A prospective surveillance of paediatric head injuries in Singapore: a dual-centre study

A Multicenter Study on the Clinical Characteristics and Outcomes Among Children With Moderate to Severe Abusive Head Trauma

INTRODUCTION

We aimed to identify clinical characteristics, risk factors for diagnosis, and describe outcomes among children with AHT.

METHODS

We performed an observational cohort study in tertiary care hospitals from 14 countries across Asia and Ibero-America. We included patients <5 years old who were admitted to participating pediatric intensive care units (PICUs) with moderate to severe traumatic brain injury (TBI). We performed descriptive analysis and multivariable logistic regression for risk factors of AHT.

RESULTS

47 (12%) out of 392 patients were diagnosed with AHT. Compared to those with accidental injuries, children with AHT were more frequently < 2 years old (42, 89.4% vs 133, 38.6%, p < 0.001), more likely to arrive by private transportation (25, 53.2%, vs 88, 25.7%, p < 0.001), but less likely to have multiple injuries (14, 29.8% vs 158, 45.8%, p = 0.038). The AHT group was more likely to suffer subdural hemorrhage (SDH) (39, 83.0% vs 89, 25.8%, p < 0.001), require antiepileptic medications (41, 87.2% vs 209, 60.6%, p < 0.001), and neurosurgical interventions (27, 57.40% vs 143, 41.40%, p = 0.038). Mortality, PICU length of stay, and functional outcomes at 3 months were similar in both groups. In the multivariable logistic regression, age <2 years old (aOR 8.44, 95%CI 3.07-23.2), presence of seizures (aOR 3.43, 95%CI 1.60-7.36), and presence of SDH (aOR 9.58, 95%CI 4.10-22.39) were independently associated with AHT.

CONCLUSIONS

AHT diagnosis represented 12% of our TBI cohort. Overall, children with AHT required more neurosurgical interventions and the use of anti-epileptic medications. Children younger than 2 years and with SDH were independently associated with a diagnosis of AHT.

TYPE OF STUDY

Observational cohort study.

LEVEL OF EVIDENCE

III.

Profile of Pediatric Traumatic Brain Injury in South-West Nigeria

BACKGROUND

Traumatic brain injury (TBI) is a major cause of morbidity and mortality in children. In Nigeria, there is paucity of information about TBI in children. We describe the profile of pediatric TBI in a university hospital in South-West Nigeria.

METHODS

A retrospective study of children who had TBI from 2012 to 2022 was performed. Data were extracted from the neurosurgery database. Patient demographics, etiology/patterns of injuries, clinical/radiologic findings, management, and outcomes were assessed. We performed simple descriptive analyses.

RESULTS

Pediatric TBIs represented 20% (128) of the head injury admissions (631). There was male preponderance (male/female = 1.8:1); most patients were adolescents (29%). In total, 61%, 18%, and 21% had mild, moderate, and severe TBI, respectively. Road traffic crashes were responsible for 74% of cases, with motorcycle accidents (46%) much greater than motor vehicular accidents (28%), mostly pedestrian (51%). Fall from heights accounted for 21%, mostly in toddlers. A total of 70% had associated injuries, mainly skull fractures (54%) and soft-tissue injuries (47%). In total, 31% had post-traumatic seizures. Only 40 (31%) had a cranial computed tomography scan. Common findings were contusions in 70%, extradural hematomas in 28%, and intracranial aerocoeles in 18%. There were no neurosurgical lesions in 20%. Six had operative intervention. Mortality rate was 12%. In total, 84% had good recovery. The average follow-up period was 7 months.

CONCLUSIONS

Children account for a large number of TBIs in our environment, which are mostly from road traffic crashes and falls. Only a few received computed tomography scan of the brain. Most cases had nonoperative care, and outcomes are worse with increasing severity of head injury. Specific preventive measures need to be formulated and/or enforced by governments at all levels.

Traumatic Brain Injury Outcomes in 10 Asian Pediatric ICUs: A Pediatric Acute and Critical Care Medicine Asian Network Retrospective Study

OBJECTIVES

Traumatic brain injury remains an important cause of death and disability. We aim to report the epidemiology and management of moderate to severe traumatic brain injury in Asian PICUs and identify risk factors for mortality and poor functional outcomes.

DESIGN

A retrospective study of the Pediatric Acute and Critical Care Medicine Asian Network moderate to severe traumatic brain injury dataset collected between 2014 and 2017.

