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Context: Objective and expedient assessments of standing postural control incorporating static and dynamic tasks are necessary for identifying subtle motor deficits and clearing children to return to high-risk activities after concussion. The Revised Physical and Neurological Examination for Subtle Signs (PANESS) gaits and stations tasks evaluate both static and dynamic aspects of postural control. While the PANESS gaits and stations subscale is sensitive to concussion in youth, the benefit of each specific task for this purpose is unknown. Purpose: This study evaluated whether specific PANESS tasks identify postural impairments after youth concussion. Design: Cross-sectional study. Setting: Academicallyaffiliated research laboratory. Participants: Sixty youth, ages 10–17 years, comprised 3 groups: (1) youth symptomatic from concussion (4–14 d postinjury [n = 18]), (2) clinically-recovered youth (27–122 d postinjury [n = 15]), and (3) age- and gender-matched never-concussed controls (n = 27). Main Outcome Measure: PANESS gaits and stations tasks (6 dynamic and 3 static) at the time of the initial research visit. Results: Kruskal–Wallis statistic identified a significant main effect of group on standing on one foot (a 30-s task). Both symptomatic and clinically-recovered youth showed deficits on standing on one foot relative to controls. Conclusions: Single-leg tasks of longer duration may maximize the ability to detect residual postural deficits after concussion and can be readily incorporated in targeted sport rehabilitation protocols.

The Physical and Neurological Examination of Subtle Signs (PANESS) is a brief neuromotor exam designed for use in children. This study examined the inter-rater reliability of PANESS scoring using video review in 23 typically developing youth, aged 10-18 years, who were either never-concussed or evaluated following clinical recovery from concussion. Moderate to excellent inter-rater reliability was identified across PANESS subscores and total score. The strongest inter-rater reliability was observed for the Timed Motor portion of the PANESS (ICCs.90) suggesting that this section in particular may be a strong candidate for video-based scoring or telehealth administration.

BACKGROUND: Survival following pediatric out-of-hospital cardiac arrest (OHCA) has improved over the past 2 decades but data on survivors’ long-term outcomes are limited. We aimed to evaluate long-term outcomes in pediatric OHCA survivors more than one year after cardiac arrest. METHODS: OHCA survivors 1 or worsening from pre-arrest baseline to discharge. FINDINGS: Forty four patients were evaluable. Follow-up occurred at a median of 5.6 years [IQR 4.4, 8.9] post-arrest. Median age at arrest was 5.3 [1.3,12.6] years; median CPR duration was 5 [1.5, 7] minutes. Survivors with unfavorable outcome at discharge had worse FSS Sensory and Motor Function scores and higher rates of rehabilitation service utilization. Parents of survivors with unfavorable outcome reported greater disruption to family functioning. Healthcare utilization and educational support requirements were common among all survivors. CONCLUSIONS: Survivors of pediatric OHCA with unfavorable outcome at discharge have more impaired function multiple years post-arrest. Survivors with favorable outcome may experience impairments and significant healthcare needs not fully captured by the PCPC at hospital discharge.

Purpose: To facilitate precise diagnosis and provide tailored treatment of postural anomalies in the pediatric population, appropriate assessments are essential. In light of the multicomponent structure of postural control, understanding underlying constructs of an assessment is valuable in selecting and interpreting assessments. This study investigates the construct validity of the Gaits and Stations variables in the Revised Physical and Neurological Examination of Subtle Signs, a measure used to evaluate standing postural control in youth with mild neurological deficits. Methods: Data were included from 350 healthy participants ages 10–19 years old. An exploratory factor analysis with varimax rotation was performed. Individual loadings of ≥0.4 were used for factor designation. Results: Three latent factors were identified and labeled, based on evidence, as dynamic stability, movement strategies/coordination, and underlying motor systems—musculoskeletal strength. Conclusions: These brief, easily administered Gaits and Stations measures of the Physical and Neurological Examination of Subtle Signs facilitate evaluation of three constructs of standing postural control relevant to youth with mild neuromotor impairments. This information will potentially assist in clinical practice to identify youth with postural control deficits and establish developmentally appropriate interventions and in research to refine understanding of pathology and the impact on components of postural control.

OBJECTIVES: To investigate functional outcomes and state of consciousness at 1 year and ≥2 years postinjury in children who sustained a traumatic brain injury and were in a disorder of consciousness (DOC), either vegetative state (VS) or minimally conscious state (MCS), upon admission to inpatient rehabilitation. DESIGN: Retrospective chart review. SETTING: Pediatric inpatient rehabilitation unit. PARTICIPANTS: Children aged 2–18 years (N=37) who were admitted to inpatient rehabilitation with admission scores

Neuropsychologists working in a pediatric neurorehabilitation setting provide care for children and adolescents with acquired brain injuries (ABI) and play a vital role on the interdisciplinary treatment team. This role draws on influences from the field of clinical neuropsychology and its pediatric subspecialty, as well as rehabilitation psychology. This combination of specialties is uniquely suited for working with ABI across the continuum of recovery. ABI recovery often involves a changing picture that spans across stages of recovery (e.g., disorders of consciousness, confusional state, acute cognitive impairment), where each stage presents with distinctive characteristics that warrant a specific evidence-based approach. Assessment and intervention are used reciprocally to inform diagnostics, treatment, and academic planning, and to support patient and family adjustment. Neuropsychologists work with the interdisciplinary teams to collect and integrate data related to brain injury recovery and use this data for treatment planning and clinical decision making. These approaches must often be adapted and adjusted in real time as patients recover, demanding a dynamic expertise that is currently not supported through formal training curriculum or practice guidelines. This paper outlines the roles and responsibilities of pediatric rehabilitation neuropsychologists across the stages of ABI recovery with the goal of increasing awareness in order to continue to develop and formalize this role.

