Pediatric Traumatic Brain Injury Patients in Southwestern Nigeria: Presentation Patterns and Outcome

Abstract

Background:

Traumatic brain injury (TBI) is less common in children than in adults but is a leading cause of mortality in children globally. The study aimed to explore the prevalence, etiological factors, management, and outcomes of pediatric TBI at Lagos University Teaching Hospital (LUTH), a major referral center in Nigeria.

Materials and Methods:

This prospective study included children under 18 diagnosed with TBI from January 1 to December 31, 2022. Ethical clearance was obtained, and informed consent was collected from caregivers. Data were gathered using a pre-designed proforma covering socio-demographics, injury mechanisms, pre-hospital management, clinical findings, and outcomes. Analysis was performed using IBM SPSS Statistics(v28).

Results:

Twenty-six patients with a mean age of 9.0 ± 5.99 years with a male-to-female ratio of 1.6:1 were enrolled. Only two (7.7%) had health insurance. Pediatric TBI accounted for 0.03% of all surgical emergencies at LUTH. Road traffic accidents (RTAs) were the cause for TBI in 11 (42.3%) of cases, whereas falls (7, 26.9%) and household accidents (5, 19.2%) were leading non-RTA causes. Only one patient (3.8%) was selected by skilled personnel and received immediate C-spine stabilization. Only 15 (57.7%) had a CT scan, constrained by financial issues. Four (15.4%) required surgery, but only half of them could undergo surgery due to financial constraints. Only one patient needed ICU admission, and three patients (11.5%) died. Mortality was only seen in severe TBI cases.

Conclusion:

The study found a low prevalence of pediatric TBI but highlighted significant mortality, especially in severe cases. Poverty and lack of health insurance were major factors affecting outcomes.

Introduction

Pediatric traumatic brain injury (TBI) is less common when compared with TBI in the adult population.[1] Despite its rarity, it is implicated as one of the leading causes of mortality in children worldwide. The Centers for Disease control and Prevention (CDC) estimates that 400,000 children between the ages of 0 and 14 years visit the Emergency Departments on account of TBI, out of which 29,000 children are admitted and 3000 children die each year in the United States of America.[2]

Children living in low- and middle-income countries are more likely to report higher morbidity and mortality rates as a result of traumatic injuries. Studies show that over 95% of pediatric injury-associated deaths occur in developing countries.[3,4,5] A prospective study carried out in South Southern Nigeria over the span of 5 years yield 127 cases of pediatric TBI with a relative male-to-female ratio of 1:1, showing no sex predilection and a resultant mortality of 8.6%.[6]

The mechanism of injury in both adult and pediatric TBI remains the same, but the etiology differs within the age groups, although RTA is the most common cause of TBI in adults, and falls and domestic accidents are common causes in children. Generally, road traffic accidents (RTAs), falls, and assault remain the common mode of injury in TBI in both populations.[6] Children involved in RTA are most likely to be pedestrian, falls are commoner in toddlers, while adolescents are more likely to have TBI as a result of RTA, assaults, and sports injuries.[4,7]

Pediatric TBI remains a cause for concern as affected children are likely to experience long-term effects in the future due to complications of the injury and its sequelae; they are likely to experience cognitive, motor, and psycho-social difficulties as they get older. Severe cases are likely to be dependents for life.[8] There is a paucity of data studying the epidemiology of pediatric TBI in developing countries, hence the need to narrow the data gap.[9] This study aims to determine the prevalence of pediatric TBI, explore the etiological factors, pre-hospital and in-hospital management of pediatric TBI, and determine outcomes and study its associated factors so as to help stakeholders in the development and implementation of effective preventive measures, development of national management and reporting protocols, and equipping the healthcare system to manage TBIs in an appropriate and timely manner.

Materials and Methods

This prospective cohort study was aimed at studying the presentation pattern and outcomes of pediatric TBI at the Lagos University Teaching Hospital (LUTH), which is one of the foremost and largest teaching hospitals in Nigeria with over 950 admission beds.[10] LUTH serves as the largest referral point in the state providing 24-h emergency and neurosurgical care. Ethical clearance was obtained from the Health Research Ethics Committee (HREC) of the LUTH with code ADM/DCST/HREC/APP/2688 assigned.

