1
|
Salberg S, Smith MJ, Lamont R, Chen Z, Beauchamp MH, Craig W, Doan Q, Gravel J, Zemek R, Lannin NA, Yeates KO, Mychasiuk R. Shorter Telomere Length Is Associated With Older Age, Poor Sleep Hygiene, and Orthopedic Injury, but Not Mild Traumatic Brain Injury, in a Cohort of Canadian Children. J Head Trauma Rehabil 2024:00001199-990000000-00178. [PMID: 39019487 DOI: 10.1097/htr.0000000000000982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
BACKGROUND Predicting recovery following pediatric mild traumatic brain injury (mTBI) remains challenging. The identification of objective biomarkers for prognostic purposes could improve clinical outcomes. Telomere length (TL) has previously been used as a prognostic marker of cellular health in the context of mTBI and other neurobiological conditions. While psychosocial and environmental factors are associated with recovery outcomes following pediatric mTBI, the relationship between these factors and TL has not been investigated. This study sought to examine the relationships between TL and psychosocial and environmental factors, in a cohort of Canadian children with mTBI or orthopedic injury (OI). METHODS Saliva was collected at a postacute (median 7 days) timepoint following injury to assess TL from a prospective longitudinal cohort of children aged 8 to 17 years with either mTBI (n = 202) or OI (n = 90), recruited from 3 Canadian sites. Questionnaires regarding psychosocial and environmental factors were obtained at a postacute follow-up visit and injury outcomes were assessed at a 3-month visit. Univariable associations between TL and psychosocial, environmental, and outcome variables were assessed using Spearman's correlation. Further adjusted analyses of these associations were performed by including injury group, age, sex, and site as covariates in multivariable generalized linear models with a Poisson family, log link function, and robust variance estimates. RESULTS After adjusting for age, sex, and site, TL in participants with OI was 7% shorter than those with mTBI (adjusted mean ratio = 0.93; 95% confidence interval, 0.89-0.98; P = .003). As expected, increasing age was negatively associated with TL (Spearman's r = -0.14, P = .016). Sleep hygiene at 3 months was positively associated with TL (adjusted mean ratio = 1.010; 95% confidence interval, 1.001-1.020; P = .039). CONCLUSION The relationships between TL and psychosocial and environmental factors in pediatric mTBI and OI are complex. TL may provide information regarding sleep quality in children recovering from mTBI or OI; however, further investigation into TL biomarker validity should employ a noninjured comparison group.
Collapse
Affiliation(s)
- S Salberg
- Author Affiliations: Department of Neuroscience, School of Translational Medicine, Monash University, Melbourne, Victoria, Australia (Drs Salberg, Smith, Lannin, Mychasiuk and Chen); Department of Psychology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada (Dr Lamont); Department of Psychology, Montreal University, Montreal, Quebec, Canada, and Sainte-Justine Hospital Research Center, Montrea, Quebec, Canada (Dr Beauchamp); Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada (Dr Craig); Department of Pediatrics, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada (Dr Doan); Department of Pediatric Emergency Medicine, CHU Sainte-Justine, Montreal, Quebec, Canada, and Université de Montreal, Montreal, Quebec, Canada (Dr Gravel); Department of Pediatrics and Emergency Medicine, University of Ottawa, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada (Dr Zemek); Alfred Health, Melbourne, Australia (Dr Lannin); and Department of Psychology, Alberta Children's Hospital Research Institute, and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (Dr Yeates)
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
2
|
Dupont D, Tang K, Beaudoin C, Dégeilh F, Gagnon I, Yeates KO, Rose SC, Gravel J, Burstein B, Stang AS, Stanley RM, Zemek RL, Beauchamp MH. Postconcussive Symptoms After Early Childhood Concussion. JAMA Netw Open 2024; 7:e243182. [PMID: 38512252 PMCID: PMC10958232 DOI: 10.1001/jamanetworkopen.2024.3182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/26/2024] [Indexed: 03/22/2024] Open
Abstract
Importance Research on postconcussive symptoms (PCS) following early childhood concussion has been hindered by a lack of measures suitable for this age group, resulting in a limited understanding of their evolution in young children. Objective To document PCS in the first 3 months after early childhood concussion using a developmentally appropriate measure. Design, Setting, and Participants This cohort study used data collected at 3 Canadian and 1 US urban pediatric emergency departments (EDs) and 8 Canadian daycares from December 2018 to December 2022 as part of the Kids' Outcomes and Long-Term Abilities (KOALA) project, a prospective, multicenter, longitudinal cohort study. Participants included children aged 6 to 72 months with early childhood concussion or orthopedic injury (OI) or uninjured children from the community to serve as controls. Data were analyzed from March 2023 to January 2024. Exposure Concussion sustained between ages 6 and 72 months. Main Outcomes and Measures Primary outcomes were cognitive, physical, behavioral and total PCS assessed prior to injury (retrospectively), acutely (within 48 hours), and at 10 days, 1 month, and 3 months after injury or recruitment through caregiver observations using the Report of Early Childhood Traumatic Injury