Objectives To describe telephone interview completion rates among 12-month cardiac arrest survivors enrolled in the Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital and Out-of-Hospital trials, identify key characteristics of the completed follow-up interviews at both 3- and 12-month postcardiac arrest, and describe strategies implemented to promote follow-up. Setting Centralized telephone follow-up interviews. Design Retrospective report of data collected for Therapeutic Hypothermia after Pediatric Cardiac Arrest trials, and summary of strategies used to maximize follow-up completion. Patients Twelve-month survivors (n = 251) from 39 Therapeutic Hypothermia after Pediatric Cardiac Arrest PICU sites in the United States, Canada, and United Kingdom. Interventions Not applicable. Measurements and main results The 3- and 12-month telephone interviews included completion of the Vineland Adaptive Behavior Scales, Second Edition. Vineland Adaptive Behavior Scales, Second Edition data were available on 96% of 3-month survivors (242/251) and 95% of 12-month survivors (239/251) with no differences in demographics between those with and without completed Vineland Adaptive Behavior Scales, Second Edition. At 12 months, a substantial minority of interviews were completed with caregivers other than parents (10%), after calls attempts were made on 6 or more days (18%), and during evenings/weekends (17%). Strategies included emphasizing the relationship between study teams and participants, ongoing communication between study team members across sites, promoting site engagement during the study's final year, and withholding payment for work associated with the primary outcome until work had been completed. Conclusions It is feasible to use telephone follow-up interviews to successfully collect detailed neurobehavioral outcome about children following pediatric cardiac arrest. Future studies should consider availability of the telephone interviewer to conduct calls at times convenient for families, using a range of respondents, ongoing engagement with site teams, and site payment related to primary outcome completion.

To examine professional stakeholders' perspectives of barriers to behavioral health care (BHC) follow-up and telepsychology after pediatric traumatic brain injury (TBI).Twenty-nine professionals participated in a focus group (FG) or key informant interview (KII) between January and March 2020. Professionals answered questions about facilitators and barriers to BHC follow-up and telepsychology. Given widespread telepsychology implementation since COVID-19, a follow-up survey assessing telehealth perceptions since the pandemic was sent out in December 2020. Nineteen professionals completed the survey.Professionals identified individual (e.g., family factors, insurance coverage/finances, transportation/distance, availability, planning follow-up care) and system-level (e.g., lack of access to BHC providers) barriers to BHC post-injury. Possible solutions, like collaborative follow-up care, were also identified. Generally, clinical professionals have favorable impressions of telepsychology and utilized services as a delivery modality for clinical care. Though telepsychology could reduce barriers to care, professionals also expressed concerns (e.g., technology issues, security/safety) and challenges (e.g., funding, accessibility, training/licensure for clinicians) with implementing telepsychology.Barriers identified highlight the need for context-specific solutions to increase BHC access, with telepsychology generally recognized as a beneficial modality for BHC. Future work should continue to focus on understanding barriers to BHC and potential solutions after pediatric TBI.

Objectives To (1) determine if items on the Cognitive and Linguistic Scale (CALS) follow a Rasch distribution and (2) explore the relationship between Rasch-derived Cognitive Ability Estimates (CAE) and outcome trajectory parameters using a nonlinear mixed effects modeling approach. Design Retrospective study. Setting Pediatric inpatient rehabilitation hospital. Participants 252 children between the ages of 2 and 21 years (median 11.8; interquartile range [IQR] 6.4-15.9) consecutively admitted to an inpatient rehabilitation brain injury unit (2008-2014) for a first inpatient admission following acquired brain injury. Interventions Not applicable. Main outcome measures Rasch-derived CAE from the CALS and associated outcome trajectory parameters. Results The CALS demonstrates adequate interval-scale properties with removal of scores from the arousal and responsivity items. Rasch-derived CAE were associated with age (β =.025, p =.000) such that older age was associated with a faster rate of recovery and more complete ultimate recovery. Slower recovery initiation was associated with a less complete overall cognitive recovery (Spearman ρ= -0.31; p =.000). Conclusions The CAE derived from the CALS and associated outcome parameters (e.g., rate of recovery) may serve as an ideal outcome measure for clinical trials evaluating interventions for acquired brain injury in a pediatric rehabilitation setting.

The COVID-19 pandemic has changed healthcare utilization patterns and clinical practice, including pediatric mTBI evaluation and management. Providers treating pediatric mTBI, including neuropsychologists, have a unique role in evaluating and managing an already complex injury in the context of the COVID-19 pandemic with limited empirically based guidelines. In the present paper, we review usual, evidence-based pediatric mTBI care, highlight changes experienced by healthcare providers since the onset of the pandemic, and provide possible considerations and solutions. Three primary challenges to usual care are discussed, including changes to post-injury evaluation, management, and treatment of persistent symptoms. Changing patterns of healthcare utilization have created unique differences in mTBI identification and evaluation, including shifting injury frequency and mechanism, reluctance to seek healthcare, and increasing access to telemedicine. Typical injury management has been compromised by limited access to usual systems/activities (i.e., school, sports, social/leisure activities). Patients may be at higher risk for prolonged recovery due to pre-injury baseline elevations in acute and chronic stressors and reduced access to rehabilitative services targeting persistent symptoms. Considerations and solutions for addressing each of the three challenges are discussed. Neuropsychologists and other pediatric healthcare providers will need to continue to flexibly adapt to the changing needs of youth recovering from mTBI through the duration of the pandemic and beyond. Consistent with pre-pandemic consensus statements, neuropsychologists remain uniquely qualified to evaluate and manage mTBI and provide an increasingly integral role as members of multidisciplinary teams in the context of the global pandemic.Abbreviations: AAP: American Academy of Pediatrics; CDC: Centers for Disease Control and Prevention; COVID-19: coronavirus disease 19; ED: emergency department; mTBI: Mild traumatic brain injury.

BACKGROUND: Children with traumatic brain injury (TBI) are reported to have persistent deficits in executive functioning and subtle motor functions. AIM: This study examined the relationship between subtle motor signs and executive functioning in children with TBI. METHODS: Eighteen children aged 13-18 years with mild to severe TBI at least one year before study participation and 16 age-matched typically-developing controls were examined using the Revised Physical and Neurological Examination of Subtle Signs (PANESS), a simplified Go/No-go task, portions of the Delis-Kaplan Executive Function System Verbal Fluency and Trail Making tests, and a Wechsler Coding test. RESULTS: There were significant associations between PANESS scores and executive functioning measures in children with TBI but not in controls. CONCLUSION: Results suggest that assessment of subtle motor signs may provide broader information regarding functioning after paediatric TBI.

