A brain injury can be devastating – for the person affected, their family and their friends. Brain injuries can affect how a child moves, speaks, thinks, and acts. An acquired brain injury can impact one area, multiple areas or all areas of the brain. Some changes may be temporary. Some may be permanent.

The Paediatric Brain Injury Rehabilitation Team aims to provide assessment, therapy, education and support for children and families throughout their childhood until they leave school.

The brain controls and manages every part of our body. There are many different areas of the brain and each part is responsible for a specific role.

• Frontal lobe – planning, self-control, initiation, attention, and emotion
• Parietal lobe – touch, pain, temperature, reading and writing, attention to detail
• Temporal lobe – hearing, memory, learning, mood, and vision
• Occipital lobe- vision, interpreting shapes, colours
• Cerebellum- balance, speech
• Brain stem- basic life functions, control of movement



An interactive infographic by Open Colleges

Accidents, illnesses and infections can cause damage to the brain and lead to an Acquired Brain Injury. A brain injury occurs after birth and is not related to developmental disability, degenerative disease or congenital disorder.

An Acquired Brain Injury can occur from either a Non-Traumatic Brain Injury or Traumatic Brain Injury.

Traumatic Brain Injury (TBI)

A traumatic head injury most often occurs when there has been an unexpected force on the head/body which causes the brain to move quickly inside the skull. These forces cause the brain to be hit, bruised, stretched, torn, penetrated, bruised or become swollen. These injuries cause bleeding and result in disruption of blood flow/oxygen getting to certain areas of the brain.

Children with a brain injury can also have secondary injuries from further bleeding, increased pressure in the skull and prolonged lack of oxygen to the cells.

Typically, Traumatic Brain Injuries occur from:

• Car accidents
• Motorbike accidents
• Boat and Bike accidents
• Assault
• Falls
• Sporting accidents
• Domestic violence
  

Non-Traumatic Brain Injury

There are several different causes of non-traumatic illnesses/injuries that can lead to an Acquired Brain Injury:

• Infections and diseases
• Meningitis
• Encephalitis
• Brain abscess
• Hydrocephalus
• Brain Tumours and Brain Cancer
• Stoke

Hypoxic Brain Injury

• Near drowning
• Poisoning
• Aneurysm
• Anoxia (any event where the brain does not receive oxygen)
• Hypoxia (any event where there is decreased oxygen to the brain)

For more information, please visit Kids Health Information.

CT

A Computed Tomography (CT) scan is a machine which uses a series of x-rays of the head. CTs are useful for seeing fresh blood after an injury and are often the first scan a doctor will order.

MRI

Magnetic Resonance Imaging (MRI) scans use magnetic fields and have a higher degree of resolution than a CT. MRI’s are better at detecting the remnants of old blood, or damaged but intact nerve tissue. They are often ordered well after the injury has occurred.

Sedation for CT/MRI

For medical scans to be successful they require a patient to be very still. An MRI can take up to 30 minutes for some images. Therefore, younger children and patients who are not able to stay still are required to have their medical imaging done whilst they are anaesthetized.

MRI under sedation requires coordination between the radiology department, anesthetics and your treatment team. Your child or young person will often receive gas via a mask whilst you are cuddling them and will then be looked after by the team until the scan is complete and your child returns to the recovery unit. Once your child begins to wake, you will be called and will be able to be at their bedside.

Intracranial Pressure Monitoring

After a severe traumatic head injury, the pressure inside the skull can increase from increased bleeding or swelling. If swelling/bleeding occurs in the skull, the skull is unable to increase in size and therefore the pressure inside rises.Intracranial pressure (ICP) monitoring can be used in the PICU. Medical teams can measure ICP by placing a small tube through the skull into the fluid-filled part of the brain called the ventricle. This gives the PICU team and Neurosurgical team an exact measurement of ICP and helps them care for your child or young person.

Following traumatic brain injury, it is common to suffer from Post Traumatic Amnesia. This is referred to a PTA.