Observations & Symptoms inventory. Group comparisons were analyzed using ordinal regression models. Results The study included 303 children (mean [SD] age, 35.8 [20.2] months; 152 [50.2%] male). Of these, 174 children had a concussion (mean [SD] age, 33.3 [19.9] months), 60 children had an OI (mean [SD] age, 38.4 [19.8] months) and 69 children were uninjured controls (mean [SD] age, 39.7 [20.8] months). No meaningful differences were found between the concussion and comparison groups in retrospective preinjury PCS. Significant group differences were found for total PCS at the initial ED visit (concussion vs OI: odds ratio [OR], 4.33 [95% CI, 2.44-7.69]; concussion vs control: OR, 7.28 [95% CI, 3.80-13.93]), 10 days (concussion vs OI: OR, 4.44 [95% CI, 2.17-9.06]; concussion vs control: OR, 5.94 [95% CI, 3.22-10.94]), 1 month (concussion vs OI: OR, 2.70 [95% CI, 1.56-4.68]; concussion vs control: OR, 4.32 [95% CI, 2.36-7.92]), and 3 months (concussion vs OI: OR, 2.61 [95% CI, 1.30-5.25]; concussion vs control: OR, 2.40 [95% CI, 1.36-4.24]). Significant group differences were also found for domain-level scores (cognitive, physical, behavioral) at various time points. Conclusions and Relevance In this early childhood cohort study, concussion was associated with more PCS than OIs or typical development up to 3 months after injury. Given the limited verbal and cognitive abilities typical of early childhood, using developmentally appropriate manifestations and behaviors is a valuable way of tracking PCS and could aid in concussion diagnosis in young children.
Collapse
Affiliation(s)
- Dominique Dupont
- Department of Psychology, Université de Montréal, Montreal, Quebec, Canada
- Centre de recherche Azrieli du Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Ken Tang
- Independent Statistical Consultant, Richmond, British Columbia
| | - Cindy Beaudoin
- Department of Psychology, Université de Montréal, Montreal, Quebec, Canada
- Centre de recherche Azrieli du Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Fanny Dégeilh
- Univ Rennes, CNRS (Centre national de recherche scientifique), Inria, Inserm, IRISA (Institut de recherche en informatique et systèmes aléatoires) UMR (Unité mixte de recherche) 6074, EMPENN - ERL (Equipe de recherche labellisée) U1228, Rennes, France
| | - Isabelle Gagnon
- Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
| | - Keith Owen Yeates
- Hotchkiss Brain Institute, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
| | - Sean C Rose
- Child Neurology, Nationwide Children's Hospital, Columbus, Ohio
- The Ohio State University College of Medicine Columbus, Columbus
| | - Jocelyn Gravel
- Centre de recherche Azrieli du Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Brett Burstein
- Montreal Children's Hospital, Division of Pediatric Emergency Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Biostatistics, Epidemiology and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Antonia S Stang
- Department of Pediatrics, University of Calgary, Calgary Alberta, Canada
| | - Rachel M Stanley
- The Ohio State University College of Medicine Columbus, Columbus
- Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Roger L Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ontario, Canada
| | - Miriam H Beauchamp
- Department of Psychology, Université de Montréal, Montreal, Quebec, Canada
- Centre de recherche Azrieli du Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| |
Collapse
|
3
|
Crowe LM, Rausa VC, Anderson V, Borland ML, Kochar A, Lyttle MD, Gilhotra Y, Dalziel SR, Oakley E, Furyk J, Neutze J, Bressan S, Davis GA, Babl FE. Mild Traumatic Brain Injury Characteristics and Symptoms in Preschool Children: How Do They Differ to School Age Children? A Multicenter Prospective Observational Study. Arch Phys Med Rehabil 2024; 105:120-124. [PMID: 37715760 DOI: 10.1016/j.apmr.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 07/20/2023] [Accepted: 08/06/2023] [Indexed: 09/18/2023]
Abstract
OBJECTIVE To investigate if preschool children differ to school age children with mild traumatic brain injury (TBI) with respect to injury causes, clinical presentation, and medical management. DESIGN A secondary analysis of a dataset from a large, prospective and multisite cohort study on TBI in children aged 0-18 years, the Australian Paediatric Head Injury Rules Study. SETTING Nine pediatric emergency departments (ED) and 1 combined adult and pediatric ED located across Australia and New Zealand. PARTICIPANTS 7080 preschool aged children (2-5 years) were compared with 5251 school-age children (6-12 years) with mild TBI (N= (N=12,331) MAIN OUTCOME MEASURES: Clinical report form on medical symptoms, injury causes, and management. RESULTS Preschool children were less likely to be injured with a projectile than school age children (P<.001). Preschool children presented with less: loss of consciousness (P<.001), vomiting (P<.001), drowsiness (P=.002), and headache (P<.001), and more irritability and agitation (P=.003), than school-age children in the acute period after mild TBI. Preschool children were less likely to have neuroimaging of any kind (P<.001) or to be admitted for observation than school age children (P<.001). CONCLUSIONS Our large prospective study has demonstrated that preschool children with mild TBI experience a different acute symptom profile to older children. There are significant clinical implications with symptoms post-TBI used in medical management to aid decisions on neuroimaging and post-acute intervention.