SETTING

Patients were from the participating PICUs of Pediatric Acute and Critical Care Medicine Asian Network.

PATIENTS

We included children less than 16 years old with a Glasgow Coma Scale less than or equal to 13.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We obtained data on patient demographics, injury circumstances, and PICU management. We performed a multivariate logistic regression predicting for mortality and poor functional outcomes. We analyzed 380 children with moderate to severe traumatic brain injury. Most injuries were a result of road traffic injuries (174 [45.8%]) and falls (160 [42.1%]). There were important differences in temperature control, use of antiepileptic drugs, and hyperosmolar agents between the sites. Fifty-six children died (14.7%), and 104 of 324 survivors (32.1%) had poor functional outcomes. Poor functional outcomes were associated with non-high-income sites (adjusted odds ratio, 1.90; 95% CI, 1.11-3.29), Glasgow Coma Scale less than 8 (adjusted odds ratio, 4.24; 95% CI, 2.44-7.63), involvement in a road traffic collision (adjusted odds ratio, 1.83; 95% CI, 1.04-3.26), and presence of child abuse (adjusted odds ratio, 2.75; 95% CI, 1.01-7.46).

CONCLUSIONS

Poor functional outcomes are prevalent after pediatric traumatic brain injury in Asia. There is an urgent need for further research in these high-risk groups.

Epidemiology and risk stratification of minor head injuries in school-going children

INTRODUCTION

Head injuries occur commonly in children and can lead to concussion injuries. We aim to describe the epidemiology of head injuries among school-going children and identify predictors of brain concussions in Singapore.

METHODS

This is a retrospective study of children 7-16 years old who presented to the Emergency Department (ED) of KK Women's and Children's Hospital in Singapore with minor head injury between June 2017 and August 2018. Data including demographics, clinical presentation, ED and hospital management were collected using a standardised electronic template. Multivariable logistic regression analysis was performed to identify early predictors for brain concussion. Concussion symptoms were defined as persistent symptoms after admission, need for inpatient intervention, or physician concerns necessitating neuroimaging.

RESULTS

Among 1,233 children (mean age, 6.6 years; 72.6% boys) analysed, the commonest mechanism was falls (64.6%). Headache and vomiting were the most common presenting symptoms. A total of 395 (32.0%) patients required admission, and 277 (22.5%) had symptoms of concussion. Older age (13-16 years old) (adjusted odds ratio [aOR] 1.53, 95% confidence interval [CI] 1.12-2.08), children involved in road traffic accidents (aOR 2.12, CI 1.17-3.85) and a presenting complaint of headache (aOR 2.64, CI 1.99-3.50) were significantly associated with symptoms of concussion.

CONCLUSION

This study provides a detailed description of the pattern of head injuries among school-going children in Singapore. High risk patients may require closer monitoring to detect post-concussion syndrome early.

Long-term outcomes in children with moderate to severe traumatic brain injury: a single-centre retrospective study

Traumatic brain injury (TBI) is a significant cause of mortality and disability in the pediatric population. Non-accidental trauma (NAT) has specifically been reported to result in more severe injury as compared to accidental mechanisms of injury. We aim to investigate the long-term neurological outcomes in children with moderate to severe traumatic brain injury. Our secondary aim is to evaluate the difference in outcomes between children presenting with NAT and non-NAT, in our study population. We performed a retrospective study in a tertiary pediatric hospital between January 2008 to October 2017 of all patients with TBI <16 years old with a Glasgow Coma Scale (GCS) ≤13. The dual primary outcomes were mortality and Paediatric Functional Independence Measure (WeeFIM) scores, recorded at the start of rehabilitation, discharge, 3 months and 6 months post-injury. The secondary outcome was the development of post-traumatic epilepsy. There were 68 patients with a median age of 4.5 [interquartile range (IQR) 1.0-9.0] years old. The most common presenting symptom was vomiting for children <2 years (11/20, 55.0%) while confusion and disorientation were common for those ≥2 years (27/48, 56.3%). WeeFIM scores at the start of rehabilitation [median 122.0, IQR 33.8-126.0] improved at 6 months post-injury (median 126.0, IQR 98.5-126.0). There was a greater incidence of post-traumatic epilepsy in age <2 years (6/20, 30.0%) compared to age ≥2 years (1/48, 2.1%) (p = .002). When comparing NAT versus non-NAT survivors, cognition WeeFIM scores were significantly different at the start of rehabilitation (p = .017) and at 3 months post-injury (p = .025). NAT predicts for poorer long-term outcomes, specifically in cognition, as measured by WeeFIM scores. Younger children <2 years had a higher incidence of post-traumatic epilepsy compared to older children.

