Pediatric Brain Injury
Injury patterns by age
Mechanism tracks with development: abusive head trauma in infants (rotational acceleration causing diffuse axonal injury, retinal hemorrhage, rib fractures), falls in toddlers, pedestrian and bicycle trauma in school-age children, and motor vehicle crashes and sport in adolescents. Focal contusions (frontal and temporal poles) and diffuse axonal injury often coexist. The rehabilitation team's most powerful lever is secondary injury prevention - avoiding hypoxia, hypotension, hyperthermia, and uncontrolled seizures from the ICU onward.
Recovery trajectory and prognosis
Gross motor recovery concentrates in the first 6 to 12 months, but cognitive and behavioral deficits frequently surface later as academic and social demands rise. Early neuropsychological testing can therefore underestimate need; repeat testing before school re-entry. Duration of post-traumatic amnesia and early Glasgow Coma Scale help but do not determine outcome. Do not reflexively pick "greater plasticity means better outcome" - younger age protects focal language function but worsens diffuse cognitive outcome in many studies.
Traps
Seizure prophylaxis reduces early (within 7 days) seizures but does not prevent late post-traumatic epilepsy. Feeding, vision, hearing, and endocrine (pituitary) screening are commonly missed. In infants, a new scalp bump weeks after a known fracture suggests a growing skull fracture (leptomeningeal cyst) and needs imaging. Heterotopic ossification and spasticity may appear months after the injury.
Worked rule of thumb
Concussion: return to learn precedes return to play, each step requires at least 24 symptom-free hours, and symptom recurrence sends the child back one step. Spasticity timing: if tone blocks emerging function, start with focal chemodenervation plus therapy before considering intrathecal baclofen.