Collapse
Affiliation(s)
- Louise M Crowe
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia; School of Psychological Sciences, University of Melbourne, Melbourne, Australia.
| | - Vanessa C Rausa
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| | - Vicki Anderson
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia; School of Psychological Sciences, University of Melbourne, Melbourne, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Australia; School of Medicine, Divisions of Emergency Medicine and Paediatrics, University of Western Australia, Perth, Australia
| | - Amit Kochar
- Emergency Department, Women's & Children's Hospital, Adelaide, Australia
| | - Mark D Lyttle
- Faculty of Health & Life Sciences, University of the West of England, Bristol, UK
| | - Yuri Gilhotra
- Emergency Medicine Education and Training, Retrieval Services, Queensland, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Health, Auckland, New Zealand; Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Ed Oakley
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia; Emergency Department, Royal Children's Hospital, Melbourne, Australia
| | - Jeremy Furyk
- Emergency Department, The Townsville Hospital, Townsville, Australia; Emergency Department, University Hospital Geelong, Geelong, Australia; School of Medicine, Faculty of Health, Deakin University, Geelong, Australia
| | - Jocelyn Neutze
- Emergency Department, Kidzfirst Middlemore Hospital, Auckland, New Zealand
| | - Silvia Bressan
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia; Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Gavin A Davis
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia; Department of Neurosurgery, Austin and Cabrini Hospitals, Melbourne, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia; Emergency Department, Royal Children's Hospital, Melbourne, Australia; Department of Critical Care Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| |
Collapse
|
4
|
Dupont D, Larivière-Bastien D, Caron JG, Beaudoin C, Gravel J, Gagnon I, Burstein B, Beaudin M, Rose SC, Yeates KO, Beauchamp MH. "What If?": Caregivers' Experiences Following Early Childhood Concussion. J Pediatr Psychol 2023; 48:971-981. [PMID: 37579243 DOI: 10.1093/jpepsy/jsad044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/27/2023] [Accepted: 07/01/2023] [Indexed: 08/16/2023] Open
Abstract
OBJECTIVE Little is known about the symptoms, signs, and management guidelines for children under the age of 6 years after they sustain a concussion. Caregivers of such young children may have unique concerns and encounter different challenges from those of school-age children given the distinctive developmental characteristics of the early childhood period. This study aimed to explore the experience of caregivers through semistructured interviews to inform clinical practice. METHODS Fifty caregivers of children aged 6 months to 5.99 years were interviewed 3 months postinjury for this qualitative study to document their experience in relation to their child's accident, recovery, and healthcare provisions. RESULTS Four main themes were identified: (1) visible changes associated with caregiver concerns, (2) a roller-coaster of emotions after the injury, (3) healthcare providers' role in addressing the need for reassurance, and (4) the need for better information after the injury. CONCLUSION The findings provide critical insight into the unique experiences and information needs of caregivers of young children who sustain concussion. The challenges identified can inform healthcare professionals regarding the needs of caregivers after early concussion and contribute to building a knowledge base for the development of age-appropriate anticipatory guidance for caregiver mental health and child recovery.
Collapse
Affiliation(s)
- Dominique Dupont
- Department of Psychology, University of Montreal, Canada
- CHU Sainte-Justine Research Center, Canada
| | - Danaë Larivière-Bastien
- Department of Psychology, University of Montreal, Canada
- CHU Sainte-Justine Research Center, Canada
| | - Jeffrey G Caron
- School of Kinesiology and Physical Activity Sciences, University of Montreal, Canada
- Center for Interdisciplinary Research in Rehabilitation of Greater Montreal, Canada
| | - Cindy Beaudoin
- Department of Psychology, University of Montreal, Canada
| | | | - Isabelle Gagnon
- Montreal Children's Hospital, McGill University Health Centre, Canada
- School of Physical and Occupational Therapy, McGill University, Canada
| | - Brett Burstein
- Montreal Children's Hospital, McGill University Health Centre, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada
| | - Myriam Beaudin
- Department of Psychology, University of Quebec in Montreal, Canada
| | - Sean C Rose
- Department of Neurology, Nationwide Children's Hospital, USA
| | - Keith O Yeates
- Department of Psychology, Alberta Children's Hospital Research Institute, Canada
- Hotchkiss Brain Institute, University of Calgary, Canada
| | - Miriam H Beauchamp
- Department of Psychology, University of Montreal, Canada
