Neurostimulant Prescribing Patterns in Children Admitted to the Intensive Care Unit after Traumatic Brain Injury

The Use of Methylphenidate During Inpatient Rehabilitation After Pediatric Traumatic Brain Injury: Population Characteristics and Prescribing Patterns

OBJECTIVE

To understand how methylphenidate (MPH) is used in youth with traumatic brain injury (TBI) during inpatient pediatric rehabilitation.

SETTING

Inpatient pediatric rehabilitation.

PARTICIPANTS

In total, 234 children with TBI; 62 of whom received MPH and 172 who did not. Patients were on average 11.6 years of age (range, 2 months to 21 years); 88 of 234 were female; the most common mechanism of injury was motor vehicle collision (49%); median (IQR) acute hospital length of stay (LOS) and inpatient rehabilitation LOS were 16 (10-29) and 23 (14-39), respectively; 51 of 234 were in a disorder of consciousness cognitive state at time of inpatient rehabilitation admission.

DESIGN

Multicenter, retrospective medical record review.

MAIN MEASURES

Patient demographic data, time to inpatient pediatric rehabilitation admission (TTA), cognitive state, MPH dosing (mg/kg/day).

RESULTS

Patients who received MPH were older (P = .011); TTA was significantly longer in patients who received MPH than those who did not (P =.002). The lowest recorded dose range by weight was 0.05 to 0.89 mg/kg/d, representing an 18-fold difference; the weight-based range for the maximum dose was 0.11 to 0.97 mg/kg/d, a 9-fold difference. Patients in lower cognitive states at admission (P = .001) and at discharge (P = .030) were more likely to receive MPH. Five patients had side effects known to be associated with MPH; no serious adverse events were reported.

CONCLUSION

This multicenter study indicates that there is variable use of MPH during acute inpatient rehabilitation for children with TBI. Children who receive MPH tend to be older with lower cognitive states. Dosing practices are likely consistent with underdosing. Clinical indications for MPH use during inpatient pediatric rehabilitation should be better defined. The use of MPH, as well as its combination with other medications and treatments, during inpatient rehabilitation needs to be further explored.

Disorders of Consciousness in Children: Assessment, Treatment, and Prognosis

Children with acquired brain injury may experience prolonged disorders of consciousness (DoC); research on children with DoC lags behind adult literature. Rigorous evaluation of assessment tools used in children with DoC is lacking, though recent developments may contribute to improvements in care, particularly for assessment of young children and those without overt command following. Literature on prognosis continues to grow, reinforcing that early signs of consciousness suggest better long-term outcome. Although large clinical trials for children with DoC are lacking, single-site and multisite programmatic data inform standards of care and treatment options for children with DoC.

Dual Neurostimulant Therapy May Optimize Acute Neurorecovery for Severe Traumatic Brain Injuries

BACKGROUND

Neurostimulants (NS) can be used to treat patients with a traumatic brain injury (TBI) with altered levels of consciousness. We sought to determine if amantadine alone (monotherapy) versus amantadine + methylphenidate (dual therapy) would correlate with better neurorecovery (NR) among acutely hospitalized patients with a severe TBI.

METHODS

We performed a retrospective review of adult patients admitted to our level I trauma center from 2016-2019 with a severe TBI. NR was calculated by dividing the difference between admission and discharge Glasgow Coma Scale (GCS) scores by 12. Resulting ratios were used to divide the cohort into two groups: excellent NR (1) and non-excellent NR (<1).

RESULTS

A total of 76 patients comprised the cohort; 19.7% (n = 15) had excellent NR. The excellent NR group had a larger proportion of patients receiving dual therapy compared to the non-excellent group (86.7% versus 59%, P = 0.04). In monotherapy (n = 27), amantadine was initiated 13 (8-20) d following injury and treatment lasted 7 (2-16) d. In dual therapy (n = 49), amantadine was initiated 12 (6-19) d following injury and continued for 9 (4-25.5) d. Methylphenidate was initiated 15 (7-20.5) d following injury and continued for 5 (2-13.5) d. After adjusting for confounders, dual versus monotherapy predicted excellent NR (OR 5.4, 95% CI 1.2 - 38.9, P = 0.03).

CONCLUSIONS

During the acute hospitalization for a severe TBI, dual NS therapy compared to monotherapy is associated with an increased likelihood of excellent NR. Larger prospective trials are warranted to validate these findings.

Paediatric traumatic brain injury

PURPOSE OF REVIEW

To provide a summary of recent developments in the field of paediatric traumatic brain injury (TBI).

RECENT FINDINGS

The epidemiology of paediatric TBI with falling rates of severe TBI, and increasing presentations of apparently minor TBI. There is growing interest in the pathophysiology and outcomes of concussion in children, and detection of 'significant' injury, arising from concern about risks of long-term chronic traumatic encephalopathy. The role of decompressive craniectomy in children is still clarifying.

SUMMARY

Paediatric TBI remains a major public health issue.