Predictors of post-concussion syndrome in children following a traumatic brain injury

Problem

Traumatic brain injury (TBI) is a leading cause of death and disability in people under 40 in the UK. Following a TBI, some people develop post-concussion syndrome (PCS), which includes somatic, cognitive, psychological, and/or behavioural symptoms that can continue for several months. While most recover over time, a proportion of cases experience long term symptoms. It is likely that early recognition and targeted interventions speed recovery and reduce persistence of symptoms in the longer term. To target interventions for children who are at higher risk of developing PCS, it is important to know who the risk groups are. We aimed to identify predictors of PCS in children, following any medically attended TBI event.

Approach

Using linked Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) data we identified patients aged 1-17 years with a medically attended TBI event. Our primary outcome was a binary indicator of PCS or suspected PCS, measured using either a clinical code for PCS or medical attendances for one or more PCS symptom 3-12 months after a TBI. Patient descriptives (age, gender, area-level deprivation and ethnicity) and potential clinical predictors of PCS (headaches, learning disabilities, ADHD, anxiety, depression and sleep disorders preceding TBI) were derived from CPRD and HES data. We included all potential predictors in a multivariable logistic regression model.

Findings

We identified 137,873 children with TBI between 2013-17 from CPRD and HES data and 4,620 (3.4%) children with PCS or suspected PCS. More female TBI patients (3.8%) had PCS, compared with males (3.1%). Those with PCS were, on average, older at the time of TBI compared with those without PCS (7.8 vs 6.5 years). In a fully adjusted model, older age (odds ratio [OR]=1.02 per year increase in age, 95% confidence interval [CI] 1.01-1.03), female gender (OR=1.20, 95% CI 1.13-1.28), being Asian (OR=1.37, 95% CI 1.22-1.54) or mixed ethnicity (OR=1.18, 95% CI 1.01-1.37) (compared with white ethnicity), and having a history of headaches (OR=3.52, 95% CI 3.13-3.95), learning disabilities (OR=2.06, 95% CI 1.69-2.52), ADHD (OR=2.41, 95% CI 1.91-3.04), anxiety (OR=2.58, 95% CI 2.18-3.05), depression (OR=4.00, 95% CI 3.28-4.89) and sleep disorders (OR=2.35, 95% CI 1.99-2.78) were all associated with increased odds of PCS.

Consequences

These results may be used to identify patients who are more likely to develop PCS following a TBI and patients who may benefit from targeted health care for any PCS symptom. Identifying cases of PCS in primary care data was a challenge as perhaps many children do not attend services for suspected PCS, or, if they did, are not diagnosed with PCS and no record is made. Furthermore, the clinical predictors are a measure of healthcare access for these symptoms, thus results could be influenced heavily by patients’ health seeking behaviour.