- CHU Sainte-Justine Research Center, Canada
| |
Collapse
|
5
|
Yumul JN, Catroppa C, McKinlay A, Anderson V. Post-Concussive Symptoms in Preschool Children up to Three Months Post-Injury. Dev Neurorehabil 2023; 26:338-347. [PMID: 37548355 DOI: 10.1080/17518423.2023.2242945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 06/20/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND AND AIMS Post-concussive symptoms (PCS) are central to the assessment and management of mild traumatic brain injury (mTBI); however, this remains poorly understood in children aged ≤5 years. The study aimed to explore individual PCS, pattern of parents' PCS report over time, proportion of symptomatic children, and variables associated with parents' report of PCS in their preschool child after a mTBI. METHODS Children aged 2-5 years with either a mTBI (n=13) or limb injury (n=6) were recruited from the emergency department (ED). Parent ratings of child PCS were assessed at ED presentation, at one month, and at three months post-injury. Injury (e.g. injury group, pain), child (e.g. pre-existing behavior, symptoms), and parent (e.g. parental stress, education) characteristics were considered when investigating variables that may be relevant to parent report of PCS. RESULTS The number of total, physical, and sleep PCS were significantly higher after mTBI, with a significant decrease in physical and sleep PCS over time. The proportion of symptomatic children was comparable between injury groups at each time point. Acute pain and pre-injury symptoms were significantly associated with parents' acute PCS report in the mTBI group. Further research is needed on variables that may be relevant to parents' PCS report at follow-up. CONCLUSION Preliminary findings suggest a general trauma response after a mTBI or limb injury, but acute physical and sleep PCS may help differentiate the injury groups. Injury and premorbid child variables may be relevant to parents' report of acute PCS in their child. Additional research is needed to investigate PCS in preschoolers and variables that may predict parents' PCS report.
Collapse
Affiliation(s)
- Joy Noelle Yumul
- Murdoch Children's Research Institute, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Cathy Catroppa
- Murdoch Children's Research Institute, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- The Royal Children's Hospital, Melbourne, Australia
| | - Audrey McKinlay
- Murdoch Children's Research Institute, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- University of Canterbury, Christchurch, New Zealand
| | - Vicki Anderson
- Murdoch Children's Research Institute, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- The Royal Children's Hospital, Melbourne, Australia
| |
Collapse
|
6
|
Rose SC, Levine DA, Shi J, Wheeler K, Aungst T, Stanley RM, Beauchamp MH. Emergency department visits for mild traumatic brain injury in early childhood. Am J Emerg Med 2023; 65:36-42. [PMID: 36580699 DOI: 10.1016/j.ajem.2022.12.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 12/13/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Brain injury during early childhood may disrupt key periods of neurodevelopment. Most research regarding mild traumatic brain injury (mTBI) has focused on school-age children. We sought to characterize the incidence and healthcare utilization for mTBI in young children presenting to U.S. emergency departments (ED). METHODS The Nationwide Emergency Department Sample was queried for children age 0-6 years with mTBI from 2016 to 2019. Patients were excluded for focal or diffuse TBI, drowning or abuse mechanism, death in the ED or hospital, Injury Severity Score > 15, neurosurgical intervention, intubation, or blood product transfusion. RESULTS National estimates included 1,372,291 patient visits: 63.5% were two years or younger, 57.5% were male, and 69.4% were injured in falls. The most common head injury diagnosis was "unspecified injury of head" (83%); this diagnosis decreased in frequency as age increased, in favor of a concussion diagnosis. Most patients were seen at low pediatric volume EDs (64.5%) and non-children's hospital EDs (86.2%), and 64.9% were seen at a non-teaching hospital. Over 98% were treated in the ED and discharged home. Computed tomography of the head and cervical spine were performed in 18.7% and 1.6% of patients, respectively, less often at children's hospitals (OR = 0.55, 95%CI = 0.41-0.76 for head and OR = 0.19, 95%CI = 0.11-0.34 for cervical spine). ED charges resulted in $540-681 million annually, and more than half of patients utilized Medicaid. CONCLUSIONS Early childhood mTBI is prevalent and results in high financial burden in the U.S. There is wide variation in diagnostic coding and computed tomography scanning amongst EDs. More focused research is needed to identify optimal diagnostic tools and management strategies.
Collapse
Affiliation(s)
- Sean C Rose
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Division of Pediatric Neurology, Columbus, OH 43205, United States.
