Developmental Outcomes and Risk Factors in Traumatic Brain Injury Among Infants and Young Children: A Comparative Study of ASQ-3 and Bayley-III

Developmental Outcomes and Risk Factors in Traumatic Brain Injury Among Infants and Young Children: A Comparative Study of ASQ-3 and Bayley-III"

Batoul M. Abdel Raouf ¹, Shaymaa A. Deif-Allah¹, Walid A. Abdel Ghany²

Esmail K. Abdelaziz ¹, Hani A. Elmikaty³, Marwa Salah¹

¹Pediatric, and neurosurgery² Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt

³Pediatric Department, National Research Center

Corresponding Author:Marwa Salah

Mobile:  01014413948                      Emails: elsherifmarwa@ymail.com

Abstract

Background: Children's traumatic brain injury (TBI) is a serious worldwide health issue. Among people who are not elderly, children ages 0–4 have the highest rate of TBI. These children have chronic neurological conditions that drastically affect their everyday lives and general well-being.

Aim of the study: to identify factors that affect developmental outcomes after TBI and to compare two tools used for assessing these outcomes: the Ages and Stages Questionnaire (ASQ-3) and the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III).

Subjects and methods: A comparative descriptive study was carried out on 85 children and infants who had traumatic brain injury and are recruited from Emergency room, Intensive care units and general clinic of the Children’s Hospital and Surgery Hospital, Ain Shams University, Cairo, Egypt. The study spanned six months, from August 2021 to January 2022, with the sample selected through randomization. The Age and Stage Questionnaire 3rd edition (ASQ-3) was used to measure developmental outcomes twice: once upon hospital discharge and again three months later. Additionally, the second visit was the only time the Bayley scales of infants and toddlers' development III were evaluated. Results were compared and associated between follow-up and discharge.

Results: Better developmental outcomes were indicated by the statistically significant difference between the ASQ-3 at discharge and follow-up, which was greater at follow-up than at discharge (P<0.001 for all elements). At follow-up, a comparison of the Bayley Scale and ASQ-3 revealed no statistically significant difference. This indicates that both tests were similar.

Conclusions: Following TBI, the majority of children continued on their normal developmental path. Prior to referral to the third edition of the Bayley scales of infants' and toddlers' development, Following traumatic brain damage, children can be screened using the ASQ-3. Convulsions, aberrant head CT results, lower GCS, the need for neurosurgical intervention, and hospitalisation were among the factors that negatively impacted development after traumatic brain injury.

Keywords: Traumatic Brain damage, Ages and Stages Questionnaire 3rd Edition.

Introduction:

Traumatic brain injury (TBI) in children is a major global health concern. Incidences of paediatric TBI range from 47 to 280 per 100,000 children, with significant country-to-country variation ⁽¹⁾. Among the non-elderly, children ages 0 to 4 have the highest prevalence of TBI, accounting for almost 300,000 Emergency Department visits, 9,250 hospitalisations, and 760 fatalities every year ⁽²⁾.

As the baby brain is going through a period of fast development, it may be especially vulnerable to injury, making infants and toddlers especially susceptible to the effects of traumatic brain injury. The primary white matter connections are established in term infants at birth, but as they grow into toddlers, the baby brain is actively going through a period of intense fibre myelination, synapse creation ⁽³⁾.

White matter myelination and refinement are associated with improvements in motor, cognitive, and socioemotional functioning. The timing of the injury during a time of fast brain and behavioural development may contribute to the poor outcomes of TBI in early childhood. To raise awareness about appropriate referrals for school-based services and rehabilitation, it is essential to identify times when people are most vulnerable to the effects of traumatic brain injury ⁽⁴⁾. Few studies have evaluated risks and monitored developmental trajectories, despite the high prevalence of TBI in newborns and toddlers. Despite these drawbacks, research indicates that, in comparison to children who are usually developing, infants and preschoolers with moderate-to-severe TBI exhibit long-term deficits in intellectual, academic, adaptive behaviour, social, and certain attentional domains ⁽⁵⁾. The social context, which includes family dynamics, socioeconomic standing, and Positive home environments are linked to better recovery outcomes for older children, and to influence these outcomes ⁽⁶⁾.

