Predicting how well children will heal from brain injuries is something of a mystery. However, doctors are getting clues from the growing numbers of cases in recent decades.
After reviewing decades of studies on children with neurological trauma, Rob Forsyth, PhD, and Fennela Kirkham, MD, have published research that reveals some of the basic principles associated with treatments and outcomes.
To the extent that the likely outcomes of particular disorders and injuries can be predicted, childhood neurology may develop into more of a mature science.
Part of what makes understanding recovery from brain injuries in children so difficult is that at the same time they are growing and developing. Many of the principles of recovery from central nervous system injuries and trauma in adults are fairly well understood, but children are different due to ongoing development.
Factoring in childhood growth complicates an already murky domain of medical knowledge, but medical science is recognizing the problem and seeking solutions.
Doctors face a complex situation in helping children heal from brain injuries
Doctors confront tremendous variation in how children coping with neurological recovery fare. Children of about the same age with similarly severe head trauma of the same type might show quite different results after treatment.
Medical science has a great deal to learn about how children heal from brain injuries, and why some heal better than others, or more quickly.
Part of the problem with developing more robust basic clinical knowledge is that the numbers of children coping with neurological disabilities have increased in more recent times. Recognizing the patterns of cause and effect from injury to clinical outcome is harder with smaller numbers of patients.
While movement disorders in children classified as having "cerebral palsy" have attracted considerable research over the decades, doctors are still in the process of developing a comprehensive knowledge base from case studies that can be used to predict recovery from brain trauma in children.
When adults suffer from traumatic insults to the central nervous system, such as with a car wreck, there are robust and basically mature medical concepts to guide doctors in diagnosis and treatment. Centuries of case studies support classification and categorization of particular neurological problems and disorders, though some of these are subject to debate.
This is not as obviously the case with children, however.
The brains of children are engaged with growth and dynamic changes based on learning and experience in a different way than those of adults.
Children's lives are marked by a series of developmental milestones that are (hopefully) achieved. Language use, motor skills, general knowledge acquisition, navigating social spaces and situations and other facets of learning define much of what childhood is.
A child who is recovering from a forceful impact to the skull will be not only healing from a medical problem, they are simultaneously already engaged in the ongoing process of growing up. Dr. Forsyth and Dr. Kirkham, writing in the current issue of the Canadian Medical Association Journal, characterize their still-maturing central nervous system as undergoing a "complex interaction between recovery from injury and ongoing development".
Results of childhood brain injuries are hard for clinicians to predict
Physicians, families, and other caregivers confront a wide array of possible clinical outcomes to pediatric neurological disorders. With adults, the very large number of case studies available for review supports predicting clinical outcomes from injury type and severity.
The goal for medical science is to have a set of concepts, tests, measures, and predictive tools available, such that the doctor who knows the type of injury, the severity of it, the child's age, and other basic information.
With adults, neurologists can use medical statistics, reviews of previous studies, and a great many case studies gathered over many decades to help their treatment plans for their patients.
With young persons, the still-developing science of pediatric neurology faces real challenges in helping clinicians. In the past, many severe injuries caused death, but advances in emergency response and critical care have changed the situation. In recent decades, larger numbers of children are surviving quite serious accidents and other medical problems.
Doctors are still establishing some of the foundational tools and concepts that specify how children's recoveries are similar and yet distinct from those of adults.
Over time, the factors that determine how various injuries at different severity levels tend to generate a series of outcomes will be much better understood than today. Forsyth and Kirkham suggest that genes may play a role in the variation of clinical outcomes.
Medical science will have much work to do to learn how genetic, behavioral, and environmental factors affect how children heal.
Can leading edge science and engineering predict outcomes of childhood brain injury?
The gradual emergence of basic principles determining childhood recovery from brain injury may be able to take advantage of new developments in brain imaging. EEG and fMRI systems can be used to map which areas of the brain have suffered damage, how nearby areas may be affected or are compensating, and the overall state of the recovering brain.
The electrical signaling in the outer layers of the brain measured through EEG can be of great value to doctors, as is assessing the metabolic and structural states of the brain. Injured brains show markedly different images, revealing altered signaling and patterns of energy consumption.
Clinicians have used such techniques with adults recovering from neurological problems, and children may increasingly benefit as well.
Clinicians routinely do chemical profiles of adult and child patients, and try to use these data to understand health and disease. Pediatric neurology may be able to use chemical "biomarkers" that predict healing from injury.
The injured brain responds with a flood of chemical signals, and doctors would like to use these to be able to chart a patient's likely course of progress.
Brain imaging and biomarker technologies may be of great value in adult neurology, but Forsyth and Kirkham state their use "has not been validated for children" . There remains a gap between the use of such leading-edge technologies in treating adults with neurological deficits, and children.
As more children recover from accidents and injuries that used to be fatal, clinicians have an opportunity to address these disparities.
Recovery from neurological injury: healing the child, not just the brain
Doctors have made progress in recent decades with helping young people recover motion and movement after accidents and other neurological problems. Pediatric neurology is making important strides in helping children regain the ability to walk, dress oneself, participate in school and other activities.
Learning to perform these everyday functions is important enough in normal development, and can be of critical necessity in recovery contexts.
However, the focus on improving the motor networks of the brain such that the patient can move their limbs again should not distract pediatricians or neurologists from paying close attention to the child's mental and emotional state.
Forsyth and Kirkham caution clinicians by writing that "relatively good motor outcomes may obscure cognitive and behavioral problems, worsening the child’s quality of life and that of his or her family."
A child's brain networks may very well respond better after therapy, and while this is necessary, it is not sufficient. Effective performance on a test of motor function should not obscure the bigger picture of the child's emotional response to the disorder, making good choices, and movement towards life goals. Forsyth and Kirkham's paper emphasizes a more holistic way of thinking about recovery.
Conclusion
Overall the situation is that of a gradually maturing clinical field: the recovery from neurological problems in childhood.
Some principles derived from the better developed field of adult neurological recovery will be the same, others will be specific to children.
Gene studies, brain imaging, and biomarker tests may help predict response to trauma. We can hope to see a robust medicine in the near future where the whole child is treated, not just their brain.
