Guiding children through traumatic brain injuries

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‘When will my child eat and talk again?’—is a question no parent wants to ask but is one that Associate Professor Angela Morgan frequently hears when she’s treating children suffering from traumatic brain injury (TBI).

TBI—often due to car accidents, sporting incidents or falls—is a significant cause of disability in Australian children. Affecting up to 2,000 children per 100 000 each year, it often results in speech, language and swallowing disorders.

Professor Morgan is Lead of the Neuroscience of Speech research group at Murdoch Childrens Research Institute (MCRI) and Head of Speech Pathology at the University of Melbourne. She is also one of the guideline developers for MCRI’s first Clinical practice guideline for the management of communication and swallowing disorders following paediatric traumatic brain injury for children 0 to 18 years of age (communication and swallowing guideline).

This NHMRC-approved guideline provides clinical recommendations based on the best available evidence to ensure children with communication and swallowing disorders following moderate or severe TBI can receive the highest quality care. Professor Morgan was able to use her two decades of experience in looking after TBI victims to drive the guideline development.

‘There was literally one article that had six case studies in it from 1999 and no further evidence,’ she said.

‘That’s what made me really want to do a PhD and track individuals after moderate and severe brain injury. Now 20 years on this guideline has tackled how they recover their eating and speaking abilities over time in that first year.’

The guideline consists of 30 recommendations to be used by health professionals who are involved in the management of communication and swallowing disorders in the first year following paediatric TBI. 

‘The recommendations aim to optimise children’s outcomes and ensure equality of care,’ Professor Morgan said.

What are guidelines?

Guidelines are sets of non-mandatory rules, principles or recommendations for procedures or practices in a particular field. In clinical practice, they are evidence-based statements that include recommendations to optimise patient care and assist in shared decision making.

MCRI communication and swallowing guideline

The communication and swallowing guideline was developed by a multidisciplinary committee led by MCRI and underwent public consultation and independent expert review as part of the NHMRC third party guideline approval process. The expert working committee—from across the country—are now embedding the guideline into their practices.

‘We also solicited people from key rehabilitation centres and  sent out personalised letters to other key centres around the nation—for example, Brain Injury Australia—to improve uptake and support groups and families. We are sending out the guideline to key international partners in the United Kingdom. We also engaged with New Zealand in developing the guideline,’ said Professor Morgan. 

‘There was also really great emphasis in including the carer and the consumer by the NHMRC. That was something a little new to guidelines in my experience which I absolutely celebrated—I definitely think that it is the way to go.’

In about a year’s time Professor Morgan and the committee will approach those individuals again to gauge implementation and use of the guideline, their experience and what could be learnt from the user experience.

What’s next?

Running alongside the guideline development, Professor Morgan’s NHMRC fellowship focused on the use of magnetic resonance imaging techniques as possible predictors for outcome in kids with TBI.

‘We were trying to understand why some of the kids have speech, swallowing and language problems and some of the kids don’t,’ she said.

Using more sophisticated MRI techniques, Professor Morgan’s group were able to really look at the brain white matter pathways—the connections of the brain which are affected in TBI.

‘Due to the acceleration/deceleration forces from say a car accident you get what’s called diffuse axonal injury,’ she said.

Axons are the ‘arms’ of brain cells that allow them to communicate with one another and they can stretch as a result of shear stress caused by head trauma, as one part of the brain moves in relation to another. Between the brain tissue this causes a shearing effect—stretching axons or the ‘arm’ of the neural cells. This occurs particularly in areas of different density—such as between white and grey matter.

‘And it’s all the connections between the pathways that help us speak and swallow that are damaged,’ she explained.

‘We now have techniques using modelling representing neural tracts that can measure those white matter pathways called fibre tractography [3D modelling technique used to visually represent neural tracts].

‘Some of my NHMRC fellowship work examined MRI predictors of outcomes, showing that it’s a particular speech-motor pathway of the brain that leads to these problems…I felt like just studying the symptoms wasn’t getting us far enough.