Aim of the study: to compare the Ages and Stages Questionnaire (ASQ-3) and the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III), two instruments used to evaluate developmental outcomes following traumatic brain injury (TBI), and to determine the factors that influence these outcomes.

Ethical consideration: 

• Ain Shams University Research Ethics Committee (REC) granted consent for this study under approval number FWA 000017585.
• All enrolled parents and/or carers provided their informed consent prior to the start of the trial.
• Medical record data was gathered and utilised for private, confidential study.
• The parents are free to leave at any moment.
• The study and publication did not present any conflicts of interest.
• There is no sponsorship or financial assistance.

Sample size: the sample size was calculated using the PASS 11 programme, establishing power at 95%, alpha error at 5%, and examining the findings of prior research of (Keenan et al., (2019). ⁽⁷⁾

Inclusion Criteria: Infants and children with traumatic brain injury who were previously developmentally normal and between the ages of 0 and 42 months of both sex will be the subjects to the study.

Exclusion criteria: Children and infants whose parents had any concerns regarding their development prior to the head injury.

Study procedures

This comparative prospective study included 85 children and infants after TBI recruited from Emergency room, Intensive care units and general clinic of the Children’s Hospital and Surgery Hospital, Ain Shams University, Cairo, Egypt, The study spanned six months, from August 2021 to January 2022, with the sample selected through randomization.

All the studied cases were subjected to:

1) Full history taking: including

• Developmental history prior to the head trauma.
• Detailed history of the head trauma.
• Duration of hospital admission.
• Presence or absence of convulsions.

Whether surgical intervention was required during hospital admission.

2) Clinical assessment comprising:

- General assessment (vital signs, anthropometric measurement)

- Pediatric Glasgow Coma scale

- Systemic examination:

Cardiovascular

Chest

Abdominal examination.

Complete neurological examination

3) CT scan of brain.

4) Outcome measures

• Upon discharge: Age and Stages Questionnaire-3 will be done for all the included children which Can be completed by parents or non-trained person in 12-18 minutes. it have five compartment that test: (i) personal social, (ii) gross motor, (iii) fine motor, (iv) problem solving, and (v) communication for children from 2-66 months⁽⁸⁾.
• Follow up Three months later: Age and Stages Questionnaire-3 will be repeated together with Bayley scales for infant and toddler 3rd edition that is a composite score calculated for the cognitive scale, language scales and motor scales ⁽⁹⁾.
• Statistical Analysis: The mean, standard deviations, medians, and interquartile ranges will be used to summarise numerical data. P-values less than 0.005 are deemed significant, and qualitative data will be displayed as counts and percentages. Statistical programme: The statistical programme for social science (SPSS) will be used to conduct the statistical analysis.

Results

Table (1): Demographic data of the studied cases

Table (1) shows there were more boys (63.5%) than girls (36.5%) in the study. The average age was 24 months, with most children between 12 and 34 months old.

Table (2): Clinical and Radiological Findings post Head Trauma

Significant if the P-value is less than 0.05, non-significant if it is greater than 0.05, and highly significant if it is less than 0.01: paired t-test

Table (2):  This table shows that  the most prevalent CT brain finding was extra parenchymal injury, (17.6%) of cases. Regarding hospital admission, 64.7% of cases required inpatient care,. Convulsions were reported in 16.5% of cases., surgical intervention was necessary in 17.6% of cases

Table (3) Comparison between hospital admitted and non admitted patients regarding clinical and CT finding.

P-value > 0.05: Non significant; P-value < 0.05: Significant; P-value < 0.01: Highly significant

*: Chi-square test; •: Independent t-test; ≠: Mann-Whitney test

Table (3) Shows Hospital-admitted patients had significantly lower GCS scores and a higher prevalence of abnormal CT findings, particularly extra parenchymal injuries and combined skull fractures with extra parenchymal injuries were observed exclusively in admitted patients,

Table (4): Comparison between ASQ-3 at discharge and follow up

P-value > 0.05: Non significant; P-value < 0.05: Significant; P-value < 0.01: Highly significant: Paired t-test.

Figure 1: Comparison between ASQ at discharge and follow up

Table (4) and figure (1) shows that there is highly significant improvement in development at follow up regarding ASQ3 scale.

