Pediatric Sleep Difficulties after Moderate–Severe Traumatic Brain Injury

AbstractThe objective of this study is to systematically investigate sleep following moderate–severe pediatric traumatic brain injury (TBI). School-aged children with moderate–severe TBI identified via hospital records were invited to participate, along with a school-age sibling. Subjective reports and objective actigraphy correlates of sleep were recorded: Children's Sleep Habits Questionnaire (CSHQ), Sleep Self-Report questionnaire (SSR), and 5-night actigraphy. TBI participants (n= 15) and their siblings (n= 15) participated. Significantly more sleep problems were parent-reported (CSHQ:p= 0.003;d= 1.57), self-reported (SSR:p= 0.003;d= 1.40), and actigraph-recorded in the TBI group (sleep efficiency:p= 0.003;d= 1.23; sleep latency:p= 0.018;d= 0.94). There was no evidence of circadian rhythm disorders, and daytime napping was not prevalent. Moderate–severe pediatric TBI was associated with sleep inefficiency in the form of sleep onset and maintenance problems. This preliminary study indicates that clinicians should be aware of sleep difficulties following pediatric TBI, and their potential associations with cognitive and behavioral problems in a group already at educational and psychosocial risk. (JINS, 2013,19, 1–6)

Download Full-text

Unraveling the Biopsychosocial Factors of Fatigue and Sleep Problems After Traumatic Brain Injury: Protocol for a Multicenter Longitudinal Cohort Study (Preprint)

10.2196/preprints.11295 ◽

2018 ◽

Author(s):

Jessica Bruijel ◽

Sven Z Stapert ◽

Annemiek Vermeeren ◽

Jennie L Ponsford ◽

Caroline M van Heugten

Keyword(s):

Social Support ◽

Traumatic Brain Injury ◽

Cohort Study ◽

Brain Injury ◽

Brain Damage ◽

Emotional State ◽

Sleep Problems ◽

Family Participation ◽

Severe Tbi ◽

Support Family

BACKGROUND Fatigue and sleep problems are common after a traumatic brain injury (TBI) and are experienced as highly distressing symptoms, playing a significant role in the recovery trajectory, and they can drastically impact the quality of life and societal participation of the patient and their family and friends. However, the etiology and development of these symptoms are still uncertain. OBJECTIVE The aim of this study is to examine the development of fatigue and sleep problems following moderate to severe TBI and to explore the changes in underlying biological (pain, brain damage), psychological (emotional state), and social (support family, participation) factors across time. METHODS This study is a longitudinal multicenter observational cohort study with 4 measurement points (3, 6, 12, and 18 months postinjury) including subjective questionnaires and cognitive tasks, preceded by 7 nights of actigraphy combined with a sleep diary. Recruitment of 137 moderate to severe TBI patients presenting at emergency and neurology departments or rehabilitation centers across the Netherlands is anticipated. The evolution of fatigue and sleep problems following TBI and their association with possible underlying biological (pain, brain damage), psychological (emotional state), and social (support family, participation) factors will be examined. RESULTS Recruitment of participants for this longitudinal cohort study started in October 2017, and the enrollment of participants is ongoing. The first results are expected at the end of 2020. CONCLUSIONS To the authors’ knowledge, this is the first study that examines the development of both post-TBI fatigue and sleep longitudinally within a biopsychosocial model in moderate to severe TBI using both subjective and objective measures. Identification of modifiable factors such as mood and psychosocial stressors may give direction to the development of interventions for fatigue and sleep problems post-TBI. CLINICALTRIAL Netherlands Trial Register NTR7162; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=7162 (Archived by WebCite at http://www.webcitation.org/6z3mvNLuy) INTERNATIONAL REGISTERED REPOR RR1-10.2196/11295

Download Full-text

Critical Update on the Third Edition of the Guidelines for Managing Severe Traumatic Brain Injury in Children

American Journal of Critical Care ◽

10.4037/ajcc2020228 ◽

2020 ◽

Vol 29 (1) ◽

pp. e13-e18

Author(s):

