TRAUMA

ANZJSurg.com

Epidemiology of traumatic head injury from a major paediatric trauma

centre in New South Wales, Australia

Jeevaka E. Amaranath,* Mahesh Ramanan,† Jessica Reagh,* Eilen Saekang,* Narayan Prasad,*
Raymond Chaseling† and Sannappa Soundappan‡
*Douglas Cohen Department of Paediatric Surgery, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
†Department of Neurosurgery, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia and
‡Douglas Cohen Department of Paediatric Surgery and Trauma, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia

Key words Abstract

epidemiology, paediatric, traumatic head injury.
Correspondence
Dr Jeevaka E. Amaranath, Unit 7/9-27 Park Avenue,
Sydney, NSW 2047, Australia.
Email: jamaranath@optusnet.com.au
J. E. Amaranath MBBS; M. Ramanan MBBS;
J. Reagh MBBS; E. Saekang MBBS; N. Prasad MBBS;
R. Chaseling FRACS; S. Soundappan FRACS.
Accepted for publication 7 October 2013.
doi: 10.1111/ans.12445
Background: Traumatic brain injury (TBI) is common and is a leading cause of
presentations to emergency departments. Understanding the epidemiology of TBI can
aid in improving overall management and identifying opportunities for prevention.
Currently, there is a paucity of data on paediatric TBI in NSW. The purpose of this
study was to determine the demographics, causes, treatment and outcome of TBI at
The Children’s Hospital at Westmead (CHW), a large trauma referral paediatric
hospital.
Methods: A retrospective chart review was conducted of patients admitted to CHW
emergency from 2006 to 2011 with a TBI. Patients who presented to the emergency
department and had a history of TBI with either symptoms of concussion and/or
positive computed tomography (CT) findings of head injury were selected. Informa-
tion regarding demographics, injury pattern, CT findings, treatment and outcome were
retrieved.
Results: Over the 6-year period, there were 1489 presentations at the CHW. Of these,
65% were male and 35% were female. The mean age was 7 years. A total of 93% were
classified as mild, 1.5% as moderate and 5.5% as severe. Sports and recreational
injuries accounted for 26% of all TBI presentations, while motor vehicle accidents
(MVAs) accounted for 77% of all TBI deaths. Sixty-two per cent of children under-
went a CT brain, and of those, 40% were normal.
Conclusion: The majority of TBI are mild in nature, with younger children and males
at greatest risk. There was a low rate of operative intervention and a high rate of good
outcomes. Many injuries may be preventable with the adaptation of better public
health education programmes, particularly in very young children and those related to
MVAs.

Introduction Department of Health Emergency showed that head injuries consti-

Traumatic brain injury (TBI) is common1 and is one of the leading causes
of presentations to hospital emergency departments.2,3 The reported
incidence of paediatric TBI hospital admissions in the USA is 70 per
100 000 population.1 It is one of the major causes of mortality and
morbidity related to childhood trauma,4 and is associated with significant
personal, financial and social consequences. Further, a large proportion
of childhood TBI occurs due to preventable causes, such as falls, motor
vehicle accidents (MVAs) and sports injuries.5
The incidence of paediatric TBI in New South Wales (NSW) has
not recently been formally reported; however, data from the NSW
tuted 7% of all paediatric presentations to NSW emergency depart-
ments from July 2008 to July 2009.6 This places considerable
demands on health services, families and the wider community.
Epidemiological data enable the identification of those groups at
greatest risk, explore causative factors and analyse variables that
may predict outcome. The information is then useful in developing
preventative strategies and plan for necessary health services. There
have been no population-based studies to date in NSW, Australia,
that have reviewed the epidemiology of paediatric TBI.
The Children’s Hospital at Westmead (CHW) is a paediatric
trauma hospital servicing a population of 2.02 million people,7 with