What is PTA?

PTA is the period of time after a head injury when temporary changes to level of consciousness occur. The child or young person can become temporarily confused, disorientated and have difficulty remembering new information.

How do we measure it?

PTA can be measured for children 7 and older. In the first 24 hours after injury, PTA can be measured using the Abbreviated Western Post Traumatic Amnesia assessment (AWPTAS).

If the AWPTAS test is passed, the patient is cleared of any further testing. Passing this test means the patient has likely experienced a mild Traumatic Brain Injury (mTBI). Also known as concussion. If the patient does not pass their AWPTAS, then formal PTA testing should occur. Formal PTA testing occurs once a day and requires the patient to recall 12 names/objects. A patient must score 12/12 for 3 days in a row to pass this assessment. The test is administered by an Occupational Therapist or Registered Nurse.

Why do we measure it?

The PBIRT team use PTA scores, imaging results, and recovery factors to help understand the severity of injury.

The PTA assessment is needed to apply for motor vehicle insurance schemes. These include CTP insurance or Lifetime Care and Support through iCare. The Lifetime Care and Support Scheme pays for treatment, rehabilitation and care for people who have been severely injured in a motor vehicle accident in NSW. PTA duration is an indicator of the severity of a brain injury.

Children less than 7 years.

For children 6 years of age and younger, it is difficult to test PTA. Therefore, the team will use informal functional assessments and clinical judgement to assess PTA length and therefore severity of the injury.

GCS

The Glasgow Coma Scale (GCS) is the most common scale used to measure the depth and duration of coma/level of consciousness. GCS measures the eye, verbal and motor responses of a patient. Each of these areas are scored (out of 5) and when combined measures the patient’s severity of coma. From deep coma (score of 3) up to fully awake and responsive (score of 15). You can find out more at: https://synapse.org.au/fact-sheet/coma-and-brain-injury/

John Hunter Children's Hospital cares for children and young people who are unwell following their injury or illness. This may be in the Paediatric Intensive Care Unit if they are very unwell. Once your child is ready, they will be transferred to one of the children’s wards and will likely be referred to the Paediatric Brain Injury Rehabilitation Team.

Paediatric Intensive Care Unit (PICU)

The Paediatric Intensive Care Unit provides intensive care services to critically ill, children and young people across Northern NSW. The Paediatric Intensive Care Unit is a dedicated eight-bed unit, consisting of six individual intensive care rooms, along with two isolation rooms.

This highly specialised unit is staffed by paediatric intensivists and nursing staff trained in paediatric intensive care, who deliver services to children and young people with a wide range of medical and surgical conditions and to those who have sustained a major trauma, including brain injury.

Doctors from across the Children’s Hospital, along with Allied Health staff will also contribute to the care of children and young people admitted to the PICU.

Ward J1: Paediatric Surgery/Oncology

J1 cares for up to 19 children and young people aged 0-18 years. J1 cares for children receiving surgical care including ENT, General Surgery, Gastrointestinal Surgery, Urology, Orthopaedics etc. J1 also provides specialist treatment for children and young people with all forms of childhood cancer, including solid tumours and blood cancers.

The ward has 2 four-bedded rooms and 11 single rooms.

Ward H1: Paediatric Medical

H1 is a 24 bed General Medical unit catering for patients aged from birth to 18 years old, requiring care from many different specialties. Specialties include General medicine, Respiratory, Neurology, Endocrine, Gastroenterology, Infectious Diseases and Paediatric Brain Injury Rehabilitation

Ward J2: Adolescent Unit/Day Stay Unit

J2A is a 12-bed ward for young people over the age of 12. Patients receive care from a wide range of surgical and medical conditions. J2A provides a safe and friendly environment for adolescent patients and their families, which is focused on meeting their specialized needs.

If you are a medical professional and wish to make a referral to the Paediatric Brain Injury Team, please confirm your patient’s eligibility below.