Karin Reuter-Rice ◽

Elise Christoferson

Keyword(s):

Traumatic Brain Injury ◽

Critical Care ◽

Brain Injury ◽

Severe Traumatic Brain Injury ◽

Current Evidence ◽

Care Providers ◽

The Third ◽

Guideline Document ◽

Severe Tbi ◽

Pediatric Tbi

Background Severe traumatic brain injury (TBI) is associated with high rates of death and disability. As a result, the revised guidelines for the management of pediatric severe TBI address some of the previous gaps in pediatric TBI evidence and management strategies targeted to promote overall health outcomes. Objectives To provide highlights of the most important updates featured in the third edition of the guidelines for the management of pediatric severe TBI. These highlights can help critical care providers apply the most current and appropriate therapies for children with severe TBI. Methods and Results After a brief overview of the process behind identifying the evidence to support the third edition guidelines, both relevant and new recommendations from the guidelines are outlined to provide critical care providers with the most current management approaches needed for children with severe TBI. Recommendations for neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, ventilation therapies, temperature control/hypothermia, nutrition, and corticosteroids are provided. In addition, the complete guideline document and its accompanying algorithm for recommended therapies are available electronically and are referenced within this article. Conclusions The evidence base for treating pediatric TBI is increasing and provides the basis for high-quality care. This article provides critical care providers with a quick reference to the current evidence when caring for a child with a severe TBI. In addition, it provides direct access links to the comprehensive guideline document and algorithms developed to support critical care providers.

Download Full-text

White Matter Disruption in Pediatric Traumatic Brain Injury: Results from ENIGMA Pediatric Moderate to Severe Traumatic Brain Injury

Neurology ◽

10.1212/wnl.0000000000012222 ◽

2021 ◽

pp. 10.1212/WNL.0000000000012222

Author(s):

Emily L Dennis ◽

Karen Caeyenberghs ◽

Kristen R Hoskinson ◽

Tricia L Merkley ◽

Stacy J Suskauer ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

White Matter ◽

Behavioral Problems ◽

Child Behavior Checklist ◽

Injury Severity ◽

Meta Analysis ◽

Post Injury ◽

Severe Tbi ◽

Future Work

Objective:Our study addressed aims: (1) test the hypothesis that moderate-severe TBI in pediatric patients is associated with widespread white matter (WM) disruption; (2) test the hypothesis that age and sex impact WM organization after injury; and (3) examine associations between WM organization and neurobehavioral outcomes.Methods:Data from ten previously enrolled, existing cohorts recruited from local hospitals and clinics were shared with the ENIGMA (Enhancing NeuroImaging Genetics through Meta-Analysis) Pediatric msTBI working group. We conducted a coordinated analysis of diffusion MRI (dMRI) data using the ENIGMA dMRI processing pipeline.Results:Five hundred and seven children and adolescents (244 with complicated mild to severe TBI [msTBI] and 263 controls) were included. Patients were clustered into three post-injury intervals: acute/subacute - <2 months, post-acute - 2-6 months, chronic - 6+ months. Outcomes were dMRI metrics and post-injury behavioral problems as indexed by the Child Behavior Checklist (CBCL). Our analyses revealed altered WM diffusion metrics across multiple tracts and all post-injury intervals (effect sizes ranging between d=-0.5 to -1.3). Injury severity is a significant contributor to the extent of WM alterations but explained less variance in dMRI measures with increasing time post-injury. We observed a sex-by-group interaction: females with TBI had significantly lower fractional anisotropy in the uncinate fasciculus than controls (𝞫=0.043), which coincided with more parent-reported behavioral problems (𝞫=-0.0027).Conclusions:WM disruption after msTBI is widespread, persistent, and influenced by demographic and clinical variables. Future work will test techniques for harmonizing neurocognitive data, enabling more advanced analyses to identify symptom clusters and clinically-meaningful patient subtypes.