ANZ J Surg 84 (2014) 424–428 © 2014 Royal Australasian College of Surgeons

Epidemiology of traumatic head injury 425

approximately 50 000 hospital presentations annually.8 We describe
the demographics, causes, radiological findings, treatment, prognos-
tic factors and outcomes of TBI at CHW to inform the planning and
delivery of health-care services and public health interventions. We
received approval from the Sydney Children’s Hospitals Network
Human Research Ethics Committee prior to commencement of this
study.
Methods
We conducted a retrospective chart review of patients aged 0–16
years that were admitted to CHW emergency from January 2006 to
December 2011 with a TBI. Patients who presented to the emer-
gency department or were transferred directly to the intensive care
unit and had a history of TBI with either symptoms of concussion9
and/or positive computed tomography (CT) findings of head injury
were selected. We took into account that the definition of concussion
varies with the age of the child. For infants, subtle symptoms, such
as listlessness, irritability and change in eating or sleeping patterns,10
were included. Whereas for older children, a wider range of symp-
toms, including headache, amnesia, confusion, dizziness, fatigue,
slurred speech, inattentiveness, sensitivity to light and noise, disor-
ders of taste and smell, and co-ordination deficits, were used to
define concussion.11 Patients who had trivial head trauma without
symptoms of concussion and without a CT scan were excluded.
Positive CT findings included skull fracture, extradural haematoma
(EDH), subdural haematoma (SDH), subarachnoid haematoma, cer-
ebral contusion and brain oedema. We extracted data on the age,
gender, mechanism of injury, Glasgow coma score (GCS), CT
findings, surgery and outcome using a computerized hospital
medical record database (Cerner Millennium Powerchart Version
2009.06.1.6). We searched the database for TBI cases using Inter-
national Classification of Diseases 10th revision (ICD-10) codes. We
between proportions, and t-test was used without assuming equal
variances for differences between means.
Results
There were 1489 presentations with head injury meeting the inclu-
sion criteria over the 6-year period from 2006 to 2011. The total
number of children was 1441; 1396 with a single presentation, 42
children with two presentations and 3 children with three presenta-
tions. The data collection was complete. Of the presentations, 973
(65%) were male and 516 (35%) female. The mean age overall was
7.0 years, while the mean age for males was 7.9 and females was 5.3
(Fig. 1). A total of 28% of presentations were transfers from other
hospitals. Of the 422 (28%) patients that were transferred, 11% went
onto have an operation. The highest number of presentations was
observed in the 0–1 year age group.
As demonstrated in Figure 1, there was a strong trend towards
increased proportion of boys above the age of 5. Of those under the
age of 5, 54% were boys, compared with 74% among children aged
5 and above. This difference of 20% (95% CI: 16–25%) in the
proportion of boys between the two groups was highly statistically
significant (χ2 = 67.71, df = 3, P < 0.001).
The distribution of TBI severity is displayed in Table 1. A total of
1384 (93%) presentations were classified as mild TBI, 23 (1.5%)
moderate and 82 (5.5%) severe. Most presentations (98.7%) resulted
in a good recovery (GOS 4 and 5). The mortality rate was 0.87% (13
120
100
80
Frequency

then assessed these cases for potential inclusion. 60

Severity of TBI was classified into mild (GCS 13–15), moderate

(GCS 9–12) and severe (GCS 3–8) based on established criteria.12,13 40

Patient outcomes were measured using the Glasgow outcome scale

20
(GOS)14,15 based on the level of recovery and disability recorded in
the medical record at latest follow-up. Standard practice at our
0
institution is to follow-up all patients admitted with TBI at 6–12 <1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 and
above
weeks after discharge, and then subsequently as indicated. However, Age (years)

it is likely that some patients with mild TBI who were admitted to
the Emergency Department but not the Neurosurgery ward would Fig. 1. Age and gender distribution of all paediatric traumatic brain inju-
ries. ( ) males; ( ) females.
have been discharged with general practitioner follow-up. For these
patients, the outcome was recorded at hospital discharge. GOS 4 and
5 were classified as a good outcome, and GOS 1–3 as poor outcome. Table 1 Distribution of severity of TBI and GOS
We entered data into Microsoft Excel and used the Excel ToolPak
Severity Mild Moderate Severe
for basic data analysis including summary statistics and the genera- GOS GCS 13–15 GCS 9–12 GCS 3–8
tion of tables. We used Statistical Analysis Software 9.1 to generate
1 0 1 12
univariate and multivariate logistic regression models to test the
2 0 0 1
effect of various factors on mortality and GOS. We used odds ratios 3 0 0 4
(OR) as the measure of association between these factors and out- 4 7 2 22
5 1377 20 43
comes for categorical variables. We used P < 0.05 as threshold of
significance and calculated 95% confidence intervals (CI) for the GCS, Glasgow coma score; GOS, Glasgow outcome scale; TBI, traumatic
brain injury.
OR. The chi-squared statistic was calculated to test for differences

© 2014 Royal Australasian College of Surgeons

426 Amaranath et al.

Table 2 Distribution of GOS by severity of TBI and mechanism

GOS 1 2–3 4 5 Total

Severity† Moderate Severe Moderate Severe Moderate Severe Moderate Severe
n 1 12 0 5 2 22 20 43 105

Mechanism
Sports/Recreation 0 0 0 0 0 4 6 7 17 (16%)
Fall 0 2 0 3 1 3 6 11 26 (24%)
MVA/MBA 1 9 0 2 1 14 5 20 52 (51%)
Assault 0 1 0 0 0 1 2 5 9 (8%)
Other 0 0 0 0 0 0 1 0 1 (1%)

†Moderate = GCS 9–12 at presentation, severe = GCS 3–8 at presentation. GCS, Glasgow coma score; GOS, Glasgow outcome scale; MBA, motor bike accident;
MVA, motor vehicle accident; TBI, traumatic brain injury.