Table (5): Comparison between ASQ-3 and Bayley Scale at follow up:

Table (5) shows that there was insignificant difference between ASQ3 on follow up and Bayely scale regarding problem solving, motor and communication of ASQ3 and its corresponding cognitive, motor and language of Bayely scale respectively in studied cases.

Table (6): Correlation between ASQ-3 follow up scores and its counterpart Bayley Scales:

This table shows that there was positive correlation between ASQ-3 and its counterpart Bayley Scale.

Table (7) comparison regarding Bayley scale at follow-up between negative and positive hospital admission.

P-value > 0.05: Non significant; P-value < 0.05: Significant; P-value < 0.01: Highly significant

• : Independent t-test

Table (7) Regarding cognitive and motor scales, there was significant difference between hospital admitted cases than non-admitted but regarding language scale, there was non-significant difference.

Discussion

In our study, we used the ASQ-3 (Ages and Stages Questionnaires, Third Edition) to assess children's development at hospital discharge and again three months later. We found a significant improvement in ASQ-3 scores at follow-up, suggesting better developmental progress over time.

The original ASQ-3 study, which included over 15,000 North American children, showed that the tool is highly accurate. It has strong specificity and negative predictive value (NPV), meaning that a normal result reliably indicates typical development and reduces the chance of missing children with actual developmental delays⁽¹⁰⁾.

A national study in Canada also supported the ASQ-3's ability to identify children who are not at risk of neurodevelopmental disorders⁽¹¹⁾. Similarly, other research has shown that the ASQ-3 is useful for screening both children who may need further evaluation and those who are developing normally. This makes it a valuable tool for early developmental assessment ⁽¹²⁾.

At the three-month follow-up, we also used the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III), to assess development and compare its results with the ASQ-3. We found a positive correlation between ASQ-3 domains (problem-solving, language, and motor) and the corresponding Bayley-III scales (cognitive, language, and motor). There were no significant differences between the two tools, supporting the ASQ-3 as a useful screening tool before a more detailed Bayley-III assessment.

The ASQ-3 is recommended by NICE guidelines for identifying children at risk of developmental delay before referring them for a Bayley evaluation ⁽¹³⁾. Screening tools like the ASQ-3 are preferred in many settings because they take less time to administer compared to Bayley-III, as noted by Del Rosario et al. ⁽¹⁴⁾ Bayley-III is the gold standard for assessing children aged 1 to 42 months, covering cognitive, language, motor, social-emotional, and adaptive behaviour skills.

Other study found moderate to strong correlations between ASQ-3 communication and Bayley-III language scores, as well as between ASQ-3 personal-social and Bayley-III social-emotional scores. ASQ-3 gross motor and Bayley-III gross motor scores also showed a moderate correlation, while ASQ-3 fine motor and Bayley-III fine motor scores had a weaker correlation. Additionally, the ASQ-3 problem-solving domain had a low correlation with the Bayley-III cognitive scale ⁽¹²⁾.

Our study found that certain factors negatively affected development after traumatic brain injury. Children who were hospitalized, had lower Glasgow Coma Scale (GCS) scores, experienced convulsions, had abnormal head CT scans, or required neurosurgery were at higher risk for delayed development.

A study of 1,438 children with TBI reported that 258 (17.9%) had a GCS of 13 or lower. It also found that 30.3% had abnormal CT scans, and 15.4% experienced serious outcomes such as death, intubation, or neurosurgery ⁽¹⁵⁾. Another study on the same group showed that 7.5% of children under 2 years and 8.2% of those over 2 years required neurosurgery, with significantly lower GCS scores than those who did not need surgery ⁽¹⁶⁾.

Conclusion:

Before being referred to the Bayley scale, infants and children who have experienced traumatic brain injury can be screened using the ASQ-3. Most newborns and toddlers with TBI showed improvements in developmental milestones at follow-up.

Factors that negatively impacts on development after TBI were need for hospital admission, lower GCS, convulsion, abnormal head CT finding and need for neurosurgical intervention.

Recommendations

Before referring children and infants with traumatic brain injury to the third edition of the Bayley Scales of Infant and Toddler Development, we advise using the ASQ-3 as a screening tool. Also recommend to follow up infants and children with TBI especially those with risk factors (hospital admission, low Gcs, CT brain finding) as they at risk for developmental delay.

Limitations:

Relatively small sample size

The study was conducted at a single center, which may limit generalizability.

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