All patients aged below 18 years were recruited into the study at the Accident and Emergency Department following a diagnosis of TBI from the 1^st of January 2022 to the 31^st of December 2022. Informed consent was obtained from the responsible care givers or parents in addition to assent obtained from children aged 7 years and above. Patients’ relatives who refused to give consent were excluded from the study. Patients were reviewed daily from admission till discharge. Participants and their caregivers were informed about their rights, including confidentiality, privacy, and the ability to withdraw from the study at any point in time.

Study data were obtained with the aid of a pre-designed, pre-tested study proforma administered in English language. Collected data include participants’ socio-demographic characteristics, medical history relating to the mode of injury, pre-hospital management parameters such as the mode of extraction, clinical examination findings, in-hospital mode of management, and eventual outcomes.

Data obtained were analyzed using IBM SPSS Statistics for Windows, Version 28.0 (Armonk, NY: IBM Corp). Data were presented in the form of charts and tables. Continuous variables were presented using measures of centrality and dispersion, whereas categorical variables are presented as frequencies and percentages. Associations between variables were tested using chi-square and Fisher’s exact tests. The level of statistical significance was set as P < 0.05, at a 95% confidence interval.

Results

Twenty-six patients with a median age and interquartile range of 8 and 12 years, respectively, were recruited into the study on account of TBI. Patients’ age ranged from 1 to 17 years [Table 1]. The male-to-female ratio was 1.6:1, with the majority of respondents living within the Lagos metropolis [Table 1]. Only two out of 26 patients (7.7%) had access to some form of health insurance [Table 1].

Table 1.

Socio-demographics of patients with paediatric traumatic brain injury(TBI)

Variables (n = 26)	Frequency (%)/Mean (±S.D)
Age (years)	9.0 ± 5.99
Range (years)	1–17
Median (IQR)	8 (12)
Sex
Male	16 (61.5)
Female	10 (38.5)
Place of residence
Urban	20 (76.9)
Semi-urban	4 (15.4)
Rural	2 (7.7)
Availability of health insurance
Yes	2 (7.7)
No	24 (92.3)

^*IQR, Inter quartile range

A total of 860 patients were admitted to Accident and Emergency (Surgery); hence, pediatric TBI accounted for 0.03% of all surgical emergencies and 17.2% (26 out of 151) of all TBI cases admitted in LUTH during the study period. RTA accounted for the etiology in 11 (42.3%) patients, while 15 (57.7%) patients had TBI caused by non-RTA means [Table 2]. Falls (7, 26.9%) were the most common causes of non-RTA TBI, followed by household accidents (5, 19.2%) [Table 2]. Only one patient (3.8%) suffered from assault with no incidence of gunshot wounds [Table 2]. About 23.1% (6 out of 26) of patients had severe TBI [Table 2]. The majority of RTAs involving the pediatric population was pedestrian–vehicle accidents, with the children being pedestrians [Table 2].

Table 2.

Classification and etiology of paediatric TBI

Variables (n = 26)	Frequency (%)
Classification of TBI based on Glasgow coma scale
Mild[13,14,15]	7 (26.9)
Moderate[9,10,11,12]	3 (11.5)
Severe[3,4,5,6,7,8]	6 (23.1)
Not available	10 (36.5)
Etiology of TBI
Road traffic accidents (RTAs)	11 (42.3)
Falls	7 (26.9)
Household accidents	5 (19.2)
Industrial accidents	2 (7.7)
Assault	1 (3.8)
Gunshot	0 (0.0)
Mode of RTA (n = 11)
Lone accident	0 (0)
Pedestrian–vehicle	8 (72.7)
Vehicle–vehicle	3 (27.3)

Only one patient (3.8%) was extracted by healthcare or law enforcement officers who had a basic understanding in paramedical protocols and transported to the hospital via an ambulance [Table 3]. Similarly, only one patient (3.8%) received immediate C-spine stabilization with a cervical collar during extraction from the accident site [Table 3].

Table 3.

Accident-related factors

Variables (n = 26)	Frequency (%)
Mode of extraction from the accident site
Healthcare/law enforcement worker	1 (3.8)
Non-healthcare worker	25 (96.2)
Availability of cervical collar during extraction
Yes	1 (3.8)
No	25 (96.2)
Mode of transportation to point of care
Ambulance	1 (3.8)
Personal/private vehicle	21 (80.8)
Not disclosed	4 (15.4)

Twenty (76.9%) patients had no associated injuries [Table 4]. Fifteen (57.7%) patients had CT scan of the brain at presentation with finances being the major constraint in those otherwise not able to perform necessary investigation [Table 5]. Four (15.4%) patients required surgical intervention, with only half of them eventually undergoing surgery, also as a result of financial constraints [Table 5]. Only one (3.8%) patient needed ICU admission [Table 5]. The overall patient mortality was 11.5% (3 out of 26) in the study [Table 4].