Download Full-text

Increased S-Nitrosothiols and S-Nitrosoalbumin in Cerebrospinal Fluid after Severe Traumatic Brain Injury in Infants and Children: Indirect Association with Intracranial Pressure

Journal of Cerebral Blood Flow & Metabolism ◽

10.1097/01.wcb.0000040399.30600.e3 ◽

2003 ◽

Vol 23 (1) ◽

pp. 51-61 ◽

Cited By ~ 20

Author(s):

Hülya Bayir ◽

Patrick M. Kochanek ◽

Shang-Xi Liu ◽

Antonio Arroyo ◽

Anatoly Osipov ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Cerebrospinal Fluid ◽

Brain Injury ◽

Intracranial Pressure ◽

Fold Increase ◽

Infants And Children ◽

No Production ◽

Secondary Damage ◽

Severe Tbi ◽

Pediatric Tbi

Nitric oxide (NO) is implicated in both secondary damage and recovery after traumatic brain injury (TBI). Transfer of NO groups to cysteine sulfhydryls on proteins produces S-nitrosothiols (RSNO). S-nitrosothiols may be neuroprotective after TBI by nitrosylation of N-methyl-D-aspartate receptor and caspases. S-nitrosothiols release NO on decomposition for which endogenous reductants (i.e., ascorbate) are essential, and ascorbate is depleted in cerebrospinal fluid (CSF) after pediatric TBI. This study examined the presence and decomposition of RSNO in CSF and the association between CSF RSNO level and physiologic parameters after severe TBI. Cerebrospinal fluid samples (n = 72) were obtained from 18 infants and children on days 1 to 3 after severe TBI (Glasgow Coma Scale score < 8) and 18 controls. Cerebrospinal fluid RSNO levels assessed by fluorometric assay peaked on day 3 versus control (1.42 ± 0.11 μmol/L vs. 0.86 ± 0.04, P < 0.05). S-nitrosoalbumin levels were also higher after TBI (n = 8, 0.99 ± 0.09 μmol/L on day 3 vs. n = 6, 0.42 ± 0.02 in controls, P < 0.05). S-nitrosoalbumin decomposition was decreased after TBI. Multivariate analysis showed an inverse relation between CSF RSNO and intracranial pressure and a direct relation with barbiturate treatment. Using a novel assay, the presence of RSNO and S-nitrosoalbumin in human CSF, an ∼1.7-fold increase after TBI, and an association with low intracranial pressure are reported, supporting a possible neuroprotective role for RSNO. The increase in RSNO may result from increased NO production and/or decreased RSNO decomposition.

Download Full-text

Head of bed elevation in pediatric patients with severe traumatic brain injury

Journal of Neurosurgery Pediatrics ◽

10.3171/2020.4.peds20102 ◽

2020 ◽

Vol 26 (5) ◽

pp. 465-475

Author(s):

Shih-Shan Lang ◽

Amber Valeri ◽

Bingqing Zhang ◽

Phillip B. Storm ◽

Gregory G. Heuer ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Blood Flow ◽