[Causes and clinical features of children with traumatic brain injury: a retrospective analysis of 126 cases]

OBJECTIVE

To investigate the causes and clinical features of children with traumatic brain injury (TBI) who need hospitalization or emergency observation.

METHODS

A retrospective analysis was performed for the clinical data of 126 children with TBI who were admitted to the emergency department from January 1, 2014 to August 31, 2016, including causes of injury and clinical features.

RESULTS

Of the 126 children, there were 95 boys and 31 girls, with a mean age of 2.8 years (range 0.8-5.5 years). The children aged <1 year accounted for 38.1% (48/126), and 26 children died. The two most common types of TBI were epidural hematoma (54.0%) and subarachnoid hemorrhage (50.8%). Of the 126 children, 83 (65.9%) had a Glasgow Coma Scale score of ≤8 within 24 hours after admission. There were different causes of TBI and places where TBI occurred in different age groups. The two leading causes of TBI were falls (51.6%) and road traffic injuries (42.9%). Compared with those in the other age groups, the children in the age <1 year group were most likely to experience injury due to falls (46%; P=0.023). Thirty-five percent of all TBI due to road traffic injuries occurred in the children aged 3-6 years (P<0.001). Most TBI cases occurred at home (47.6%) or on roads/streets (45.2%). Among those who experienced TBI at home, the children aged <1 year accounted for the highest proportion of 48% (P=0.002), and 53% of the patients aged 3-6 years experienced TBI on roads/streets. The most common cause of death in children with TBI was road traffic injury, which accounted for 69%. Among those who died, the children aged <1 year accounted for the highest proportion (62%).

CONCLUSIONS

There are different causes of TBI and places where TBI occurs in different age groups. Among children with TBI, the children aged <1 year account for the highest proportion and have the highest number of deaths, with falls at home as the most common cause of TBI. Children aged 3-6 years tend to suffer TBI due to road traffic injury. Road traffic injury is the leading cause of death.

Parental knowledge and beliefs on the use of child car restraints in Singapore: a qualitative study

INTRODUCTION

Road traffic injuries and fatalities represent a significant public health problem. In Singapore, compliance with appropriate child car restraints (CCRs) is poor. We aimed to understand parental knowledge, beliefs and barriers regarding the use of CCRs.

METHODS

In this qualitative study, we conducted five focus group discussions with parents who drive with their children in private cars. Participants were recruited using the KK Women's and Children's Hospital's social media page. Guiding questions were derived by consensus following literature review and adaptation to the Singapore context, exploring parental perceptions of CCR use. Focus group interviews were then transcribed and analysed.

RESULTS

33 participants were recruited, with an age range of 28‒46 (mean age 35.5) years. They had a total of 46 children with ages ranging from 2.5 months to 14 years (mean age 4.2 years). Three key themes were identified: parental knowledge regarding CCRs, barriers to CCR use, and suggestions to increase CCR compliance. Barriers to compliance included lack of knowledge, difficult child behaviour and cultural norms. A multipronged approach was proposed to increase CCR use, including educating the public, reinforcing positive behaviour, legal enforcement as a deterrent to non-compliance, increasing CCR installation services, providing CCRs for taxi users and offering financial incentives.

CONCLUSION

Non-compliance to CCR use is multidimensional, including multiple potentially modifiable factors. This study could inform ongoing collaborative injury prevention efforts among healthcare professionals, industry partners and the traffic police, using public education and outreach to reduce the burden of road traffic injuries.