Objective To describe one-year cognitive and neurologic outcomes among extracorporeal cardiopulmonary resuscitation (ECPR) survivors enrolled in the Therapeutic Hypothermia after Paediatric Cardiac Arrest In-Hospital (THAPCA-IH) trial; and compare outcomes between survivors who received ECPR, later extracorporeal membrane oxygenation (ECMO), or no ECMO. Methods All children recruited to THAPCA-IH were comatose post-arrest. Neurobehavioral function was assessed by caregivers using the Vineland Adaptive Behaviour Scales, 2nd edition (VABS-II) at pre-arrest baseline and 12 months post-arrest. Age-appropriate cognitive performance measures (Mullen Scales of Early Learning or Wechsler Abbreviated Scale of Intelligence) and neurologic examinations were obtained 12 months post-arrest. VABS-II and cognitive performance measures were transformed to standard scores (mean = 100, SD = 15) with higher scores representing better performance. Only children with broadly normal pre-arrest function (VABS-II ≥70) were included in this analysis. Results One-year follow-up was attained for 127 survivors with pre-arrest VABS-II ≥70. Of these, 57 received ECPR, 14 received ECMO later in their course, and 56 did not receive ECMO. VABS-II assessments were completed at 12 months for 55 (96.5%) ECPR survivors, cognitive testing for 44 (77.2%) and neurologic examination for 47 (82.5%). At 12 months, 39 (70.9%) ECPR survivors had VABS-II scores ≥70. On cognitive testing, 24 (54.6%) had scores ≥70, and on neurologic examination, 28 (59.5%) had no/minimal to mild impairment. Cognitive and neurologic score distributions were similar between ECPR, later ECMO and no ECMO groups. Conclusions Many ECPR survivors had favourable outcomes although impairments were common. ECPR survivors had similar outcomes to other survivors who were initially comatose post-arrest.

Background Limited data exist about neurobehavioral outcomes of children treated with open-chest cardiopulmonary resuscitation (CPR). Our objective was to describe neurobehavioral outcomes 1 year after arrest among children who received open-chest CPR during in-hospital cardiac arrest and to explore factors associated with 1-year survival and survival with good neurobehavioral outcome. Methods The study is a secondary analysis of the Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital Trial. Fifty-six children who received open-chest CPR for in-hospital cardiac arrest were included. Neurobehavioral status was assessed using the Vineland Adaptive Behavior Scales, Second Edition (VABS-II) at baseline before arrest and 12 months after arrest. Norms for VABS-II are 100 ± 15 points. Outcomes included 12-month survival, 12-month survival with VABS-II decreased by no more than 15 points from baseline, and 12-month survival with VABS-II of 70 or more points. Results Of 56 children receiving open-chest CPR, 49 (88%) were after cardiac surgery and 43 (77%) were younger than 1 year. Forty-four children (79%) were cannulated for extracorporeal membrane oxygenation (ECMO) during CPR or within 6 hours of return of spontaneous circulation. Thirty-three children (59%) survived to 12 months, 22 (41%) survived to 12 months with VABS-II decreased by no more than 15 points from baseline, and of the children with baseline VABS-II of 70 or more points 23 (51%) survived to 12 months with VABS-II of 70 or more points. On multivariable analyses, use of ECMO, renal replacement therapy, and higher maximum international normalized ratio were independently associated with lower 12-month survival with VABS-II of 70 or more points. Conclusions Approximately one-half of children survived with good neurobehavioral outcome 1 year after open-chest CPR for in-hospital cardiac arrest. Use of ECMO and postarrest renal or hepatic dysfunction may be associated with worse neurobehavioral outcomes.

OBJECTIVE: To systematically examine the safety and effectiveness of transcranial direct current stimulation (tDCS) interventions in pediatric motor disorders. DATA SOURCES: PubMed, EMBASE, Cochrane, CINAHL, Web of Science, and ProQuest databases were searched from inception to August 2018. STUDY SELECTION: tDCS randomized controlled trials (RCTs), observational studies, conference proceedings and dissertations in pediatric motor disorders were included. Two authors independently screened articles based on predefined inclusion criteria. DATA EXTRACTION: Data related to participant demographics, intervention, and outcomes were extracted by two authors. Quality assessment was independently performed by two authors. DATA SYNTHESIS: Twenty-three studies involving a total of 391 participants were included. There was no difference in drop-out rates between active (1/144) and sham (1/144) tDCS groups, risk difference 0.0, 95% CI [−.05, .04]. Across studies, the most common adverse effects in the active group were tingling (17.2%), discomfort (8.02%), itching (6.79%), and skin redness (4%). Across 3 studies in children with cerebral palsy, tDCS significantly improved gait velocity (MD = .23; 95% CI [0.13, 0.34], p < .0005), stride length (MD = 0.10; 95% CI [0.05, 0.15], p< .0005), and cadence (MD = 15.7; 95% CI [9.72, 21.68], p< .0005). Mixed effects were found on balance, upper-extremity function, and overflow movements in dystonia. CONCLUSION: Based on the studies reviewed, tDCS is a safe technique in pediatric motor disorders and may improve some gait measures and involuntary movements. Research to date in pediatric motor disorders shows limited effectiveness in improving balance and upper-extremity function. tDCS may serve as a potential adjunct to pediatric rehabilitation; to better understand if tDCS is beneficial for pediatric motor disorders, more well-designed RCTs are needed.

Consciousness is a state of wakefulness with awareness of self and the environment. Disorder of consciousness (DOC) can result from any type of acquired brain injury (ABI). While children with ABI and DOC are commonly encountered in pediatric rehabilitation settings, research in this population is lacking, necessitating extrapolation from adult literature. Adults and children with DOC who participate in specialized inpatient rehabilitation programs show functional gains during and following the inpatient admission. Here, we present a model for an interdisciplinary rehabilitation program for children with DOC along with data supporting the evaluation and management approaches, where available. Careful, interdisciplinary assessment using appropriate tools as well as a range of pharmacologic and non-pharmacologic interventions supports the rehabilitation and recovery of children with DOC. Additional research focused on children with DOC will be crucial for enhancing the evidence related to this population.

AIM: Although recent out-of-hospital cardiac arrest (CA) trials found no benefits of hypothermia versus normothermia targeted temperature management, preclinical models suggest earlier timing of hypothermia improves neuroprotective efficacy. This study investigated whether shorter time to goal temperature was associated with better one-year outcomes in the Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital Trial METHODS: Patients were classified by tertiles of time to attain assigned goal temperature range (32–34°C or 36–37.5°C) following ROSC. Outcomes in the first tertile (“earlier”) Group 1 were compared with second and third tertiles (“later”) Group 2. Separate analyses were, additionally, completed for hypothermia and normothermia intervention groups. Three one-year outcomes were examined: survival; Vineland Adaptive Behavior Scale (VABS-II) score ≥70; and decrease in VABS-II ≤15 points from baseline. RESULTS: In the entire cohort (n=281), median time from ROSC to goal temperature was 7.4 [IQR 6.2–9.7] hours: Group 1, 5.8 [IQR 5.2, 6.2] and Group 2, 8.8 [IQR 7.4, 10.4] hours. Outcomes did not differ between these groups. For hypothermia subgroup, survival was lower in Group 1 than 2, [10/49(20%) versus 47/99(47%), p