| | - Deborah A Levine
- New York Presbyterian Hospital and Weill Cornell Medicine, Department of Emergency Medicine, New York, NY 10021, United States
| | - Junxin Shi
- Nationwide Children's Hospital, Division of Emergency Medicine, Columbus, OH 43205, United States
| | - Krista Wheeler
- Nationwide Children's Hospital, Division of Emergency Medicine, Columbus, OH 43205, United States
| | - Taylour Aungst
- Nationwide Children's Hospital, Division of Neurology, Columbus, OH 43205, United States
| | - Rachel M Stanley
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Division of Emergency Medicine, Columbus, OH 43205, United States
| | - Miriam H Beauchamp
- Department of Psychology, University of Montreal and Ste-Justine Hospital Research Center, Montreal, Quebec, Canada
| |
Collapse
|
7
|
What About the Little Ones? Systematic Review of Cognitive and Behavioral Outcomes Following Early TBI. Neuropsychol Rev 2022; 32:906-936. [PMID: 34994947 DOI: 10.1007/s11065-021-09517-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 06/07/2021] [Indexed: 10/19/2022]
Abstract
There is increasing empirical focus on the effects of early traumatic brain injuries (TBI; i.e., before the age of six years) on child development, but this literature has never been synthetized comprehensively. This systematic review aimed to document the cognitive, academic, behavioral, socio-affective, and adaptive consequences of early TBI. Four databases (Medline, PsycNET, CINAHL, PubMed) were systematically searched from 1990 to 2019 using key terms pertaining to TBI and early childhood. Of 12, 153 articles identified in the initial search, 43 were included. Children who sustain early TBI are at-risk for a range of difficulties, which are generally worse when injury is sustained at a younger age, injury severity is moderate to severe, and injury mechanisms are non-accidental. Early childhood is a sensitive period for the emergence and development of new skills and behaviors, and brain disruption during this time is not benign. Research, clinical management, intervention, and prevention efforts should be further developed with consideration of the unique characteristics of the early childhood period.
Collapse
|
8
|
Podolak OE, Chaudhary S, Haarbauer-Krupa J, Metzger KB, Curry AE, Kessler RS, Pfeiffer MR, Breiding MJ, Master CL, Arbogast KB. Characteristics of Diagnosed Concussions in Children Aged 0 to 4 Years Presenting to a Large Pediatric Healthcare Network. Pediatr Emerg Care 2021; 37:e1652-e1657. [PMID: 32555016 PMCID: PMC7927314 DOI: 10.1097/pec.0000000000002148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The aim of the study was to comprehensively describe the natural history of concussion in early childhood between 0 and 4 years. METHODS Retrospective cohort study of 329 patients aged 0 to 4 years, with an International Classification of Diseases, Ninth Revision, concussion diagnosis in the Children's Hospital of Philadelphia healthcare network from October 1, 2013, to September 30, 2015. Clinical data were abstracted from the Children's Hospital of Philadelphia electronic health record, which captured all clinical care visits and injury characteristics. RESULTS Nearly 9 (86.6%) of 10 patients sought care in the emergency department or urgent care setting, most commonly on the day of injury (56.2%) and as a result of a fall (64.4%). More than two-thirds (64.4%) of patients or their parent/caregiver reported somatic symptoms (ie, vomiting or headache), whereas close to half (49.2%) reported sleep issues. One of 5 patients identified emotional symptoms (21.9%) or visio-vestibular dysfunction (20.4%). Many patients also experienced symptoms not included in standard assessment tools including personality changes (34.0%) and change in appetite (12.8%). CONCLUSIONS These results provide insight into the clinical characteristics of concussion in early childhood up to 4 years of age. Because assessment in this group relies heavily on parent/caregiver symptom reporting, rather than patient self-report, these results will aid clinicians with the challenge of diagnosing concussions in this population. These findings highlight the need to develop additional tools to adequately and systematically assess common signs and symptoms of concussion in early childhood that may not be included in standard assessment scales routinely used in older adolescents and adults.
Collapse
Affiliation(s)
- Olivia E. Podolak
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Sofia Chaudhary
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Juliet Haarbauer-Krupa
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kristina B. Metzger
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Allison E. Curry
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Ronni S. Kessler
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Melissa R. Pfeiffer
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Matthew J. Breiding
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA
| | - Christina L. Master
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Sports Medicine and Performance Center, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Kristy B. Arbogast
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
9
|
Yumul JN, Crowe L, Catroppa C, Anderson V, McKinlay A. Post-concussive Signs and Symptoms in Preschool Children: A Systematic Review. Neuropsychol Rev 2021; 32:631-650. [PMID: 34390464 DOI: 10.1007/s11065-021-09518-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 05/20/2021] [Indexed: 11/30/2022]
Abstract
Mild traumatic brain injury (mTBI) is common in children aged < 5 years, however, less is known about their experience of post-concussive signs and symptoms. This systematic review aims to identify post-concussive signs and symptoms experienced by preschool children up to 12 months post-injury, and to review the methods used to report this data. Relevant findings, including rates, progression, and possible predictors of post-concussive signs and symptoms were also identified. Databases (Ovid MEDLINE, EMBASE, PsycInfo, PubMed, Scopus) and reference lists were searched for relevant articles, which were screened based on specified criteria. Eleven articles met the inclusion criteria, being original studies published in English and presenting data on post-concussive signs and symptoms specific to preschool children with mTBI. Most reviewed studies investigated acute presentations of mTBI, and identified that preschool children demonstrate post-concussive symptoms (PCS) similar to other age groups. Post-traumatic amnesia duration of approximately one day was reported in preschool children following mTBI, as were changes in mood and behavior during the recovery period. Parents were the main informants, with data obtained through either interview or questionnaire. Review findings highlight the lack of empirical data regarding the presentation and progression of PCS in preschoolers following mTBI and evidence on how to best manage this group during recovery.