An enemy hides in the ceiling; pediatric traumatic brain injury caused by metallic ceiling fan: Case series and literature review

Purpose: We report a series of 29 pediatric patients who sustained head injuries due to metallic ceiling fans. They all were admitted to the Emergency Department of Neurosurgery Teaching Hospital in Baghdad, Iraq, during January 2015 to January 2017. Results: Pediatric ceiling fan head injuries are characterized by four traits which distinguish them from other types of head injuries; 1- Most of them were because of climbing on or jumping from furniture between the ages of two and five. 2- Most of them sustained compound depressed skull fracture which associated with intracranial lesions and pneumocephalus. 3- The most common indication for surgical intervention was because of dirty wound which mixed with hairs. 4- These variables were statistically significantly correlated with the outcome: Level of consciousness, neurologic deficit, fracture site (occipital fracture had worse outcome), intracranial hemorrhage and surgery. Conclusion: Pediatric metallic ceiling fan head injury should be seen as a distinct type of head injury because it has special presentations, managements, and outcomes. In addition, we should start applying preventive methods to minimize its occurrence.

Estimating the global incidence of traumatic brain injury

OBJECTIVETraumatic brain injury (TBI)-the "silent epidemic"-contributes to worldwide death and disability more than any other traumatic insult. Yet, TBI incidence and distribution across regions and socioeconomic divides remain unknown. In an effort to promote advocacy, understanding, and targeted intervention, the authors sought to quantify the case burden of TBI across World Health Organization (WHO) regions and World Bank (WB) income groups.METHODSOpen-source epidemiological data on road traffic injuries (RTIs) were used to model the incidence of TBI using literature-derived ratios. First, a systematic review on the proportion of RTIs resulting in TBI was conducted, and a meta-analysis of study-derived proportions was performed. Next, a separate systematic review identified primary source studies describing mechanisms of injury contributing to TBI, and an additional meta-analysis yielded a proportion of TBI that is secondary to the mechanism of RTI. Then, the incidence of RTI as published by the Global Burden of Disease Study 2015 was applied to these two ratios to generate the incidence and estimated case volume of TBI for each WHO region and WB income group.RESULTSRelevant articles and registries were identified via systematic review; study quality was higher in the high-income countries (HICs) than in the low- and middle-income countries (LMICs). Sixty-nine million (95% CI 64-74 million) individuals worldwide are estimated to sustain a TBI each year. The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). The incidence of RTI was similar in Southeast Asia (1.5% of the population per year) and Europe (1.2%). The overall incidence of TBI per 100,000 people was greatest in North America (1299 cases, 95% CI 650-1947) and Europe (1012 cases, 95% CI 911-1113) and least in Africa (801 cases, 95% CI 732-871) and the Eastern Mediterranean (897 cases, 95% CI 771-1023). The LMICs experience nearly 3 times more cases of TBI proportionally than HICs.CONCLUSIONSSixty-nine million (95% CI 64-74 million) individuals are estimated to suffer TBI from all causes each year, with the Southeast Asian and Western Pacific regions experiencing the greatest overall burden of disease. Head injury following road traffic collision is more common in LMICs, and the proportion of TBIs secondary to road traffic collision is likewise greatest in these countries. Meanwhile, the estimated incidence of TBI is highest in regions with higher-quality data, specifically in North America and Europe.

A retrospective review of paediatric head injuries in Asia - a Pan Asian Trauma Outcomes Study (PATOS) collaboration

OBJECTIVE

We aim to examine the mechanisms of head-injured children presenting to participating centres in the Pan Asian Trauma Outcomes Study (PATOS) and to evaluate the association between mechanism of injury and severe outcomes.

DESIGN AND SETTING

We performed a retrospective review of medical records among emergency departments (EDs) of eight PATOS centres, from September 2014 - August 2015.

PARTICIPANTS

We included children <16 years old who presented within 24 hours of head injury and were admitted for observation or required a computed tomography (CT) of the brain from the ED. We excluded children with known coagulopathies, neurological co-morbidities or prior neurosurgery. We reviewed the mechanism, intent, location and object involved in each injury, and the patients' physical findings on presentation.

OUTCOMES

Primary outcomes were death, endotracheal intubation or neurosurgical intervention. Secondary outcomes included hospital and ED length of stay.

RESULTS

1438 children were analysed. 953 children (66.3%) were male and the median age was 5.0 years (IQR 1.0-10.0). Falls predominated especially among children younger than 2 years (82.9%), while road traffic injuries were more likely to occur among children 2 years and above compared with younger children (25.8% vs 11.1%). Centres from upper and lower middle-income countries were more likely to receive head injured children from road traffic collisions compared with those from high-income countries (51.4% and 40.9%, vs 10.9%, p<0.0001) and attended to a greater proportion of children with severe outcomes (58.2% and 28.4%, vs 3.6%, p<0.0001). After adjusting for age, gender, intent of injury and gross national income, traffic injuries (adjusted OR 2.183, 95% CI 1.448 to 3.293) were associated with severe outcomes, as compared with falls.