The aim of the study was to characterize subtle motor signs in children with moderate-severe traumatic brain injury in the chronic phase of injury.Fourteen children with moderate (n = 6) or severe (n = 8) traumatic brain injury, ages 11-18 yrs, who had sustained their injury at least 1-yr before study participation (range 1-14 yrs since injury), and 14 matched typically developing controls were examined using the Physical and Neurological Examination of Subtle Signs (PANESS). To examine the neural correlates of subtle motor signs, measures of total cerebral volume and motor/premotor volume were derived from magnetic resonance imaging.Children with traumatic brain injury had significantly poorer PANESS performance than controls on the total timed subscore, proximal overflow, and the PANESS total score. Participants with severe traumatic brain injury had greater proximal overflow than those with moderate injury, after controlling for age at injury. Across all participants, greater proximal overflow correlated with reduced total cerebral volume, whereas within the traumatic brain injury group, reduced motor/premotor volume correlated with lower PANESS total score.The study highlights the importance of examining subtle motor signs including overflow during clinical evaluation of chronic pediatric traumatic brain injury and establishes the clinical utility of the PANESS as a measure sensitive to chronic subtle motor signs in this population.Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Define subtle motor signs including motor overflow; (2) Identify subtle motor signs such as motor overflow during clinical evaluation of children with brain injury; and (3) Explain the relevance of examining subtle motor signs in chronic pediatric brain injury during clinical evaluations.Advanced.The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Background Separate trials to evaluate therapeutic hypothermia after paediatric cardiac arrest for out-of-hospital and in-hospital settings reported no statistically significant differences in survival with favourable neurobehavioral outcome or safety compared to therapeutic normothermia. However, larger sample sizes might detect smaller clinical effects. Our aim was to pool data from identically conducted trials to approximately double the sample size of the individual trials yielding greater statistical power to compare outcomes. Methods Combine individual patient data from two clinical trials set in forty-one paediatric intensive care units in USA, Canada and UK. Children aged at least 48 h up to 18 years old, who remained comatose after resuscitation, were randomized within 6 h of return of circulation to hypothermia or normothermia (target 33.0 °C or 36.8 °C). The primary outcome, survival 12 months post-arrest with Vineland Adaptive Behaviour Scales, Second Edition (VABS-II) score at least 70 (scored from 20 to 160, higher scores reflecting better function, population mean = 100, SD = 15), was evaluated among patients with pre-arrest scores ≥70. Results 624 patients were randomized. Among 517 with pre-arrest VABS-II scores ≥70, the primary outcome did not significantly differ between hypothermia and normothermia groups (28% [75/271] and 26% [63/246], respectively; relative risk, 1.08; 95% confidence interval [CI], 0.81 to 1.42; p = 0.61). Among 602 evaluable patients, the change in VABS-II score from baseline to 12 months did not differ significantly between groups (p = 0.20), nor did, proportion of cases with declines no more than 15 points or improvement from baseline [22% (hypothermia) and 21% (normothermia)]. One-year survival did not differ significantly between hypothermia and normothermia groups (44% [138/317] and 38% [113/ 297], respectively; relative risk, 1.15; 95% CI, 0.95 to 1.38; p = 0.15). Incidences of blood-product use, infection, and serious cardiac arrhythmia adverse events, and 28-day mortality, did not differ between groups. Conclusions Analysis of combined data from two paediatric cardiac arrest targeted temperature management trials including both in-hospital and out-of-hospital cases revealed that hypothermia, as compared with normothermia, did not confer a significant benefit in survival with favourable functional outcome at one year.

Objective To examine whether children with brain tumors treated with resection benefit from inpatient rehabilitation and to explore what factors present at admission may predict better functional outcomes. Design Retrospective cohort design. Setting Pediatric inpatient rehabilitation unit. Participants Forty patients (N=40; ages 3-21y; 42.5% female) admitted to the rehabilitation unit between 2003 and 2015 after brain tumor resection. Interventions Patients received multidisciplinary rehabilitation therapies as part of their admission to inpatient rehabilitation, including occupational, physical, and speech-language therapy. Main Outcome Measures Functional outcomes included the FIM for Children (WeeFIM) at discharge and 3-month follow-up as well as WeeFIM efficiency. Results A repeated-measures analysis of variance using patient WeeFIM Developmental Functional Quotients (DFQs) at admission, discharge, and 3-month follow-up showed significant gains in total WeeFIM DFQ scores across time. Admission WeeFIM DFQ, time from surgery to admission, and age at admission provided the strongest model for predicting discharge and 3-month follow-up WeeFIM DFQ scores. Admission WeeFIM DFQ and time from surgery to admission provided the strongest model for predicting WeeFIM efficiency. Total Neurological Predictor Scale (NPS) at admission did not add predictive power to any of the 3 models over and above patient characteristics (admission WeeFIM DFQ, age at admission, time from surgery to admission). Conclusions Patients admitted to inpatient rehabilitation after brain tumor resection made significant functional gains (as measured by the WeeFIM) during inpatient rehabilitation and continued to make significant gains 3 months after discharge. Age and timing of admission provided the strongest models for predicting patient outcomes. The NPS did not predict functional outcomes after rehabilitation when controlling for other variables known to influence rehabilitation outcomes.

Aim Determine 1) frequency and risk factors for acute kidney injury (AKI) after in-hospital cardiac arrest (IHCA) in the Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital (THAPCA-IH) trial and associated outcomes; 2) impact of temperature management on post-IHCA AKI. Methods Secondary analysis of THAPCA-IH; a randomized controlled multi-national trial at 37 children’s hospitals. Eligibility Serum creatinine (Cr) within 24 h of randomization. Outcomes Prevalence of severe AKI defined by Stage 2 or 3 Kidney Disease Improving Global Outcomes Cr criteria. 12-month survival with favorable neurobehavioral outcome. Analyses stratified by entire cohort and cardiac subgroup. Risk factors and outcomes compared among cohorts with and without severe AKI. Results Subject randomization: 159 to hypothermia, 154 to normothermia. Overall, 80% (249) developed AKI (any stage), and 66% (207) developed severe AKI. Cardiac patients (204, 65%) were more likely to develop severe AKI (72% vs 56%,p = 0.006). Preexisting cardiac or renal conditions, baseline lactate, vasoactive support, and systolic blood pressure were associated with severe AKI. Comparing hypothermia versus normothermia, there were no differences in severe AKI rate (63% vs 70%,p = 0.23), peak Cr, time to peak Cr, or freedom from mortality or severe AKI (p = 0.14). Severe AKI was associated with decreased hospital survival (48% vs 65%,p = 0.006) and decreased 12-month survival with favorable neurobehavioral outcome (30% vs 53%,p Conclusion Severe post-IHCA AKI occurred frequently especially in those with preexisting cardiac or renal conditions and peri-arrest hemodynamic instability. Severe AKI was associated with decreased survival with favorable neurobehavioral outcome. Hypothermia did not decrease incidence of severe AKI post-IHCA.