Collapse
Affiliation(s)
- Joy Noelle Yumul
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Australia. .,Murdoch Children's Research Institute, Melbourne, Australia.
| | - Louise Crowe
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Australia.,Royal Children's Hospital, Melbourne, Australia
| | - Cathy Catroppa
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Australia.,Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Vicki Anderson
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Australia.,Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Audrey McKinlay
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Australia.,Department of Psychology, University of Canterbury, Christchurch, New Zealand
| |
Collapse
|
10
|
Sarmiento K, Daugherty J, Haarbauer-Krupa J. Healthcare Providers' Self-Reported Pediatric Mild Traumatic Brain Injury Diagnosis, Prognosis, and Management Practices: Findings From the 2019 DocStyles Survey. J Head Trauma Rehabil 2021; 36:282-292. [PMID: 33656487 PMCID: PMC8249309 DOI: 10.1097/htr.0000000000000671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess adherence to 5 key recommendations in the Centers for Disease Control and Prevention evidence-based guideline on pediatric mild traumatic brain injury, this article presents results from the 2019 DocStyles survey. STUDY DESIGN Cross-sectional, web-based survey of 653 healthcare providers. RESULTS Most healthcare providers reported adhering to the recommendations regarding the use of computed tomography and providing education and reassurance to patients and their families. However, less than half reported routinely examining their patients with mild traumatic brain injury (mTBI) using age-appropriate, validated symptom scales, assessing for risk factors for prolonged recovery, and advising patients to return to noncontact, light aerobic activities within 2 to 3 days. Self-reported mTBI diagnosis, prognosis, and management practices varied by specialty. Only 3.8% of healthcare providers answered all 7 questions in a way that is most consistent with the 5 recommendations examined from the Centers for Disease Control and Prevention Pediatric mTBI Guideline. CONCLUSION This study highlights several important information gaps regarding pediatric mTBI diagnosis and management. Further efforts to improve adoption of guideline recommendations may be beneficial to ensure optimal outcomes for children following an mTBI.
Collapse
Affiliation(s)
- Kelly Sarmiento
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Injury Prevention, Atlanta, GA
| | - Jill Daugherty
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Injury Prevention, Atlanta, GA
| | - Juliet Haarbauer-Krupa
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Injury Prevention, Atlanta, GA
| |
Collapse
|
11
|
Report of Early Childhood Traumatic Injury Observations & Symptoms: Preliminary Validation of an Observational Measure of Postconcussive Symptoms. J Head Trauma Rehabil 2021; 37:E102-E112. [PMID: 33935228 DOI: 10.1097/htr.0000000000000691] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report preliminary empirical data on a novel, developmentally appropriate, observational postconcussive symptoms inventory for infants, toddlers, and preschoolers. SETTING Emergency departments of 2 tertiary, urban pediatric hospitals. PARTICIPANTS Ninety-eight children (0-8 years of age; mean age at injury = 33.00, SD = 24.7 months) with mild traumatic brain injury (concussion) divided into younger (0-2 years) and older (3-8 years) age groups. DESIGN Observational study. MAIN MEASURE The Report of Early Childhood Traumatic Injury Observations & Symptoms (REACTIONS) documents 17 postconcussive symptoms representing observable manifestations thereof and was completed by parents in the acute (24-48 hours; n = 65), subacute (7-14 days; n = 78), and/or persistent phase (25-35 days; n = 72) post-mild traumatic brain injury. RESULTS Different patterns of postconcussive symptoms were reported by age group, with behavioral manifestations particularly salient in younger children. More children younger than 2 years had sleep and comfort-seeking symptoms at each of the 3 postinjury time points. CONCLUSION Postconcussive symptoms may manifest differently after mild traumatic brain injury sustained during early childhood. To fully understand and address their presence and evolution, developmentally sound measures such as the REACTIONS inventory are required.