CONCLUSIONS

Among children with head injuries, traffic injuries are independently associated with death, endotracheal intubation and neurosurgery. This collaboration among Asian centres holds potential for future prospective childhood injury surveillance.

A machine learning based approach for identifying traumatic brain injury patients for whom a head CT scan can be avoided

Head CT scan is more often used to evaluate patients with suspected traumatic brain injury (TBI). However, the use of head CT scans in evaluating TBI is costly with low value endeavor. In this paper, we propose a new algorithm and a set of features to help clinicians determine which patients evaluated for TBI need a head CT scan using cost sensitive random forest (CSRF) classifier. We show that random forest (RF) and CSRF are useful methods for identifying patients likely to have a positive head CT scan. The proposed algorithm has superior diagnostic accuracy in comparison to the Canadian head CT algorithm, which is currently the most accurate and widely used algorithm for determining which TBI patients need a head CT scan. In the highest sensitivity (i.e. 100%), our method outperforms the Canadian rule in terms of specificity, accuracy and area under ROC curve using cost sensitive classifier. Clinical implementation of this algorithm can help decrease financial costs associated with Emergency Department evaluations for traumatic brain injury, while decreasing patient exposure to avoidable ionizing radiation.

Road traffic injuries among children and adolescents in Singapore - Who is at greatest risk?

INTRODUCTION

Pediatric road traffic injuries remain a significant cause of death and disability in many countries in Asia, despite the implementation of road traffic safety laws. We aim to describe the injuries, the use of restraints among road users, and risk factors associated with severe injuries for children in Singapore.

METHODS

We performed a retrospective chart review of road traffic injuries presenting to the only two pediatric tertiary care hospitals in Singapore, from January 2012 to April 2016. We included children <16years old presenting to the emergency departments within 24h after injury (pedestrian, bicycle, motorcycle, motor vehicle). We calculated the frequencies for specific injury mechanisms, injury severity scores (ISS), and in-hospital outcomes of severe injuries (death, urgent resuscitation and emergent surgery). We performed a multivariate logistic regression to determine risk factors associated with severe injury.

RESULTS

There were 2468 patients during the study period. The mean age was 7.9 years (SD 4.7); 60.1% of road injuries involved motor vehicle occupants (1483/2468). Most bicyclist/motorcyclists were not wearing helmets (70.0%, 245/350) and 51.1% of motor vehicle passengers (758/1483) were not restrained. Compared to motor vehicle passengers, pedestrians (adjusted OR 2.38, 95% CI 1.41-3.99), bicyclists (adjusted OR 2.12, 95% CI 1.04-4.32) and motorcyclists (adjusted OR 6.09, 95% CI 2.04-18.24) were more likely to sustain severe injuries.

CONCLUSION

Child pedestrians, bicyclists and motorcyclists are especially vulnerable for severe injures. Further injury prevention efforts must focus on the enforcement of legislation to protect these high-risk groups.

Childhood Injuries in Singapore: Can Local Physicians and the Healthcare System Do More to Confront This Public Health Concern?

Childhood injury is one of the leading causes of death globally. Singapore is no exception to this tragic fact, with childhood injuries accounting up to 37% of Emergency Department visits. Hence, it is important to understand the epidemiology and risk factors of childhood injuries locally. A search for relevant articles published from 1996–2016 was performed on PubMed, Cochrane Library and Google Scholar using keywords relating to childhood injury in Singapore. The epidemiology, mechanisms of injury, risk factors and recommended prevention strategies of unintentional childhood injuries were reviewed and described. Epidemiological studies have shown that childhood injury is a common, preventable and significant public health concern in Singapore. Home injuries and falls are responsible for majority of the injuries. Injuries related to childcare products, playground and road traffic accidents are also important causes. Healthcare professionals and legislators play an important role in raising awareness and reducing the incidence of childhood injuries in Singapore. For example, despite legislative requirements for many years, the low usage of child restraint seats in Singapore is worrisome. Thus, greater efforts in public health education in understanding childhood injuries, coupled with more research studies to evaluate the effectiveness and deficiencies of current prevention strategies will be necessary.