OBJECTIVES: More children are surviving critical illness but are at risk of residual or new health conditions. An evidence-informed and stakeholder-recommended core outcome set is lacking for pediatric critical care outcomes. Our objective was to create a multinational, multistakeholder-recommended pediatric critical care core outcome set for inclusion in clinical and research programs. DESIGN: A two-round modified Delphi electronic survey was conducted with 333 invited research, clinical, and family/advocate stakeholders. Stakeholders completing the first round were invited to participate in the second. Outcomes scoring greater than 69% "critical" and less than 15% "not important" advanced to round 2 with write-in outcomes considered. The Steering Committee held a virtual consensus conference to determine the final components. SETTING: Multinational survey. PATIENTS: Stakeholder participants from six continents representing clinicians, researchers, and family/advocates. MEASUREMENTS AND MAIN RESULTS: Overall response rates were 75% and 82% for each round. Participants voted on seven Global Domains and 45 Specific Outcomes in round 1, and six Global Domains and 30 Specific Outcomes in round 2. Using overall (three stakeholder groups combined) results, consensus was defined as outcomes scoring greater than 90% "critical" and less than 15% "not important" and were included in the final PICU core outcome set: four Global Domains (Cognitive, Emotional, Physical, and Overall Health) and four Specific Outcomes (Child Health-Related Quality of Life, Pain, Survival, and Communication). Families (n = 21) suggested additional critically important outcomes that did not meet consensus, which were included in the PICU core outcome set-extended. CONCLUSIONS: The PICU core outcome set and PICU core outcome set-extended are multistakeholder-recommended resources for clinical and research programs that seek to improve outcomes for children with critical illness and their families.

Studies of pediatric cardiac arrest use inconsistent outcomes, including return of spontaneous circulation and short-term survival, and basic assessments of functional and neurological status. In 2018, the International Liaison Committee on Resuscitation sponsored the COSCA initiative (Core Outcome Set After Cardiac Arrest) to improve consistency in reported outcomes of clinical trials of adult cardiac arrest survivors and supported this P-COSCA initiative (Pediatric COSCA). The P-COSCA Steering Committee generated a list of potential survival, life impact, and economic impact outcomes and assessment time points that were prioritized by a multidisciplinary group of healthcare providers, researchers, and parents/caregivers of children who survived cardiac arrest. Then expert panel discussions achieved consensus on the core outcomes, the methods to measure those core outcomes, and the timing of the measurements. The P-COSCA includes assessment of survival, brain function, cognitive function, physical function, and basic daily life skills. Survival and brain function are assessed at discharge or 30 days (or both if possible) and between 6 and 12 months after arrest. Cognitive function, physical function, and basic daily life skills are assessed between 6 and 12 months after cardiac arrest. Because many children have prearrest comorbidities, the P-COSCA also includes documentation of baseline (ie, prearrest) brain function and calculation of changes after cardiac arrest. Supplementary outcomes of survival, brain function, cognitive function, physical function, and basic daily life skills are assessed at 3 months and beyond 1 year after cardiac arrest if resources are available.

Objective: To describe the challenges related to COVID-19 affecting pediatric neuropsychologists practicing in inpatient brain injury rehabilitation settings, and offer solutions focused on face-to-face care and telehealth.Methods: A group of pediatric neuropsychologists from 12 pediatric rehabilitation units in North America and 2 in South America have met regularly since COVID-19 stay-at-home orders were initiated in many parts of the world. This group discussed challenges to clinical care and collaboratively problem-solvedsolutions.Results: Three primary challenges to usual care were identified, these include difficulty providing 1) neurobehavioral and cognitive assessments; 2) psychoeducation for caregivers and rapport building; and 3) return to academic instruction and home. Solutions during the pandemic for the first two areas focus on the varying service provision models that include 1) face-to-face care with personal protective equipment (PPE) and social distancing and 2) provision of care via remote methods, with a focus on telehealth. During the pandemic,neuropsychologists generally combine components of both the face-to-face and remote care models. Solutions to the final challenge focus on issues specific to returning to academic instruction and home after an inpatient stay.Conclusions: By considering components of in-person and telehealth models of patient care during the pandemic, neuropsychologists successfully serve patients within the rehabilitation setting, as well as the patient's family who may be limited in their ability to be physically present due to childcare, illness, work-related demands, or hospital restrictions.

This study examined the relationship between postconcussive symptom domain and school attendance. Retrospective chart review was completed for 88 children aged 6 to 18 years who were evaluated within 30 days postinjury. Hierarchical multiple regression was used to assess the association of physical, cognitive, emotional, and sleep symptoms with extent of school attendance. A subgroup multiple regression analysis was conducted to evaluate whether age affected the relationship of symptoms to school attendance. After controlling for demographic variables and total number of symptoms, a higher number of postconcussive sleep symptoms strongly predicted less school attendance. Specifically, older children (≥14 years old) with more sleep symptoms demonstrated less school attendance. For children presenting for specialty care after concussion, sleep symptoms are unfavorably associated with return to school. Future work aimed at optimizing sleep regulation following concussion may assist with early reengagement in school as recommended by current concussion management guidelines.