Collapse
|
12
|
Beauchamp MH, Séguin M, Gagner C, Lalonde G, Bernier A. The PARENT model: a pathway approach for understanding parents’ role after early childhood mild traumatic brain injury. Clin Neuropsychol 2020; 35:846-867. [DOI: 10.1080/13854046.2020.1834621] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- M. H. Beauchamp
- Department of Psychology, University of Montreal, Canada
- Sainte-Justine Hospital Research Center, Montreal, Canada
| | - M. Séguin
- Department of Psychology, University of Montreal, Canada
- Sainte-Justine Hospital Research Center, Montreal, Canada
| | - C. Gagner
- Department of Psychology, University of Montreal, Canada
- Sainte-Justine Hospital Research Center, Montreal, Canada
| | - G. Lalonde
- Department of Psychology, University of Montreal, Canada
- Sainte-Justine Hospital Research Center, Montreal, Canada
| | - A. Bernier
- Department of Psychology, University of Montreal, Canada
| |
Collapse
|
13
|
Characteristics of Concussion in Elementary School-Aged Children: Implications for Clinical Management. J Pediatr 2020; 223:128-135. [PMID: 32507622 PMCID: PMC7419017 DOI: 10.1016/j.jpeds.2020.04.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 03/11/2020] [Accepted: 04/01/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To comprehensively characterize the clinical presentation and course of care for concussion among 5- to 11-year-old children, identifying preinjury and injury factors potentially influencing clinical outcomes. STUDY DESIGN A single-institution retrospective cohort study using electronic health record data from children ages 5- to 11 years with a concussion from July 1, 2014, through June 30, 2015. Electronic health record data were abstracted for a 20% random sample of 292 patients. RESULTS Three-fourths of patients (74.3%) presenting for concussion care had a standardized visiovestibular assessment performed. Almost all of those who eventually sought specialty care (92.9%) also had such an assessment, and only 42.9% patients initially seen in the emergency department or urgent care were examined in this manner. Of those assessed, 62.7% (n = 136) demonstrated deficits, with children ages 9-11 years more frequently exhibiting deficits than their younger counterparts (67.9% vs 53.2%; P = .03). Almost all patients (95.9%) reported at least 1 somatic symptom (eg, headache, dizziness), and one-half to two-thirds reported problems with sleep (54.1%) and visiovestibular symptoms (66.1%). Only 11.6% of children were referred for rehabilitation therapies and less than one-half of concussed patients (43.8%) were provided with a letter recommending school accommodations. CONCLUSIONS Somatic symptoms, sleep problems, and visiovestibular deficits are common in elementary school-aged children with concussion, but specific visiovestibular clinical assessments are often not performed, particularly in the emergency department setting. Recommendations for school accommodations are often not provided at the time of concussion diagnosis. Incorporating a standardized visiovestibular assessment into practice could facilitate early targeted school accommodations and thereby improve return to learning for elementary school-aged children with concussion.
Collapse
|
14
|
Postconcussive Symptoms Following Mild TBI and Extracranial Injury: What Are the Contributing Factors? J Int Neuropsychol Soc 2020; 26:451-463. [PMID: 31822313 DOI: 10.1017/s1355617719001279] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Whether mild traumatic brain injury (mTBI) sustained by children results in persistent or recurrent symptoms, over and above those experienced by children who solely sustain mild extracranial injuries, remains debated. The current prospective longitudinal case-controlled study aimed to examine the relative influence of injury and noninjury factors on symptoms in preschool and primary school-aged children who sustained an mTBI or mild extracranial injury at least 8 month earlier. METHODS Participants were 64 parents of children (31 mTBI, 33 trauma controls) who sustained injury between ages 2 and 12, whose postconcussive symptoms across the first 3-month postinjury have been previously described. The current study assessed postconcussive symptoms at 8 or more months postinjury (M = 24.3, SD = 8.4) and examined a range of injury and noninjury predictive factors. RESULTS At or beyond 8-month postinjury, symptom numbers in the mTBI group were comparable with those of the group who sustained mild extracranial injury. Educational attainment of parents (below or above high-school attainment level) was the only predictor of symptoms at follow-up, with preexisting learning difficulties approaching significance as a predictor. CONCLUSIONS While our earlier study found that mTBI was associated with symptoms at 3-month postinjury, follow-up at more than 8 months showed mTBI no longer predicted symptom reporting. While mTBI contributes significantly to the presence of symptoms in the first few months postinjury, researchers and healthcare practitioners in this field need to consider the potential impact of noninjury factors on persistent or recurrent symptoms after mTBI.
Collapse
|
15
|
Evans E, Cook NE, Iverson GL, Townsend EL, Duhaime AC. Monitoring Outcome after Hospital-Presenting Milder Spectrum Pediatric Traumatic Brain Injury Using the Glasgow Outcome Scale-Extended, Pediatric Revision. J Neurotrauma 2020; 37:1627-1636. [PMID: 32106753 DOI: 10.1089/neu.2019.6893] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The Glasgow Outcome Scale, Pediatric Revision (GOSE-P) is an assessment of "global outcome" designed as a developmentally appropriate version of the Glasgow Outcome Scale-Extended for use in clinical trials of children with traumatic brain injury (TBI). Initial testing describes validity across a wide age and injury severity spectrum, yet the GOSE-P's utility for monitoring children with milder injuries is less clear. We examined the level of agreement between the GOSE-P and the Health and Behavior Inventory (HBI), a TBI-related symptom checklist used to assess children with mild TBI for clinical and research purposes. Participants included children and adolescents 3-16 years of age (n = 50) who presented to two level 1 trauma centers within 24 h of injury, with a GCS of 13-15, who underwent clinical neuroimaging. Outcome was assessed 2 weeks and 3 months following injury. We examined the severity of TBI-related symptoms across disability categories identified using the GOSE-P, and the level of agreement between the two measures in identifying deficits 2 weeks following injury and improvement from 2 weeks to 3 months. Using the GOSE-P, 62% had deficits at 2 weeks, and 42% improved from 2 weeks to 3 months. Agreement between the GOSE-P and HBI was fair 2 weeks after TBI (k = 0.24-0.33), and poor for identifying subsequent improvement (k = 0.10-0.16). Modest agreement between the GOSE-P and the HBI may reflect restricted participation from diverse causes, including TBI, other bodily injuries, and prescribed activity restrictions, and highlights the need for multi-dimensional outcome batteries.