60
Multiple Lesions
50 8.5%

40 Contusion
Frequency

Not Done
38% 11.8%
Fracture
30 45.1%
Abnormal
37%
20
EDH
Normal 19%
10 25%
SAH
0 SDH 3.9%
<6 6 7 8 9 10 11 12 13 14 15 and 11.8%
above
Age (years)
Fig. 3. Findings on computed tomography scanning.
Fig. 2. Age and gender distribution of sporting/recreational injuries. ( )
males; ( ) females.

chymal intracranial pressure monitor (ICPM), 48% had craniotomy

out of 1489). There was one death from the moderate TBI group, and
the rest were from the severe group. Among survivors, very few
(0.3%) had severe disabilities (GOS 2–3).
Table 2 shows the distribution of moderate and severe TBI by
mechanism of injury. Moderate and severe head injuries accounted
for 7% of TBI and all TBI deaths. MVA caused 9.3% (138 out of
1489) of all TBI. Forty-nine per cent of moderate and severe TBI (52
out of 105) were caused by MVA. MVAs were also the major cause
of TBI mortality (77%).
Sports/recreational injuries accounted for 26% (389) of TBI pres-
entations (Fig. 2). They accounted for 16% of all moderate and
severe TBI. The mean age at presentation for sports/recreational
injuries compared with all other mechanisms was significantly
higher for both males (mean age 11.7 years versus 6.0 years, t =
21.79, df = 842, P < 0.001) and females (mean age 9.9 years versus
4.6 years, t = 10.03, df = 91, P < 0.001) and overall (mean age 11.4
years versus 5.4 years, t = 26.4, df = 847, P < 0.001). Most sports/
recreational injuries occurred in males (82%).
Further, 62% of children had a CT brain. Of the patients that had
imaging, 40% had a normal CT brain and 60% had CT abnormalities
consistent with acute TBI. Of those that had an abnormal CT, 45.1%
had a fracture, 19% EDH, 11.8% SDH, 11.8% contusion, 3.9%
traumatic subarachnoid haemorrhage and 8.5% multiple lesions.
These breakdowns are shown in Figure 3.
Ninty-seven patients required surgical intervention. Of these, 30%
underwent placement of external ventricular drain (EVD) or paren-
± EVD or ICPM and 22% required elevation of depressed skull
fracture.
The mortality rate was low at 13 (0.87%). Univariate regression
analysis revealed that GCS, TBI severity, intracranial haematoma,
being intubated, unreactive pupil and MVA were all significantly
associated with mortality (P < 0.001 for all these factors). However,
the multivariate logistic regression model showed that only severe
TBI (OR = 596.25, 95% CI: 59.14 to >999.99, P < 0.001) and
unreactive pupils (OR = 158.09, 95% CI: 15.48 to >999.99, P <
0.001) remained significant predictors of mortality after adjustment
for other variables.
Discussion
We found that TBI was most frequent among children under the age
of 1 and more frequent in males in every age group. The age distri-
butions were also fundamentally different among the sexes, with
males having a bimodal distribution (peaks at 0–1 and 14–15) and
females a positively skewed distribution (peak at 0–1 and long,
right-sided tail). This is mainly due to the increased number of sports
injuries in teenage males. It is likely that the second peak for males
is higher than presented here because many older children (age 15
and above) are treated at adult hospitals. These findings are consist-
ent with previous Australian and international epidemiological study
findings.12,16 However, even though the vast majority of these were
mild in severity, most were related to falls at home. A better under-
standing of the high risk at this age group through continual parental

