Clinical Aspects of Pediatric Head Injury

Abstract: Traumatic head injury is one of the leading causes to severe morbidity and death among children. Specific and national management guidelines for pediatric head injuries are lacking in Sweden, and management routines are consequently based on adult guidelines or local guidelines. The objectives of this thesis were to investigate the current management of pediatric head injury in Sweden and to explore the possibility of introducing a brain injury marker, protein S100B, for optimizing pediatric head injury management.

Paper I, a survey in 51 Swedish hospitals, shows that the management routines vary from hospital to hospital, especially concerning criteria for computed tomography, admission, and discharge. The children are initially managed by general surgeons and pediatricians, although several other departments are involved after the admission of the child. Less than one third of the hospitals reported the use of a standardized observation scheme. The study concludes the urgent need for standardized and updated routines for pediatric head injury management. Paper II shows that children admitted to a neurosurgical unit after head injury do well. However, pediatric head injury management based solely on adult guidelines, loss of consciousness or amnesia is not reliable, since there is a non-negligible risk of missing a clinically relevant intracranial hematoma.

Before a serum marker can be properly evaluated in clinical trials, there is a need for knowing the reference levels of the marker. Capillary sampling in young children is sometimes easier and less painful and time consuming than venous sampling. In Paper III simultaneous capillary, venous and arterial samples were drawn and compared. The results show that analysis of capillary S100B is possible, but differ from venous concentrations by an average of 0.08 µg/L, while arterial and venous samples can be considered nearly equal. Hence, separate reference levels for capillary and venous S100B are required. Paper IV therefore investigates both capillary and venous reference values for S100B in 465 neurologically healthy children. Pediatric S100B reference levels are age-related and higher than those set for adults (venous S100B: 0.14 µg/L for 3-16 year old vs. 0.10 µg/L for adults), while capillary S100B for 3-16 year old is 0.40 µg/L. These reference levels should be used in the evaluation of future studies.