IMPORTANCE: Many children with return of spontaneous circulation (ROSC) following cardiac arrest (CA) experience acute kidney injury (AKI). The impact of therapeutic hypothermia on the epidemiology of post-CA AKI in children has not been fully investigated. OBJECTIVE: The study aims were to: 1) describe the prevalence of severe AKI in comatose children following out-of-hospital CA (OHCA), 2) identify risk factors for severe AKI, 3) evaluate the impact of therapeutic hypothermia on the prevalence of severe AKI, and 4) evaluate the association of severe AKI with survival and functional outcomes. DESIGN: A post hoc secondary analysis of data from the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital (THAPCA-OH) trial. SETTING: Thirty-six pediatric intensive care units in the United States and Canada. PARTICIPANTS: Of 282 eligible subjects with an initial creatinine obtained within 24 hours of randomization, 148 were randomized to therapeutic hypothermia and 134 were randomized to therapeutic normothermia. MAIN OUTCOMES AND MEASURES: Primary outcome was prevalence of severe AKI, as defined by stage 2 and 3 Kidney Disease Improving Global Outcomes (KDIGO) consensus definition; secondary outcome was survival with a favorable neurobehavioral outcome. For this study, risk factors and outcomes were compared between those with/without severe AKI. RESULTS: Of the 282 subjects enrolled, 180 (64%) developed AKI of which 117 (41% of all enrolled) developed severe AKI. Multivariable modeling found younger age, longer duration of chest compressions, higher lactate level at time of temperature intervention and higher number of vasoactive agents through day 1 of intervention associated with severe AKI. There was no difference in severe AKI between therapeutic hypothermia (39.9%) and therapeutic normothermia (43.3%) groups (p=0.629). Survival was lower in those with severe AKI at 28 days (21% vs no severe AKI 49%, p

Purpose Preschool-aged children have a high rate of traumatic brain injuries (TBI). Anecdotally, caregivers of young children describe symptoms not typically associated with TBI. The objective of this study was to preliminarily describe symptoms reported following TBI in an outpatient sample of preschool-aged children. Methods Retrospective chart review was completed of the first specialty clinic visit by 28 children ages 3 through 5 years with TBI (32% mild, 50% moderate, 18% severe) to identify post-injury symptoms elicited by caregiver interview including querying of symptoms listed on the Acute Concussion Evaluation (ACE) plus an open-ended request to describe any other symptoms. Results Visits occurred on average 38 days post-injury. Caregivers endorsed typical post-concussive symptoms, with headache being most common. In addition, caregivers described other symptoms not captured by the ACE which were grouped into the following categories: Appetite Changes, Behavioral Dysregulation, Decreased Engagement, Disrupted Sleep, Enuresis, Increased Dependence, and Stomachaches. Conclusions Caregivers of preschool-aged children with TBI endorse that young children experience many typical post-concussive symptoms but also a range of other symptoms which may not be typically associated with TBI. Additional work is needed to determine whether specialized evaluation tools and educational materials may be useful for this age group.

AIM: Children who remain comatose after in-hospital cardiac arrest (IH-CA) resuscitation are at risk for poor neurological outcome. We report results of detailed neurobehavioural testing in paediatric IH-CA survivors, initially comatose after return of circulation, and enrolled in THAPCA-IH, a clinical trial that evaluated two targeted temperature management interventions (hypothermia, 33.0°C or normothermia, 36.8°C; NCT00880087). METHODS: Children, aged 2 days to

Background Current concussion evidence is derived largely from teenagers and adults. Concussion in younger children occurs within the context of neuromaturation, with differing age-based pathophysiological responses to injury. Therefore, our current understanding of concussion in older children and adults is unlikely to directly apply to younger children. Objective To describe patient variables, clinical course, and factors associated with time to discharge from concussion care in children 6-12 years of age with concussion treated in an interdisciplinary rehabilitation-based concussion clinic. Design Retrospective chart review. Setting Interdisciplinary concussion clinic at an academically affiliated rehabilitation center. Patients Children aged 6-12 years (n = 105; mean 10.8 years of age, 70% male) seen within 60 days of concussive injury. Main Outcome Measurements Descriptive statistics explored demographic, injury, and clinical features. The primary outcome measure, time to discharge from concussion care, was estimated with survival-analysis methods based on the date of discharge from the clinic. Multivariate models were used to examine factors associated with longer time to discharge. Results Median time to discharge was 34 days postinjury (range 5-192 days); 75% of children were discharged within 60 days of injury. A minority reported persisting symptoms at discharge. Younger age and increased symptom burden at initial evaluation predicted longer time to discharge. Conclusions Although children 6-12 years old treated in a specialty concussion clinic show variability in time to discharge from concussion care, most were discharged within 2 months after injury. Risk factors for prolonged recovery, such as younger age and greater symptom burden at initial visit, can be used when counseling families and planning interventions. There may be varying contributions, including psychosocial stressors, to ongoing symptoms in children who experience persisting symptoms after other concussion-related concerns have resolved. Future work focused on the subset of children who report persisting symptoms will be useful for developing an evidence base related to their care. Level of Evidence II

To explore the safety and efficacy of targeted temperature management amongst infants with out-of-hospital cardiac arrest due to an apparent life threatening event (ALTE) recruited to the Therapeutic Hypothermia after Paediatric Cardiac Arrest Out-of-Hospital trial.Fifty-four infants (48h to1year of age) with ALTE who received chest compressions for ≥2min, were comatose, and required mechanical ventilation after return of circulation were included. Infants were randomised to therapeutic hypothermia (33°C) (n=26) or therapeutic normothermia (36.8°C) (n=28) within six hours of return of circulation. Outcomes included 12-month survival with Vineland Adaptive Behaviour Scales, Second Edition (VABS-II) score ≥70, 12-month survival, change in VABS-II score from pre-arrest to 12 months post-arrest, and select safety measures.Amongst infants with pre-arrest VABS-II ≥70 (n=52), there was no difference in 12-month survival with VABS-II ≥70 between therapeutic hypothermia and therapeutic normothermia groups (2/25 (8.0%) vs. 1/27 (3.7%); relative risk 2.16; 95% confidence interval 0.21-22.38, p=0.60). Amongst all evaluable infants (n=53), the change in VABS-II score from pre-arrest to 12 months post-arrest did not differ (p=0.078) between therapeutic hypothermia and therapeutic normothermia groups, nor did 12-month survival (5/26 (19.2%) vs. 1/27 (3.7%); relative risk 5.19; 95% confidence interval 0.65-41.50, p=0.10).Mortality was high amongst infants that were comatose after out-of-hospital cardiac arrest due to ALTE in both therapeutic hypothermia and therapeutic normothermia treated groups. Functional status was markedly reduced among survivors. (ClinicalTrials.gov, NCT00878644).

