October 2020
Current Authors and Reviewers:
Author: Lynne M. Kerr, MD, PhD
Authoring history
2018: first version: Teresa Such-Neibar, DOA; Wendy Walker, RN, BSN, CRRNCA; Jenny Wood, RN, BSN, CRRNCA
AAuthor; CAContributing Author; SASenior Author; RReviewer

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