Brain Injury ◽

Severe Traumatic Brain Injury ◽

Pediatric Patients ◽

Venous Outflow ◽

Optimal Position ◽

Significant Difference ◽

Severe Tbi ◽

Pediatric Tbi

OBJECTIVEHead of bed (HOB) elevation to 30° after severe traumatic brain injury (TBI) has become standard positioning across all age groups. This maneuver is thought to minimize the risk of elevated ICP in the hopes of decreasing cerebral blood and fluid volume and increasing cerebral venous outflow with improvement in jugular venous drainage. However, HOB elevation is based on adult population data due to a current paucity of pediatric TBI studies regarding HOB management. In this prospective study of pediatric patients with severe TBI, the authors investigated the role of different head positions on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and cerebral venous outflow through the internal jugular veins (IJVs) on postinjury days 2 and 3 because these time periods are considered the peak risk for intracranial hypertension.METHODSPatients younger than 18 years with a Glasgow Coma Scale score ≤ 8 after severe TBI were prospectively recruited at a single quaternary pediatric intensive care unit. All patients had an ICP monitor placed, and no other neurosurgical procedure was performed. On the 2nd and 3rd days postinjury, the degree of HOB elevation was varied between 0° (head-flat or horizontal), 10°, 20°, 30°, 40°, and 50° while ICP, CPP, and bilateral IJV blood flows were recorded.RESULTSEighteen pediatric patients with severe TBI were analyzed. On each postinjury day, 13 of the 18 patients had at least 1 optimal HOB position (the position that simultaneously demonstrated the lowest ICP and the highest CPP). Six patients on each postinjury day had 30° as the optimal HOB position, with only 2 being the same patient on both postinjury days. On postinjury day 2, 3 patients had more than 1 optimal HOB position, while 5 patients did not have an optimal position. On postinjury day 3, 2 patients had more than 1 optimal HOB position while 5 patients did not have an optimal position. Interestingly, 0° (head-flat or horizontal) was the optimal HOB position in 2 patients on postinjury day 2 and 3 patients on postinjury day 3. The optimal HOB position demonstrated lower right IJV blood flow than a nonoptimal position on both postinjury days 2 (p = 0.0023) and 3 (p = 0.0033). There was no significant difference between optimal and nonoptimal HOB positions in the left IJV blood flow.CONCLUSIONSIn pediatric patients with severe TBI, the authors demonstrated that the optimal HOB position (which decreases ICP and improves CPP) is not always at 30°. Instead, the optimal HOB should be individualized for each pediatric TBI patient on a daily basis.

Download Full-text

Plasma osteopontin may predict neuroinflammation and the severity of pediatric traumatic brain injury

Journal of Cerebral Blood Flow & Metabolism ◽

10.1177/0271678x19836412 ◽

2019 ◽

Vol 40 (1) ◽

pp. 35-43 ◽

Cited By ~ 4

Author(s):

Ning Gao ◽

Xiaohui Zhang-Brotzge ◽

Bushra Wali ◽

Iqbal Sayeed ◽

Joshua J Chern ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Plasma Levels ◽

Developed Countries ◽

Severity Scores ◽

Intracranial Lesions ◽

Severe Tbi ◽

Pediatric Tbi ◽

Old Mice ◽

Metalloproteinase 9

Traumatic brain injury (TBI) is the leading cause of death in children and adolescents in developed countries, but there are no blood-based biomarkers to support the diagnosis or prognosis of pediatric TBI to-date. Here we report that the plasma levels of osteopontin (OPN), a phosphoprotein chiefly secreted by macrophages and/or activated microglia, may contribute to this goal. In animal models of TBI, while OPN, fibrillary acidic protein (GFAP), and matrix metalloproteinase 9 (MMP-9) were all readily induced by controlled cortical impact in the brains of one-month-old mice, only OPN and GFAP ascended in the blood in correlation with high neurological severity scores (NSS). In children with TBI (three to nine years of age, n = 66), the plasma levels of OPN, but not GFAP, correlated with severe TBI (Glasgow Coma Score ≤ 8) and intracranial lesions at emergency department. In addition, the plasma OPN levels in severe pediatric TBI patients continued to ascend for 72 h and correlated with mortality and the days requiring ventilator or intensive care unit support, whereas the plasma GFAP levels lacked these properties. Together, these results suggest that plasma OPN outperforms GFAP and may be a neuroinflammation-based diagnostic and prognostic biomarker in pediatric TBI.

Download Full-text

626 Association between Co-Sleep and Behavioral Problems among Preschoolers in Taiwan

SLEEP ◽

10.1093/sleep/zsab072.624 ◽

2021 ◽

Vol 44 (Supplement_2) ◽

pp. A245-A246

Author(s):

Yu-Ting Wu ◽

Ya-Chuan Huang ◽

Yung-Sen Chang ◽

Chien-Ming Yang

Keyword(s):