To investigate relationships between cardiac arrest characteristics and survival and neurobehavioral outcome among children recruited to the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial.Secondary analysis of Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial data.Thirty-six PICUs in the United States and Canada.All children (n = 295) had chest compressions for greater than or equal to 2 minutes, were comatose, and required mechanical ventilation after return of circulation.Neurobehavioral function was assessed using the Vineland Adaptive Behavior Scales, Second Edition at baseline (reflecting prearrest status) and 12 months postarrest. U.S. norms for Vineland Adaptive Behavior Scales, Second Edition scores are 100 (mean) ± 15 (SD). Higher scores indicate better functioning. Outcomes included 12-month survival and 12-month survival with Vineland Adaptive Behavior Scales, Second Edition greater than or equal to 70.Cardiac etiology of arrest, initial arrest rhythm of ventricular fibrillation/tachycardia, shorter duration of chest compressions, compressions not required at hospital arrival, fewer epinephrine doses, and witnessed arrest were associated with greater 12-month survival and 12-month survival with Vineland Adaptive Behavior Scales, Second Edition greater than or equal to 70. Weekend arrest was associated with lower 12-month survival. Body habitus was associated with 12-month survival with Vineland Adaptive Behavior Scales, Second Edition greater than or equal to 70; underweight children had better outcomes, and obese children had worse outcomes. On multivariate analysis, acute life threatening event/sudden unexpected infant death, chest compressions more than 30 minutes, and weekend arrest were associated with lower 12-month survival; witnessed arrest was associated with greater 12-month survival. Acute life threatening event/sudden unexpected infant death, other respiratory causes of arrest except drowning, other/unknown causes of arrest, and compressions more than 30 minutes were associated with lower 12-month survival with Vineland Adaptive Behavior Scales, Second Edition greater than or equal to 70.Many factors are associated with survival and neurobehavioral outcome among children who are comatose and require mechanical ventilation after out-of-hospital cardiac arrest. These factors may be useful for identifying children at risk for poor outcomes, and for improving prevention and resuscitation strategies.

This paper updates guidelines for effective treatments of children with specific types of acquired brain injury (ABI) published in 2007 with more recent evidence. A systematic search was conducted for articles published from 2006 to 2017. Full manuscripts describing treatments of children (post-birth to 18) with acquired brain injury were included if study was published in peer-reviewed journals and written in English. Two independent reviewers and a third, if conflicts existed, evaluated the methodological quality of studies with an Individual Study Review Form and a Joanna Briggs Institute (JBI) Critical Appraisal Checklist. Strength of study characteristics was used in development of practice guidelines. Fifty-six peer-reviewed articles, including 27 Class I studies, were included in the final analysis. Established guidelines for writing practice recommendations were used and 22 practice recommendations were written with details of potential treatment limitations. There was strong evidence for family/caregiver-focused interventions, as well as direct interventions to improve attention, memory, executive functioning, and emotional/behavioural functioning. A majority of the practice standards and guidelines provided evidence for the use of technology in delivery of interventions, representing an important trend in the field.

Following concussion, children often experience nonspecific symptoms that overlap with those of other common pediatric conditions, including orthostatic intolerance (OI). The primary goal of this study was to evaluate OI in youth presenting for clinical care for concussion and reporting symptoms frequently observed in OI. Eighty-two of 114 patients aged 10 to 22 years endorsed symptoms based on 8 screening questions, and 24 of those 82 patients met criteria for OI based on an active standing test. No screening question generated clinically useful likelihood ratios for predicting OI. The prevalence of OI in this cohort is considerably higher than estimates in the general pediatric population, suggesting a link between concussion and OI. Future work is needed to evaluate the best method of testing for OI, the natural history of OI symptoms in youth with concussion, and the response to intervention in children with both concussion and OI.

INTRODUCTION: Novel research suggests that children engaging in physical activity during recovery from concussion may recover more rapidly. OBJECTIVE: To determine if level of physical activity at presentation to a rehabilitation-based concussion specialty clinic predicted days from injury to recovery. DESIGN: Retrospective cohort. SETTING: A concussion sub-specialty clinic at an academic institution. PATIENTS: Retrospective review of medical records between September 2015 and February 2017 identified 178 children ages 6–17 years (mean age = 13.7 years; standard deviation [SD] = 2.7 years) who presented within 60 days of concussion and were ultimately deemed recovered and cleared to progress to full return to high-risk activities. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Physical activity at initial visit was classified as none-to-light (79%) versus moderate-to-heavy (21%). A doubly robust, inverse probability of exposure weighted linear regression model was used to examine the relationship between physical activity level and days to recovery, while adjusting for 10 demographic and clinical variables. RESULTS: Children participating in moderate-to-heavy activity at initial evaluation in concussion clinic averaged recovery 21 days quicker (95% confidence interval [CI] −27.1, −15.5, P < .001) than children who were engaging in none-to-light activity. This finding did not change when removing children who were deemed recovered at the first visit (who may have initiated physical activity after becoming asymptomatic). CONCLUSIONS: These data add to growing evidence that progressive physical activity during recovery from concussion does not appear to be harmful. Physical activity represents a modifiable variable in recovery, and physicians can potentially expedite symptomatic recovery by recommending noncontact physical activity as tolerated during concussion recovery.

Objective: To examine the basic psychometric features of a modified version of the Coma Recovery Scale-Revised (CRS-R) for use in young children with disorders of consciousness (DoC).Method: The CRS-R was modified to create the Coma Recovery Scale for Pediatrics (CRS-P) and administered to 33 typically developing children (8-59 months). Total scores, subtest scores, and inter-rater reliability were evaluated. Performance on the two items representing emergence to conscious state (CS) - functional object use (FOU) and functional communication (FC) was examined across the age range.Results: Inter-rater reliability of CRS-P subscale scores was adequate (Kw = .87-1.00). All 4-year-olds, 75% of 3-year-olds, 10% of 2-year-olds, and 0% 12 months and none

IntroductionChildren with disorders of consciousness (DOC) represent the highest end of the acquired brain injury (ABI) severity spectrum for survivors and experience a multitude of functional impairments. Current clinical management in DOC uses behavioural evaluation measures and interventions that fail to (1) describe the physiological consequences of ABI and (2) elicit functional gains. In paediatric DOC, there is a critical need to develop evidence-based interventions to promote recovery of basic responses to improve rehabilitation and aid decision-making for medical teams and caregivers. The purpose of this investigation is to examine the safety, tolerability and feasibility of transcranial direct current stimulation (tDCS) in children with DOC.Methods and analysisThis study is an open-label dose escalation trial evaluating the safety, tolerability and feasibility of tDCS in 10 children (5–17 years) receiving inpatient rehabilitation for DOC. This study will follow a modified rule-based design, allowing for intrapatient escalation, where a cohort of patients will be assigned to an initial tDCS current of 0.5 or 1 mA based on participant’s head circumference and according to the safety data available in other paediatric populations. The subsequent assignment of increased current (1 or 2 mA) according to the prespecified rules will be based on the clinical observation of adverse events in the patients. The study will include up to three, 20 min sessions of anodal tDCS (sham, 0.5 or 1 mA, 1 or 2 mA) applied over the dorsolateral prefrontal cortex. The primary outcomes are adverse events, pain associated with tDCS and intolerable disruption of inpatient care. Secondary outcomes are changes in electroencephalography (EEG) phase-locking and event-related potential components and the Coma Recovery Scale-Revised total score from prestimulation to poststimulation.Ethics and disseminationThe Johns Hopkins IRB (#IRB00174966) approved this study. Trial results will be disseminated through journals and conferences.Registration numberNCT03618849.