Does the child or young person:

• Have a diagnosis of an Acquired Brain Injury which occurred after birth
• Have an identified need for a multidisciplinary assessment of function.
• Be aged 0-16 years.
• New referrals for children aged 16 to <18 years will be reviewed on an individual basis to decide allocation to paediatric or adult services.
• Reside within the Northern Child Health Network
• Require a multidisciplinary assessment, medical and therapeutic interventions (i.e. not a referral for a specific discipline or maintenance therapy)

For health care providers wanting to complete a referral, please CLICK HERE.

For discussion of a specific patient please call John Hunter Children’s Hospital (02) 49213000 and ask to speak with the PBIRT Clinical Nurse Consultant.

When your child is admitted to the hospital they will be under the care of a medical or surgical team. When your child is ready for rehabilitation your team will then refer your child to the Paediatric Brain Injury Rehabilitation Team.

Your child may also remain with their treating team, depending on the level and type of injury. Commonly, these teams may be from the Trauma service, Intensive Care Unit, Surgical Team, Respiratory Team, Orthopaedic Team, Oncology teams etc.

The PBIRT Team provides rehabilitation therapy for your child or young person. The PBIRT team meets with you to discuss progress, set goals for the week and provide discharge planning support. If you have any questions, please speak to one of our team.

Our inpatient team includes health professionals from several disciplines. These include:

• Rehabilitation Doctors
• Speech Therapy
• Occupational Therapy
• Clinical Nurse Consultants
• Social Work
• Physiotherapists
• Child Life Therapy
• School Teachers
• Clinical Psychology
• Art Therapy
• Music Therapy
• Neuropsychology
• Dietician

Following a brain injury, your team will ensure your child is medically stable and ready for rehabilitation. Some of the common issues include:

Pain

Following a head injury, it is common for children to experience some degree of pain. Pain will be assessed and managed throughout their stay in JHCH.

Medications can be extremely helpful for people who have had a brain injury. The amount and type of medication your child is given will depend on the stage of their brain injury, age and pre-existing medical history. During an intensive care unit admission, children are often given many medications. These medications are gradually reduced or stopped as soon as it is safe to do so.

Agitation

In the acute or initial stages of a severe brain injury, children may need to be sedated using medications including anesthetics. Sedation helps to protect the brain from agitation and restlessness. It promotes time for the brain to rest and heal.

During a traumatic brain injury, agitation can raise the pressure inside the skull. Some children require medications /monitoring equipment to control and measure their blood pressure.

Seizures

During the initial stages of a brain injury, seizures can be common. If a child has seizures soon after their brain injury, they may be given anticonvulsants and these medications may be continued for several months. The child may be weaned off the medication after a period of time but only if they have not had any further seizures and have been assessed properly.

Other children take seizure medication in the early days after a brain injury. In some cases this is stopped before the children go home, provided that no seizures have occurred.

It is important for nursing/medical staff to balance pain relief and level of sedation following a brain injury. If a patient requires sedation, this sedation will obviously affect PTA testing. Level of sedation from medication is considered when measuring PTA.

Please discuss any questions or concerns you have with your treating team and/or the PBIRT team.

How to help a child or young person experiencing PTA

Children who are in PTA should be cared for in a safe, quiet and calm environment.

• Where possible a single room will be provided
• Bring in familiar items such as photos, toys and comfort items. If children are sensitive to light, blinds can be shut to allow for rest.
  If you child is not sensitive to light, the blinds can be open and closed to help establish normal sleep/wake cycles.

https://www.rch.org.au/uploadedFiles/Main/Content/trauma-service/PTA%20guideline.pdf

Sleep

Following a brain injury, a child/young person can have a disturbed sleep/wake cycle.

Where possible all cares for your child will be clustered together to encourage undisturbed sleep. This will prevent frequent waking and poor sleep quality.

An example of this would be your bedside nurse conducting neurological observations, nursing observations (temperature/blood pressure/pulse) and other nursing assessments in one block.