Sleep Duration ◽

Behavioral Problems ◽

Sleep Problems ◽

Sleep Onset ◽

Emotional And Behavioral Problems ◽

Sleep Habits ◽

Developmental Problems ◽

Bed Sharing ◽

Nighttime Sleep ◽

Children’S Sleep

Abstract Introduction ‘Co-sleep’ is defined as the sleep arrangements in which parents and their child sharing a sleeping surface (bed-sharing or room-sharing). Similar to the other Asian countries, Taiwan has a high reported rates of bed-sharing. Previous researches had shown shorter sleep duration and poorer sleep quality in children with co-sleep. However, the association between co-sleep and the children’s emotional and behavioral problems has not been well studied. This study aims to explore the association between sleeping arrangements and children’s sleep, as well as their daytime emotional and behavioral problems. Methods 9,582 caregivers of preschoolers (age= 4.70±0.806; Male: Female=52%:48%) completed a questionnaire regarding their children’s sleep schedule, the Children’s Sleep Habits Questionnaire (CSHQ) and Strength and Difficulties Questions (SDQ). The reported frequency on the items of the CHSQ question regarding co-sleep, asking whether the child falls asleep in parent’s or sibling’ s bed or sleep alone, were used to divide the children into three groups: usually co-sleep group, sometimes co-sleep group and sleep-alone group. Results Among 2,967 preschoolers, 6,272 children (65.5%) reported usually co-sleep, 816 children (8.5%) reported sometimes co-sleep, and 2,494 children (26%) reported sleeping alone. One-way ANOVAs showed significant differences among three groups in: 1) sleep patterns, including weekday nighttime sleep duration (F=24.43, p<.01), weekend nighttime sleep duration (F=3.13, p<.05), weekday nap duration (F=4.24, p<.05), and weekend nap time (F=4.39, p<.05); 2) sleep problems on the CHSQ, including bed time resistance (F=7027.25, p<.01), sleep onset delay (F=33.06, p<.01), sleep duration (F=65.51, p<.01), sleep anxiety (F=788.48, p<.01), night waking (F=37.90, p<.01), parasomnias (F=47.43, p<.01), sleep disorder breathing (F=7.58, p<.01), and sleepiness (F=13.44, p<.01); 3) behavioral problems and development on the SDQ, including hyperactivity (F=21.16, p<.01), emotional symptom (F=23.08, p<.01), conduct problem (F=8.65, p<.01), peer problems (F=20.59, p<.01), and prosocial (F=17.67, p<.01). Conclusion Our results indicate that children with more frequent co-sleep may have shorter sleep duration, more sleep problems as well as more external and internal behavioral problems, while sleep-alone children showed more prosocial behaviors, longer sleep duration, and less sleep problems. The potential developmental problems related to co-sleep may be underestimated in Asian culture and need more attentions. Support (if any):

Download Full-text

Diagnosing Major Depression Following Moderate to Severe Traumatic Brain Injury – Evidence-based Recommendations for Clinicians

European Neurological Review ◽

10.17925/enr.2011.06.01.24 ◽

2011 ◽

Vol 6 (1) ◽

pp. 24 ◽

Cited By ~ 2

Author(s):

Ronald T Seel ◽

Stephen Macciocchi ◽

Jeffrey S Kreutzer ◽

Darryl Kaelin ◽

Douglas I Katz ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Major Depression ◽

Psychosocial Functioning ◽

Sleep Problems ◽

Self Report ◽

Current Evidence ◽

Diagnostic And Statistical Manual ◽

Patient Health ◽

Dsm Iv

While major depression (MD) is the most common psychiatric disorder following traumatic brain injury (TBI), diagnosing MD can be challenging due to cognitive, emotional and somatic symptoms that overlap with TBI and other psychiatric disorders. Current evidence suggests that the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) works well in the TBI population. The presence of ‘organic’ TBI sequelae that overlap with DSM-IV MD criteria do not appear to lead to false-positive MD diagnoses. Rumination, self-criticism and guilt may best differentiate depressed from non-depressed persons following TBI. Anxiety, aggression, sleep problems, alcohol use, lower income levels, poor social functioning and negative thinking are primary risk factors for the development of MD following TBI. Current evidence suggests that the Patient Health Questionnaire-9 is the best self-report scale option for depression screening after TBI. Apathy, anxiety, dysregulation and emotional lability require careful clinical consideration when making a differential diagnosis of MD in persons with TBI. Research indicates that asking specific questions about depressed mood, loss of interest or pleasure and psychosocial functioning yields the most accurate diagnosis. Practical recommendations are provided on how clinicians can improve MD diagnostic accuracy.