Aim Approximately 40% of children who have an in-hospital cardiac arrest (IHCA) in the US survive to discharge. We aimed to evaluate the impact of post-cardiac arrest hypotension during targeted temperature management following IHCA on survival to discharge. Methods This is a secondary analysis of the therapeutic hypothermia after pediatric cardiac arrest in-hospital (THAPCA-IH) trial. “Early hypotension” was defined as a systolic blood pressure less than the fifth percentile for age and sex for patients not treated with extracorporeal membrane oxygenation (ECMO) or a mean arterial pressure less than fifth percentile for age and sex for patients treated with ECMO during the first 6 h of temperature intervention. The primary outcome was survival to hospital discharge. Results Of 299 children, 142 (47%) patients did not receive ECMO and 157 (53%) received ECMO. Forty-two of 142 (29.6%) non-ECMO patients had systolic hypotension. Twenty-three of 157 (14.7%) ECMO patients had mean arterial hypotension. After controlling for confounders of interest, non-ECMO patients who had early systolic hypotension were less likely to survive to hospital discharge (40.5% vs. 72%; adjusted OR [aOR] 0.34; 95%CI, 0.12–0.93). There was no difference in survival to discharge by blood pressure groups for children treated with ECMO (30.4% vs. 49.3%; aOR = 0.60; 95%CI, 0.22–1.63). Conclusions In this secondary analysis of the THAPCA-IH trial, in patients not treated with ECMO, systolic hypotension within 6 h of temperature intervention was associated with lower odds of discharge survival. Blood pressure groups in patients treated with ECMO were not associated with survival to discharge.

OBJECTIVES To describe survival and 3-month and 12-month neurobehavioral outcomes in children with preexisting neurobehavioral impairment enrolled in one of two parallel randomized clinical trials of targeted temperature management. DESIGN Secondary analysis of Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital and Out-of-Hospital trials data. SETTING Forty-one PICUs in the United States, Canada, and United Kingdom. PATIENTS Eighty-four participants (59 in-hospital cardiac arrest and 25 out-of-hospital cardiac arrest), 49 males, 35 females, mean age 4.6 years (SD, 5.36 yr), with precardiac arrest neurobehavioral impairment (Vineland Adaptive Behavior Scales, Second Edition composite score < 70). All required chest compressions for greater than or equal to 2 minutes, were comatose and required mechanical ventilation after return of circulation. INTERVENTIONS Neurobehavioral function was assessed using the Vineland Adaptive Behavior Scales, Second Edition at baseline (reflecting precardiac arrest status), and at 3 and 12 months postcardiac arrest, followed by on-site cognitive evaluation. Vineland Adaptive Behavior Scales, Second Edition norms are 100 (mean) ± 15 (SD); higher scores indicate better function. Analyses evaluated survival, changes in Vineland Adaptive Behavior Scales, Second Edition, and cognitive functioning. MEASUREMENTS AND MAIN RESULTS Twenty-eight of 84 (33%) survived to 12 months (in-hospital cardiac arrest, 19/59 (32%); out-of-hospital cardiac arrest, 9/25 [36%]). In-hospital cardiac arrest (but not out-of-hospital cardiac arrest) survival rate was significantly lower compared with the Therapeutic Hypothermia after Pediatric Cardiac Arrest group without precardiac arrest neurobehavioral impairment. Twenty-five survived with decrease in Vineland Adaptive Behavior Scales, Second Edition less than or equal to 15 (in-hospital cardiac arrest, 18/59 (31%); out-of-hospital cardiac arrest, 7/25 [28%]). At 3-months postcardiac arrest, mean Vineland Adaptive Behavior Scales, Second Edition scores declined significantly (-5; SD, 14; p < 0.05). At 12 months, Vineland Adaptive Behavior Scales, Second Edition declined after out-of-hospital cardiac arrest (-10; SD, 12; p < 0.05), but not in-hospital cardiac arrest (0; SD, 15); 43% (12/28) had unchanged or improved scores. CONCLUSIONS This study demonstrates the feasibility, utility, and challenge of including this population in clinical neuroprotection trials. In children with preexisting neurobehavioral impairment, one-third survived to 12 months and their neurobehavioral outcomes varied broadly.

Disrupted motor performance is increasingly recognized as a critical sequela of concussion which may have relevance for diagnosis and treatment. In 17 adolescents with recent concussion and 20 never-concussed controls, we evaluated the discriminant ability of a commonly used neurocognitive measure compared to a motor subtle sign exam, which evaluates gait, balance, and fine and gross motor control. We found that the motor subtle sign exam had better discriminant ability than the neurocognitive measure, but combining both measures was superior to analyses with individual measures (Wilks’ ƛ = .297, p < .001). This supports that there is an added benefit of evaluating motor control along with neurocognitive capacities after suspected concussion to enhance diagnosis and treatment of injury.

Aims: 1. to investigate diagnostic and prognostic procedures routinely used by international profes- sionals to assess children with disorders of consciousness (DoC); 2. to explore use and availability of internal and national guidelines for pediatric DoC; 3. to identify international differences in diagnostic/ prognostic protocols.Methods: The International Brain Injury Association DoC Special Interest Group emailed a survey link to 43,469 professionals. The survey included questions on diagnostic/prognostic procedures and guidelines for children with DoC.Results: Data on 82 respondents [(50% physicians) primarily from Europe (43.9%)and North America (37.8%)] were analyzed. Common diagnostic tools included the Glasgow Coma Scale for clinical assessment (94%), the Coma Recovery Scale-Revised for outcome measurement (57%), and cerebral MRI (94%). Clinical features used most frequently to inform prognosis varied with patient age. Few respondents used national (28%) admission protocols for children with DoC, and most were unaware of published national guidelines for diagnostic (72%) and prognostic (85%) procedures. Compared to North American respondents, more European respondents were physicians and used neurophysio- logical data for prognosis.Conclusions: This international survey provides useful information about diagnostic and prognostic procedures currently used for children with DoC and highlights the need for guidelines to promote best practices for diagnosis/prognosis in pediatric DoC.