Therapy timetables will also include scheduled rest periods throughout the day. Please speak with your rehabilitation team if you have any questions.

Technology and devices

Screen time is over-stimulating for children in PTA and those recovering from a brain injury. If your child is showing signs they are still recovering from an injury then screen time should be limited. Signs can include irritability, moodiness, headache, photophobia (not liking being in bright places) or not being able to concentrate.

Safety

Children who have had a brain injury and are in PTA can be very impulsive and become agitated. In order to keep them safe, 24 hour supervision from family, and at times 1:1 nursing staff may be required.

Our team of staff are trained to identify patients who require extra strategies to keep them safe. Strategies may include lowering the bed, providing extra padding, extra mattresses, extra supervision, more rest time, darkening the room and reducing visitors. These changes can be upsetting for families, and our staff aim to provide you with education and support during this time.

Visitors

Whilst in PTA, visitors should be restricted to prevent your child becoming overwhelmed and fatigued.
We recommend only close relatives to visit your child as noise, people chatting and extra movement in the room will be over-stimulating and will cause fatigue.

As your child/young person is emerging from PTA, your team can speak with you about whether it is appropriate to have social visits with friends/extended family.

The PBIRT team can give you advice on ways to help your visit be more successful for your child. Recommendations sometimes include:

• One person speaking at a time
• Speaking calmly, clearly, and slowly.
• Repeat information if necessary
• Speak in simple developmentally appropriate sentences
• Provide reassurance
• Try to avoid discussions which are confusing or overwhelming

Meeting with the team

HNEkidsRehab meets once a week as a team to discuss your child’s progress and to set goals for the next week of therapy. This is an opportunity to bring questions to the team and to provide the team with information important to your child and family.

Meetings will discuss current progress as well as discharge planning in preparation for your child going home.

Weekly routine and timetable

Structure and routine are important for recovery following a brain injury.

Each week you will receive a timetable of the planned therapy sessions. It will also include time for meals, periods of rest and any other.

When ready, the team will begin rehabilitation therapy, working with you and your child to set functional goals which may include

• Age-appropriate mobility (moving around)
• Eating and drinking, including getting the right nutrition
• Self-care (such as dressing, toileting, showering)
• Psychosocial support provided to the family around issues of grief and loss, adjustment and other arising issues
• Playing and age appropriate leisure activities
• Age appropriate fine motor skills (using hands for activities)
• Assessing and managing muscle and bone complication, including prevention of secondary complications
• Communication (talking and listening)
• Assessing and recommending suitable equipment

Child Life Therapy, music therapy and art therapy can also engage with children/young people while recovering, these activities will also form part of your child’s timetable for the week.

Where does therapy happen?

Therapy sessions can happen at the bedside, in the hallways, in the fairy garden or predominately in the Allied Health Department. Your therapy sessions will be tailored by our team based on your child’s goals and current medical condition.

Accommodation and Visiting

Bedside accommodation and options

For PICU, J2A, H1 and J2: One adult can stay overnight next to your child’s bed.

For families who live more than 100km from the hospital, our team can help source accommodation close to John Hunter Children’s Hospital. This may include Ronald McDonald House or the John Hunter Hospital Cottages

Visiting hours
Parents are welcome 24 hours per day.
Rest time is 1-3pm and 8pm-10am.

Family and visitors are an important part of recovery following a brain injury. However, fatigue from seeing too many people is common and therefore we encourage parents and carers to monitor their child for signs they need rest.

We also recommend Sunday to be filled with rest breaks as we notice if patients have had lots of visitors over the weekend, they often are too exhausted for therapy sessions on Monday.

School

The John Hunter Hospital School is an educational facility for students from Kindergarten to Year 12 who are admitted to John Hunter Children's Hospital.

The school operates as part of a multidisciplinary team which may include parents and other family members, medical staff including social workers, physiotherapists, occupational therapists and/or play, music and therapists.