Download Full-text

Do sleep difficulties exacerbate deficits in sustained attention following traumatic brain injury?

Journal of the International Neuropsychological Society ◽

10.1017/s1355617709990798 ◽

2009 ◽

Vol 16 (1) ◽

pp. 17-25 ◽

Cited By ~ 52

Author(s):

IMOGEN L.M. BLOOMFIELD ◽

COLIN A. ESPIE ◽

JONATHAN J. EVANS

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Sustained Attention ◽

Sleep Disturbances ◽

Sleep Problems ◽

Poor Sleep ◽

Injury Rehabilitation ◽

Attentional Functioning ◽

Sleep Difficulties ◽

Good Sleep

AbstractSustained attention has been shown to be vulnerable following traumatic brain injury (TBI). Sleep restriction and disturbances have been shown to negatively affect sustained attention. Sleep disorders are common but under-diagnosed after TBI. Thus, it seems possible that sleep disturbances may exacerbate neuropsychological deficits for a proportion of individuals who have sustained a TBI. The aim of this prospective study was to examine whether poor sleepers post-TBI had poorer sustained and general attentional functioning than good sleepers post-TBI. Retrospective subjective, prospective subjective, and objective measures were used to assess participants’ sleep. The results showed that the poor sleep group had significantly poorer sustained attention ability than the good sleep group. The differences on other measures of attention were not significant. This study supports the use of measures that capture specific components of attention rather than global measures of attention, and highlights the importance of assessing and treating sleep problems in brain injury rehabilitation. (JINS, 2010, 16, 17–25.)

Download Full-text

Accuracy of Self-report as a Method of Screening for Lifetime Occurrence of Traumatic Brain Injury Events that Resulted in Hospitalization

Journal of the International Neuropsychological Society ◽

10.1017/s1355617716000497 ◽

2016 ◽

Vol 22 (7) ◽

pp. 717-723 ◽

Cited By ~ 13

Author(s):

Audrey McKinlay ◽

L. John Horwood ◽

David M. Fergusson

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Injury Severity ◽

Early Adulthood ◽

Self Report ◽

Increased Risk ◽

History Of ◽

Severe Tbi ◽

Health And Development ◽

At Risk Populations

AbstractBackgroundTraumatic brain injury (TBI) occurs frequently during child and early adulthood, and is associated with negative outcomes including increased risk of drug abuse, mental health disorders and criminal offending. Identification of previous TBI for at-risk populations in clinical settings often relies on self-report, despite little information regarding self-report accuracy. This study examines the accuracy of adult self-report of hospitalized TBI events and the factors that enhance recall.MethodsThe Christchurch Health and Development Study is a birth cohort of 1265 children born in Christchurch, New Zealand, in 1977. A history of TBI events was prospectively gathered at each follow-up (yearly intervals 0–16, 18, 21, 25 years) using parental/self-report, verified using hospital records.ResultsAt 25 years, 1003 cohort members were available, with 59/101 of all hospitalized TBI events being recalled. Recall varied depending on the age at injury and injury severity, with 10/11 of moderate/severe TBI being recalled. Logistic regression analysis indicated that a model using recorded loss of consciousness, age at injury, and injury severity, could accurately classify whether or not TBI would be reported in over 74% of cases.ConclusionsThis research demonstrates that, even when individuals are carefully cued, many instances of TBI will not recalled in adulthood despite the injury having required a period of hospitalization. Therefore, screening for TBI may require a combination of self-report and review of hospital files to ensure that all cases are identified. (JINS, 2016, 22, 717–723)

Download Full-text