Scoping Review on the Diagnosis, Prognosis, and Treatment of Pediatric Disorders of Consciousness

Abstract

Background and Objectives.Comprehensive guidelines for diagnosis, prognosis, and treatments of disorders of consciousness (DoCs) in pediatric patients have not yet been released. We aim to summarize available evidence for DoCs with >14 days duration, to support the future development of guidelines for children aged 6 months to 18 years.Methods.This scoping review was reported based on PRISMA-ScR guidelines. A systematic search identified records from 4 databases: PubMed, Embase, Cochrane Library, and Web of Science. Abstracts received 3-blind reviews. Corresponding full-text articles rated as “in-scope” and reporting data not published in any other retained article (i.e., no double reporting) were identified and assigned to 5 thematic evaluating teams. Full-text articles were reviewed using a double-blind standardized form. Level of evidence was graded, and summative statements were generated.Results.On November 9, 2022, 2167 documents had been identified; 132 articles were retained, of which 33 (25%) were published over the last 5 years. Overall, 2161 individuals met the inclusion criteria; female patients were 527 of 1554 (33.9%) cases included, whose sex was identifiable. Of 132 articles, 57 (43.2%) were single case reports, and only 5 (3.8%) clinical trials; the level of evidence was prevalently low (80/132; 60.6%). Most studies included neurobehavioral measures (84/127; 66.1%), and neuroimaging (81/127; 63.8%); 59 (46.5%) were mainly related to diagnosis, 56 (44.1%) to prognosis, and 44 (34.6%) to treatment. Most frequently used neurobehavioral tools included the Coma Recovery Scale-Revised, Coma/Near Coma Scale, Level of Cognitive Functioning Assessment Scale and Post-Acute Level of Consciousness scale. Electroencephalography, event related potentials, structural computerized tomography and Magnetic Resonance Imaging were the most frequently used instrumental techniques. In 29/53 (54.7%) cases DoC improvement was observed, which was associated to treatment with amantadine.Discussion.The literature on pediatric DoCs is mainly observational, and clinical details are either inconsistently presented or absent. Conclusions drawn from many studies convey insubstantial evidence, and have limited validity, and low potential for translation in clinical practice. Despite these limitations, our work summarizes the extant literature and constitutes a base for future guidelines related to diagnosis, prognosis and treatment of pediatric DoCs.

Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know

“…301 Serial evaluations using standardized neurobehavioral assessment tools are recommended to reduce misdiagnosis, which is common with a standard clinical exam. [302][303][304] The Coma Recovery Scale-Revised (CRS-R) is the gold standard tool in adults, but it has not been widely validated in pediatrics. 303,305 There is a need for pediatric-specific tools, especially for children younger than 4 years in whom language-based skills are less applicable.…”

“…[302][303][304] The Coma Recovery Scale-Revised (CRS-R) is the gold standard tool in adults, but it has not been widely validated in pediatrics. 303,305 There is a need for pediatric-specific tools, especially for children younger than 4 years in whom language-based skills are less applicable. 303,306 Recent advances have enabled the recognition of states of covert consciousness, including cognitive motor dissociation (CMD), in which task-based fMRI or EEG data detect volitional brain activity in a patient without command following on clinical exam.…”

“…303,305 There is a need for pediatric-specific tools, especially for children younger than 4 years in whom language-based skills are less applicable. 303,306 Recent advances have enabled the recognition of states of covert consciousness, including cognitive motor dissociation (CMD), in which task-based fMRI or EEG data detect volitional brain activity in a patient without command following on clinical exam. Adult studies suggest that the prevalence of CMD may be as high as 15 to 20% of patients with DoC, and its detection has prognostic importance.…”

Common Data Element for Disorders of Consciousness: Recommendations from the Working Group on Therapeutic Interventions

“…In pediatric DoC, the use of pharmacological interventions has been growing over the past few years. Nonetheless, dosage is poorly documented and is highly variable, often weight-based, and prescription hesitancy is observed, especially in patients of preschool age or younger [24]. Only case series are available to appraise the association of Amantadine with timing of awakening; and there is insu cient data published on Zolpidem to assess its utility in pediatric DoC [24].…”

“…Nonetheless, dosage is poorly documented and is highly variable, often weight-based, and prescription hesitancy is observed, especially in patients of preschool age or younger [24]. Only case series are available to appraise the association of Amantadine with timing of awakening; and there is insu cient data published on Zolpidem to assess its utility in pediatric DoC [24]. Beyond these two drugs, for all other pharmacological interventions there only exist, at best, one single case report each.…”