The American Academy of Pediatrics recently published its guidelines for how hospitals, and systems of hospitals, should care for injured children. The recommendations have also been endorsed by the relevant organizations of surgeons, emergency physicians, critical care physicians, and children’s hospitals.
Traumatic injuries in children are a huge issue. They are the number one killer of children, accounting for 60% of all deaths up to the age of 18. Thus injuries kill more children than all other causes combined. There is also a large burden of disability later in life for injured children, particularly those with traumatic brain injury. One study from a decade ago estimated this financial burden — initial medical costs, lifetime medical costs, and lost income — at nearly 100 billion dollars.
In spite of the importance of injuries to children’s health care needs, pediatric trauma systems have lagged behind those of adults. There are several reasons for this. For one thing, all the pediatric specialists needed to provide optimal care in fully-equipped PICUs are not available in many places. This is not so much of a problem for adolescents, but it is a major problem for pre-schoolers and infants. Another reason is that, from my perspective, children often seem to be off the radar of governmental and institutional planners. One clear purpose of the AAP publishing these guidelines is to try to change that.
Most children with significant brain injury spend time in a PICU. Like most experienced pediatric intensivists, I have seen hundreds of these children over the years, with dozens at least in the severe category. In one sense the term “traumatic brain injury” has limited usefulness because it covers such a wide range of injuries, from mild concussions to more extensive injury, to lethal damage. In another sense, however, it is a very useful diagnostic category because the brain responds to a wide variety of injuries in a very similar, stereotypic way.
Our understanding of the manifestations of TBI has grown over the years considerably. When head CT scans became available we could for the first time assess such things as bleeding inside the skull or swelling of the brain easily and safely. I remember how exciting it was in 1974 to see the first simple CT images taken on grainy Poloroid snapshots. Now we have sophisticated computer reconstructions of the brain. The technology represented such a breakthrough that its inventors received the Nobel Prize for it.
We soon realized, however, that some injuries to the brain, particularly what we call shear injury, are not well seen on CT — it takes an MRI scan to do that. We also came to realize that the most important thing we could do in the PICU for a child with severe TBI was to make sure the injury did not get worse: simple supportive measures like relieving pain and keeping the heart and lungs working well were key supportive measures to use while we waited for the child’s brain to heal.
Increasing understanding of milder forms of TBI have made us realize it is much more common than we once thought. For children, although the long-term outcome for mild to moderate TBI is good, persistent problems with such things as headache, mood changes, and difficulties in school are not uncommon, and these can last for months. There is a great deal of information available about TBI. There are many misconceptions about it, too. You can find authoritative, respected advice from the National Institutes of Health here and from the Brain Trauma Foundation here, and many more useful links here.