**Table 1.**

#### *Traumatic Brain Injury in Children DOI: http://dx.doi.org/10.5772/intechopen.96010*

*Advancement and New Understanding in Brain Injury*

further confirmation [10].

lobe maturity [1, 14].

aged 0–5 years (44%) and 6–17 years (93%) in Canada [11].

**3. Anatomical and physiological consideration**

to TBI diagnosis and management in children.

prevalence and incidence reported are 2.104 and 0.961 million, respectively. TBI incidence is among the highest compared to other neurological disorders, even with age-adjustment at 285 cases per 100,000 people [9]. Pediatric TBI contributes to a global incident range of 47–280 per 100,000 children [10]. Changes in Coronavirus disease 19 (COVID-19) pandemic circumstances since 2020 seem to affect TBI epidemiology as implied by the significant decrease in mild TBI incident for children

The epidemiological characteristics are also invariably affected by geographical and sociodemographic features. Countries with the lowest and highest incidence are Sweden (12 cases per 100,000) and Australia (486 cases per 100,000). Higher incidence, severity, and mortality in pediatric TBI are observed in rural as opposed to urban areas [12]. Bimodal age distribution with peaks at 0–4 years and 14–18 years with male-gender preponderance in the pediatric population is observed [13]. Meanwhile, the role of race and socioeconomic status requires

The most common injury mechanisms are falls and motor vehicle accidents, although the relative proportions vary by age distribution. The majority of pediatric TBI cases are mild (70–90%), and severe TBI only accounts for 3–7% of all cases. Consistently, the hospitalization rate is 129 per 100,000 in pediatric population and over 90% recover [10, 13, 14]. Nevertheless, 88% of concussions are left undiagnosed and one-third of properly diagnosed cases may experience ongoing sequelae, which would remain undetected until the development reached frontal

Before further consideration on injury mechanisms, it is important to appreciate the evolving anatomy and physiology in every stage of child development and its impact on injury biomechanics (**Table 1**). Note that this difference is also relevant

Children have a relatively higher head-body ratio and, consequently, greater relative head weight as opposed to adults. The large head size increases the possibility of experiencing head trauma, while the weight imposed results in distinct acceleration dynamics when exposed to external forces. Early-stage facial development is characterized by maximum craniofacial ratio, protruding forehead, and less developed paranasal sinuses. These unique properties subject increased likelihood of frontal trauma, especially with lesser capability of the sinuses to absorb

Younger children have thin calvarium rich in bone marrow with fontanels and sutures closing at different times. The pliable skull, along with open sutures and fontanels, allows for deformation and limited intracranial pressure (ICP) buffering. Hence, the existence of fracture should raise clinical suspicion for significant

Cranium Head-body ratio, craniofacial ratio, fontanels and sutures patency, calvarium characteristics

Cervical Relative position of the fulcrum of movement, underdeveloped neck muscles and ligaments,

Brain Underdeveloped myelin sheaths, water content, pulsatility

susceptible articulations

*CSF, cerebrospinal fluid; ICP, intracranial pressure.*

*Age-dependent characteristics in TBI.*

**88**

**Table 1.**

the energy.

underlying parenchymal injury despite lacking evidence on imaging investigation. The downside of high skull plasticity with regards to cortical vessels and brain parenchyma is that it may cause stretching and shearing of these structures in response to the external force.

The craniocervical structures depend mainly on the ligaments and soft tissues for stabilization. Weaker neck muscles and ligaments, upper position of fulcrum of the vertebral body, and flexible articulations in younger children predispose to craniocervical instability particularly when combined with the disproportional head weight. Therefore, a high index of suspicion for concomitant spinal injury has to be maintained until proven otherwise.

Cerebral white matter is less myelinated and contains more water compared to that of adults. Although the nerve fibers are pliable and less likely to rupture, their pliability increases the risk of cerebral contusion and subdural hematoma. The unmyelinated areas are significantly more prone to injury. Cerebral compliance is also affected by other age-dependent factors, such as cerebral blood flow and volume and cerebrospinal fluid (CSF)-brain ratio [13, 15].