Table 4.

Outcome-related factors

Variables (n = 26)	Frequency (%)
Associated injury noted at primary evaluation
Face	2 (7.7)
Chest	0 (0)
Abdominal	0 (0)
Extremity	0 (0)
Back and spine	1 (3.8)
More than one region	3 (11.5)
No injuries	20 (76.9)
Readiness of patient for investigations
Yes	15 (57.7)
No	11 (42.3)
If no, reason (n = 11)
Finances	10 (90.9)
Logistics	0 (0)
Not disclosed	1 (9.1)
Surgery indicated
Yes	4 (15.4)
No	22 (84.6)
Eventuality of surgery (n = 4)
Yes	2 (50.0)
No	2 (50.0)
Necessity of ICU care in patient management
Yes	1 (3.8)
No	25 (96.2)
Eventual patient outcome
Discharged alive	23 (88.5)
Death	3 (11.5)

Table 5.

Association between outcome-related factors and outcome of surgery

Variables	Eventual patient outcome		Fisher’s exact	P value
	Alive	Dead
Mode of injury
RTA	10 (90.9)	1 (9.1)	0.11	1.000
Non-RTA	13 (86.7)	2 (13.3)
Type of TBI based on GCS
Mild[13,14,15]	7 (100)	0 (0)	11.30	0.010
Moderate[9,10,11,12]	3 (100)	0 (0)
Severe[3,4,5,6,7,8]	3 (50.0)	3 (50.0)
Not available	10 (100)	0 (0)
Associated injury noted at primary evaluation
Face	2 (100)	0 (0)	1.02	0.797
Chest	0 (0)	0 (0)
Extremity	0 (0)	0 (0)
Back and spine	1 (100)	0 (0)
More than one region	3 (100)	0 (0)
No injuries	17 (85.0)	3 (15.0)
Necessity of ICU care in patient management
Yes	0 (0)	1 (100)	7.97	0.115
No	23 (92.0)	2 (8.0)

Non-RTAs were associated with a higher mortality when compared to RTAs; this relationship, however, lacked statistical significance (P > 0.05) [Table 4]. Mortality was reported only among patients with severe TBI, with 50% of patients eventually dying (P = 0.010) [Table 4]. A 100% mortality was associated with patients needing ICU admission (P > 0.050) [Table 4].

Discussion

Pediatric TBI and socio-demographic characteristics

Pediatric TBI has a bimodal age distribution, as documented in the literature as well as findings from this study. In this study, over 60% of patients fell into one of two age groups; 1–3 years (27%) and 14–17 years (35%). This is consistent with the typical bimodal age distribution (0–2 and 15–18 years) at which pediatric TBI occurs.[11] In the first peak, TBI is predominantly caused by falling, while in the second peak, the mechanism is more commonly motor vehicle accident-related.[11,12,13]

Globally, there is generally a male predilection in pediatric TBI.[14] The male-to-female ratio in our study of 1.6:1 is lower than findings reported by other indigenous researchers, including Chikani et al. (2.5:1) and Bot et al. (2.3:1), but higher than that reported by Udoh and Adeyemo (1:1).[6,14,15,16] This predominance in males has been explained at least in part by the adventurous and more physical nature of boys relative to girls.[11,14]

Pediatric TBI and socio-economic characteristics

Although the patients in our study were typically urban dwellers (76.9%), the vast majority of them (92.3%) had no available health insurance to cover their financial and medical expenses. This counterintuitive observation is a reflection of a nationwide problem, wherein only few Nigerians have health insurance (2%).[17] This access to health insurance has a profound impact on patient outcomes in terms of the readiness to pay for investigations and access surgical treatment, which are usually relatively expensive. Many of our patients were not able to afford basic investigations to guide treatment. In others, the cost of surgical intervention and critical care in ICU was out of reach as they would be required to pay out of pocket. Therefore, the outcome of TBI was severely impacted by financial constraints.