Collapse
Affiliation(s)
- Emily Evans
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,MGH Institute of Health Professions, Boston, Massachusetts, USA.,The Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA
| | - Nathan E Cook
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA.,Spaulding Rehabilitation Hospital and Spaulding Research Institute, Boston, Massachusetts, USA.,MassGeneral Hospital for Children™ Sports Concussion Program, Boston, Massachusetts, USA
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA.,Spaulding Rehabilitation Hospital and Spaulding Research Institute, Boston, Massachusetts, USA.,MassGeneral Hospital for Children™ Sports Concussion Program, Boston, Massachusetts, USA.,Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, Massachusetts, USA
| | - Elise L Townsend
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Charlestown, Massachusetts, USA
| | - Ann-Christine Duhaime
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | |
Collapse
|
16
|
Lalonde G, Bernier A, Beaudoin C, Gravel J, Beauchamp MH. Factors contributing to parent-child interaction quality following mild traumatic brain injury in early childhood. J Neuropsychol 2019; 14:98-120. [PMID: 30779296 DOI: 10.1111/jnp.12179] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 11/24/2018] [Indexed: 01/18/2023]
Abstract
There is emerging evidence that parent-child interactions are affected by early childhood traumatic brain injury (TBI). These findings are of functional importance when considering the high prevalence of TBI in early childhood alongside evidence that young children exposed to positive relationships with their parents early in life exhibit better social functioning concurrently and longitudinally. Given that the overall quality of parent-child interactions is the result of both parent and child emotional and behavioural dispositions, it remains unclear which parental or child-related factors contribute to the quality of interactions post-TBI. The aim of this study was to investigate the factors that contribute to the quality of parent-child interactions following early childhood TBI. The sample included 68 children (18-60 months at recruitment) with accidental, uncomplicated mild TBI (mTBI). The quality of parent-child interactions was assessed 6 months post-injury using the Mutually Responsive Orientation scale, an observational measure of the dyadic quality of parent-child exchanges. Potential contributing factors were assessed among parental factors (e.g., age, socioeconomic status, family burden, parental stress, marital satisfaction) and child-related factors (e.g., age, sex, symptoms, fatigue, adaptive/behavioural skills). Socioeconomic status, child post-concussive symptoms, and child sleep problems were found to be significant independent contributing factors to parent-child interactions six months post-injury. This study provides the first evidence that both parental and child factors relate to the quality of parent-child interactions following mTBI, thus contributing to a better understanding of the scope and complexity of factors that play a role in childrens' recovery.
Collapse
Affiliation(s)
- Gabrielle Lalonde
- Ste-Justine Research Center, Montreal, Quebec, Canada.,Department of Psychology, University of Montreal, Quebec, Canada
| | - Annie Bernier
- Department of Psychology, University of Montreal, Quebec, Canada
| | - Cindy Beaudoin
- Ste-Justine Research Center, Montreal, Quebec, Canada.,Department of Psychology, University of Montreal, Quebec, Canada
| | | | - Miriam H Beauchamp
- Ste-Justine Research Center, Montreal, Quebec, Canada.,Department of Psychology, University of Montreal, Quebec, Canada
| |
Collapse
|
17
|
Suskauer SJ, Houtrow AJ. Invited Commentary on "The Report to Congress on the Management of Traumatic Brain Injury in Children". Arch Phys Med Rehabil 2018; 99:2389-2391. [PMID: 29906420 DOI: 10.1016/j.apmr.2018.05.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 05/17/2018] [Accepted: 05/24/2018] [Indexed: 10/14/2022]
Abstract
The Centers for Disease Control and Prevention (CDC) published "The Report to Congress on the Management of Traumatic Brain Injury in Children" in the spring of 2018. The report is a call to action for professionals providing care for children with traumatic brain injury in the health, social, and educational sectors and for researchers, administrators, and agencies to develop strategies to improve outcomes. For pediatric rehabilitation providers there are clear opportunities to improve service delivery for individual patients and for the population of children after traumatic brain injury more generally. Notably there is a workforce shortage, and fragmentation exists among the various systems that serve children with traumatic brain injuries and their families.
Collapse
Affiliation(s)
- Stacy J Suskauer
- Kennedy Krieger Institute, Baltimore, MD; Departments of Physical Medicine and Rehabilitation and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Amy J Houtrow
- Department of Physical Medicine and Rehabilitation and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| |
Collapse
|