Longitudinal Developmental Outcomes after Traumatic Brain Injury in Young Children: Are Infants More Vulnerable Than Toddlers?

Abstract

Children under 4 years of age have the highest incidence of traumatic brain injury (TBI) among the non-elderly and may be at high risk of poor developmental outcomes. We prospectively enrolled a cohort of children injured before 31 months old with TBI or orthopedic injury (OI), from 2013 to 2015 at two pediatric level 1 trauma centers to study very young children's developmental outcomes after injury. We used Ages & Stages-3 and Ages & Stages: Social-Emotional screening tools to measure children's development at pre-injury and 3 and 12 months post-injury. The cohort included 123 children with TBI categorized as mild (n = 48), complicated-mild or moderate (n = 54), and severe (n = 21) and 45 children with OI. Generalized linear models examined effects of injury severity and age at injury controlling for pre-injury ratings. Children with mild or complicated-mild/moderate TBI generally remained on developmental track. Compared to OI, children with severe TBI tended to have a negative developmental trajectory with decrements in communication (-7.07; 95% confidence interval [CI], -13.7, -0.48), gross motor (-15.2; 95% CI, -21.1, -9.19), problem solving (-11.6; 95% CI, -17.9, -5.29), personal-social (-16.8; 95% CI, -22.8, -10.8), and social-emotional (21.0; 95% CI, 7.32, 34.7) domains 12 months post-injury. Developmental effects from TBI differed by age at injury: Infants had more difficulties than older children in communication and problem-solving domains. Despite low developmental scores in 28% of the cohort, only 5% were receiving Early Childhood Intervention (ECI) services 12 months after injury. Early age at injury is a vulnerability factor after TBI. Young age and severe injury should prompt evaluation for ECI.

Epidemiology of Pediatric Traumatic Brain Injury and Hypothalamic-Pituitary Disorders in Arizona

“…Very young children may be particularly vulnerable to the effects of TBI as the brain is under continuous development throughout childhood (2). Pediatric survivors of TBI are at increased risk for worse behavioral, social, and academic outcomes compared to their peers (3)(4)(5)(6). Moreover, pediatric survivors of TBI show high incidence of health issues including pain, cardiovascular, and metabolic disorders (2).…”

Traumatic Brain Injury in Young Children: A Scoping Review

“…Injury severity was considered in 11 studies. 20,30,33,34,[39][40][41]45,46,48,52,55 A positive correlation between severity of injury and presence of deficits was consistently reported in all outcomes. As mentioned in relation with specific outcome areas, children who experienced moderate or severe TBIs tended to demonstrate a greater range of or more significant deficits when compared with children with mild TBI.…”

“…14 Eighteen studies reported on psychosocial and behavioral outcomes. 14,16,30,34,37,39,43,[45][46][47][48][49][50][51][52][53][54][55] Generally, social functioning was negatively impacted following early childhood TBI, independent of severity. Acutely, children who experienced a TBI before 6 years of age demonstrated decreased play engagement, including gaze initiation and joint attention.…”

“…Age at the time of injury was considered by six studies. 24,29,33,35,40,52,57 For children injured before their sixth birthday, younger age of injury was consistently associated with worse outcomes. Most studies, including Campbell et al 57 and Crowe et al, 40 found that skills in a key developmental period were most negatively impacted when the injury occurs during that age span.…”

“…With so few studies meeting eligibility for inclusion, results should be interpreted with caution, especially in light of design and participant limitations within individual studies. Many of the studies included were identified as a lower level of evidence, often failing to use controls or randomization, and were conducted by the same research teams or with the same datasets (e.g., Bellerose et al 45,46 ; Crowe et al 21,[39][40][41][42] ; Ewing-Cobbs et al 43,48 ; Haarbauer-Krupa et al 5,14,22,23 ; Keenan et al 30,31,51,52 ). Included studies also varied in the number, age, and severity of participants and outcome measures utilized, making it difficult to directly compare studies and impacting the generalizability of results.…”