© 2014 Royal Australasian College of Surgeons

Epidemiology of traumatic head injury
education-based programmes may reduce the number of admissions
seen through emergency.17 This can have a positive impact on both
families and hospitals, by reducing the emotional and financial cost
of unwanted imaging and the workload on the emergency depart-
ment.
The use of CT imaging in TBI raises some issues due to the
attendant radiation exposure and subsequent risks. The increased
lifetime risk of developing cancer following radiation exposure is
not insignificant18,19 and needs to factored into any decision-making
algorithm for the use of CT in children. In our cohort, 62% of
children had a CT brain, and of those patients, 40% had normal CT
brain findings. Furthermore, the majority of these patients that went
on to have a CT brain had mild head injuries and did not require
surgical intervention. There is potential to reduce this radiation
exposure with more stringent screening of TBI in the emergency
department prior to CT scan. However, intracranial injury may occur
with only few or subtle signs,20 and at the very young age, exami-
nation and clinical findings may be hard to elicit. In addition, it can
be argued that a liberal use of CT scanning can prevent morbidity
and mortality caused by unrecognized TBI. The current evidence to
guide doctors on what constitutes appropriate criteria for obtaining
CT scans in children following TBI still remains controversial.
However, large multi-centre studies such as those published by
Oman et al.,21 along with others, will lay a foundation of evidence
and help devise criteria to guide clinicians to distinguish children
who are low risk for significant TBI and those that are higher risk
requiring CT imaging.
The analysis of moderate and severe head injuries found that they
accounted for only 7% of the total number of head injuries, but as
expected, were associated with all the TBI deaths.22 MVAs were not
only the most significant factor in the cause for moderate and severe
head injury, but also TBI death. This result is consistent with
other Australian and international paediatric-based studies on head
trauma.23 It continues to reinforce the need for broadly targeted road
safety initiatives, but also identifies the vulnerability children have in
and around motor vehicles. The current Australian public policies
and regulations relating to reduction in speed limits, school zones
and car child restraints are all important measures to help reduce the
severity of TBI, but need continuing reinforcement through educa-
tion and advertising. Education of young and learner drivers
should be a priority for governments for the protection of future
generations.
Sports and recreational injuries were another significant group
within our cohort. More than a quarter of all head injuries occurred
through sports and recreational injuries. As seen from previous
studies, this was predominantly in the adolescent years and domi-
nated by males.12,24 In a study by Crowe et al., in Victoria, it was
shown that Australian Rules Football had a high rate of TBI for
adolescents. Our study was not designed to look at the different
injury patterns among the different sports; however, our results rein-
force that appropriate education and preventative measures need to
be implemented to reduce TBI from sports and recreational injuries.
These steps, along with parental and adolescent public awareness of
the risks of sports and recreational head injuries, especially in the
teenage years, may help reduce the numbers of TBI in this age
group.
© 2014 Royal Australasian College of Surgeons
427
The study had some limitations that need to be considered. Firstly,
this is a hospital-based study and therefore is not representative of
the general population. CHW is the largest paediatric trauma centre
in the state25 and hence probably receives more paediatric TBI than
the other two paediatric hospitals in the state. However, there is still
likely to be a significant number of cases during the study period that
would have presented to other hospitals and hence not included in
our analysis. For true population estimates, TBI data would also
need to be collected from the other two paediatric hospitals in the
state of NSW. Being a retrospective chart review, we were limited to
the information that was available in the charts, with no scope for
collecting additional data. The outcome of some children was
assessed at the time of discharge rather than at any specific follow-
up. However, the patients with moderate and severe TBI, who are
most likely to suffer from adverse sequelae of TBI, are always
followed-up in the Neurosurgery outpatients clinic, and these data
were available for this study. Therefore, we feel it is unlikely that
significant follow-up information, in terms of GOS, would have
been missed in our study. We were, however, unable to comment on
