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The Impact of Traumatic Brain Injury on Neurocognitive Outcomes in Children: a Systematic Review and Meta-Analysis
  1. Mark Sen Liang Goh1,
  2. Dawn Shu Hui Looi2,
  3. Jia Ling Goh3,
  4. Rehena Sultana4,
  5. Sharon Si Min Goh5,
  6. Jan Hau Lee1,6,
  7. Shu-Ling Chong1,5
  1. 1Duke-NUS Medical School, Singapore
  2. 2Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
  3. 3Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  4. 4Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
  5. 5Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
  6. 6Children’s Intensive Care Unit, KK Women's and Children's Hospital, Singapore
  1. Correspondence to Dr Shu-Ling Chong, Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore; chong.shu-ling{at}


Objective To assess the burden of paediatric traumatic brain injury (TBI) on neurocognition via a systematic review and meta-analysis.

Methods Studies that compared neurocognitive outcomes of paediatric patients with TBI and controls were searched using Medline, Embase, PsycINFO and Cochrane Central Register of Controlled Trials, between January 1988 and August 2019. We presented a random-effects model, stratified by TBI severity, time of assessment post injury and age.

Results Of 5919 studies, 41 (patients=3717) and 33 (patients=3118) studies were included for the systematic review and meta-analysis, respectively. Studies mostly measured mild TBI (n=26, patients=2888) at 0–3 months postinjury (n=17, patients=2502). At 0–3 months postinjury, standardised mean differences between TBI and controls for executive function were −0.04 (95% CI −0.14 to 0.07; I2=0.00%), −0.18 (95% CI −0.29 to –0.06; I2=26.1%) and −0.95 (95% CI −1.12 to –0.77; I2=10.1%) for mild, moderate and severe TBI, respectively; a similar effect was demonstrated for learning and memory. Severe TBI had the worst outcomes across all domains and persisted >24 months postinjury. Commonly used domains differed largely from workgroup recommendations. Risk of bias was acceptable for all included studies.

Conclusion A dose-dependent relationship between TBI severity and neurocognitive outcomes was evident in executive function and in learning and memory. Cognitive deficits were present for TBIs of all severity but persisted among children with severe TBI. The heterogeneity of neurocognitive scales makes direct comparison between studies difficult. Future research into lesser explored domains and a more detailed assessment of neurocognitive deficits in young children are required to better understand the true burden of paediatric TBI.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Contributors MSLG and S-LC coordinated the study. MSLG, DSHL and S-LC developed the search strategy and registered the protocol. MSLG, DSHL, JLG, SSMG and S-LC reviewed the studies. MSLG, DSHL, S-LC and JLG extracted data from the studies and conducted risk of bias assessments. RS conducted the statistical analyses. MSLG, RS, JHL and S-LC performed the data interpretation. MSLG drafted the manuscript. S-LC, MSLG, JHL, RS, DSHL, JLG and SSMG helped to revise the manuscript. All authors read and approved the final manuscript.

  • Funding This review is financially supported by the Academic Medicine – Enhancing Training, Healthcare, Outcomes and Standards (ETHOS) Duke-NUS Medical Student Fellowship (AY2019-AY2020). Duke-NUS was not involved in the design of the protocol and analysis plan of the review and will not provide input on the interpretation of the results.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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