Patterns of pediatric TBI

An observation in this study compared to other local ones is that the pediatric victims of RTAs were usually pedestrians rather than vehicle occupants. This is in keeping with current literature where pediatric patients in low- and middle-income countries were more likely to be roadside pedestrians and vehicle occupants almost always the only victims in high-income countries.[11] Twenty (79.9%) patients had isolated TBI. In patients with isolated injuries, facial injury was the most common, which was corroborated in studies elsewhere. Other associated injuries include long bone fracture and skull fracture.

Management of pediatric TBI

Only one patient (3.8%) received immediate c-spine stabilization with a cervical collar during extraction, thanks to the involvement of skilled personnel. This underscores the importance of adequate training and provision of necessary equipment for paramedics and law enforcement workers for effective pre-hospital management of injured victims. Our study yielded 11.5% (three out of 25) mortality overall, and despite the small number of pediatric patients needing ICU admission, there was 100% mortality associated with patients requiring critical care, as opposed to the 8% mortality in those not needing ICU admission; however, this relationship was not statistically significant. Regarding the other patients with severe head injury needing intensive care and those who did not have the funds for ICU care (n = 2), they were therefore managed in the ER till they passed on.

Developing countries have few general ICU spaces and even fewer pediatric ICU slots. Pediatric patients with severe TBI require dedicated critical care in appropriate ICU centers. Our study center has a total of 10 ICU bed spaces as at the time of study. There is no dedicated pediatric ICU bed. The ICU is fully equipped with ventilators and monitor. The ICU is managed by dedicated ICU anesthetic consultants and staff. It is an open ICU with relevant unit consultants making daily comments/contributions

Outcomes of pediatric TBI

In our study, Glasgow Coma Scale (GCS) was found to be the only statistically significant predictor of outcome. In other studies, the GCS alongside other predictors such as age and collision-type RTA (pedestrian-motor vehicular accidents) were also found to be significant predictors of TBI outcomes in children.[12,18] There is a predominance of mild and moderate injuries in our population, which is similar to other studies and can be a rationale that severe cases may not survive long enough to reach the hospital. The mortality cases in our study were patients with severe TBI, and this relationship was statistically significant. Similar findings were also seen in another study.[16]

Limitations

The limitations of this study on pediatric TBI in South-Western Nigeria can be related to the study design as the study was conducted in a single institution, which might limit the generalizability of the findings to other regions or institutions with different demographics or healthcare infrastructure. The lack of insurance coverage and financial constraints also impacted the overall outcome due to restricted access to healthcare interventions and diagnostics. In addition, our sample size is relatively small, which reduces the statistical power.

Conclusion

The prevalence rate of pediatric traumatic brain injury (TBI) at LUTH is 0.03%. Mortality following moderate-to-severe pediatric TBI in developing countries remains high, with poor outcomes in severe cases. Poverty significantly impacts the prognosis of pediatric TBI as timely investigations and interventions are major determinants of the outcome. Over 90% of patients faced delays as a result of financial constraints. Expanding health insurance coverage to include more pediatric patients is essential most especially in relation to trauma management. Additionally, establishing dedicated ICUs in various regions to meet the critical care needs of pediatric trauma patients is necessary.

Conflicts of interest

We declare no conflict of interest.

Authors Contribution

Credit: Conceptualization: OAO; Data curation: JO, OGA; Formal Analysis: JO, CA; Funding acquisition: ; Investigation: JO, OAO, OGA, BA, OS; Methodology: JO, OAO, OGA, BA, OS; Project administration: JO, OAO; Resources: JO, OGA, BA, OS; Software: CA; Supervision: OAO; Validation: JO; Visualization: JO, OAO, OGA, BA, OS; Writing – original draft: JO, OAO, OGA, BA, OS, CA; Writing – review & editing: JO, OAO, OGA, BA, OS, CA.

Ethical Policy and Institutional Review Board Statement

All procedures performed in study involving human participants were in accordance with the ethical standards of the institutional review board of the Lagos University Teaching Hospital and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Patient Declaration of Consent

All participants in this study provided informed consent prior to their inclusion. They were informed about the purpose of the study, their voluntary participation, and the confidentiality of their responses. No identifying personal information has been published, and no images or other personally revealing materials are included in this manuscript. Participants were assured that their data would be anonymized and used solely for research purposes.

Data Availability Statement

Available on demand.

Funding Statement

Nil.