long-term neuropsychological and developmental outcomes, which
are likely to be of significant importance in paediatric TBI. This
represents an opportunity for a prospective, observational study in
the future.
In conclusion, the majority of traumatic brain injuries are mild in
nature, with younger children and males at greatest risk. There is
a low rate of operative intervention12,26 and a high rate of good
outcomes. This study provides a good starting point for the epide-
miology of head injury in NSW and identifies significant opportu-
nities that exist for further studies and public health prevention
programmes.
Acknowledgements
We would like to acknowledge Patricia Manglick for her assistance
in data extraction. We would also like to acknowledge Dr Hasantha
Gunasekera for his assistance in reviewing the manuscript.
References
1. Schneier AJ, Shields BJ, Hostetler SG, Xiang H, Smith GA. Incidence of
pediatric traumatic brain injury and associated hospital resource utiliza-
tion in the United States. Pediatrics 2006; 118: 483–92.
2. Lam WH, Mackersie A. Paediatric head injury: incidence, aetiology and
management. Paediatr. Anaesth. 1999; 9: 377–85.
3. Nolan T, Penny M. Epidemiology of non-intentional injuries in an Aus-
tralian Urban region: results from injury surveillance. J. Paediatr. Child
Health 1992; 28: 27–35.
4. Swaminathan A, Levy P, Legome E. Evaluation and management of
moderate to severe pediatric head trauma. J. Emerg. Med. 2009; 37:
63–8.
5. Debono P, Agius S, Ansari S. Paediatric head injuries – a review. Adv.
Clin. Neurosci. Rehabil. 2011; 10: 30–5.
6. NSW Health. Infants and children: Acute management of Head
Injury. NSW Department of Health, 2010. [Cited 30 Jan 2013.] Available
from URL: http://www0.health.nsw.gov.au/policies/pd/2011/pdf/PD2011
_024.pdf
7. Premier & Cabinet NSW Government. Demographics. 2011. [Cited 20
Oct 2012.] Available from URL: http://www.westernsydney.nsw.gov.au/
about-western-sydney/demographics/
428
8. National Health Performance Authority. Emergency department ser-
vices. Australian Institute of Health and Welfare, 2011. [Cited 20 Apr
2013.] Available from URL: http://www.myhospitals.gov.au/hospital/
the-childrens-hospital-at-westmead/services
9. Ropper A, Gorson K. Concussion. N. Engl. J. Med. 2007; 356: 166–72.
10. Gerber P, Coffman K. Nonaccidental head injury in infants. Childs Nerv.
Syst. 2007; 23: 499–507.
11. AAP, AAFP. Minor head injuries in children. American Academy
of Paediatrics, 2009. [Cited 26 Aug 2013.] Available from URL: http://
pediatrics.aappublications.org/content/104/6/1407.full.pdf+html
12. Crowe L, Babl F, Anderson V, Catroppa C. The epidemiology of pae-
diatric head injuries: data from a referral centre in Victoria, Australia. J.
Paediatr. Child Health 2009; 45: 346–50.
13. Anderson V, Catroppa C, Morse S, Haritrou F, Rosenfeld J. Functional
plasticity or vunerability after early brain injury? Pediatrics 2005; 116:
1374–82.
14. Cooksley D. Paediatric Neurotrauma. In: Cameron P JG, Everitt I, ed.
Textbook of Paediatric Emergency Medicine. Sydney: Churchill
Livingstone; 2006; 245–255.
15. Jennett B, Snoek J, Bond MR, Brooks N. Disability after severe head
injury: observations on the use of Glasgow Outcome Scale. J. Neurol.
Neurosurg. Psychiatry 1981; 44: 285–93.
16. Reid SR, Roesler MS, Gaichas AM, Tsai AK. The epidemiology of
paediatric traumatic brain injury in Minnesota. Arch. Pediatr. Adolesc.
Med. 2001; 155: 784–9.
Amaranath et al.
17. Bass JL, Christoffel KK, Widome M et al. Childhood injury prevention
counseling in primary care settings: a critical review of the literature.
Pediatrics 1993; 92: 544–50.
18. Kleinerman RA. Cancer risks following diagnositic and therapeutic
radiation exposure in children. Radiology 2006; 36: 121–5.
19. Ron E. Cancer risks from medical radiation. Health Phys. 2003; 85:
47–9.
20. Quayle KS, Jaffe DM, Kuppermann N et al. Diagnositc testing for acute
head injury in children: when are head computed tomography and skull
radiographs indicated? Pediatrics 1997; 95: 11.
21. Oman JA, Cooper RJ, Holmes JF et al. Performance of a decision rule to
predict need for computed tomography among children with blunt head
trauma. Pediatrics 2006; 117: 238–46.
22. Mitra B, Cameron P, Butt W. Population-based study of paediatric head
injury. J. Paediatr. Child Health 2007; 43: 154–9.
23. Berney J, Favier J, Froidevaux A. Paediatric head trauma: influence of
age and sex. Childs Nerv. Syst. 1994; 10: 509–16.
24. Tate RL, McDonald S, Lulham JM. Incidence of hospital-treated trau-
matic brain injury in an Australian community. Aust. N. Z. J. Public
Health 1998; 22: 419–23.
25. ITIM. NSWIoTaIM. The NSW Trauma Registry Profile of Serious to
Critical Injuries. 2009. [Cited 20 Apr 2013.] Available from URL: http://
www.itim.nsw.gov.au/wiki/Annual_trauma_registry_reports
26. Thiessen M, Woolridge D. Pediatric minor closed head injury. Pediatr.
Clin. North Am. 2006; 53: 1–26.
© 2014 Royal Australasian College of Surgeons