Children and concussions, what about their pituitary?

If I were to talk to Justin Trudeau one of our elected members of parliament in opposition, here’s some of the points I would emphasize since his mandate is Youth. According to some random web site information the Progressive Conservative government may test the public’s acceptance to reduce federal spending into Health Care to force provinces to make up the difference. Children are especially vulnerable to traumatic brain injury, the information I am getting is from a very recent review paper in the journal Pituitary first published online November 5 2011 by Susan R.  Rose and Bethany A . Able from the Cincinnati Children’s Hospital Medical Center.l

Here are a couple of pictures of a pituitary from Gray’s Anatomy;

The amazing thing  about the pituitary is it’s the size of a pea.The structure is right near the midbrain, right at the center of things in the brain stem. According to the authors, acute endocrine changes are commonly found after traumatic brain injury (TBI) in pediatric patients, both temporary and permanent changes have been found. the age group most affected are in the teens 15-17 years, followed by ages 0-4, with males affected more than females. Every hormonal axis can be affected by TBI in children, although growth hormone deficiency and alterations in puberty are the most common findings. What these authors admit is that there is a range of damage to traumatic brain injury. Their observations center on the extreme end of injury, moderate to severe forces into the head. What about the milder forces like concussions? To this date little is known about mild forces acting onto the head, like mild brain concussions. There is also very little medical literature analyzing endocrine function in children. So if you show up with your child who has suffered a concussion at a local children’s hospital, they do not know any endocrine parameters unless it’s a really serious injury, then it’s most likely intensive care as treatment. But what seems to become worrisome is that pituitary dysfunction in children is common after TBI so perhaps it should be worrisome for concussions too?

Currently if your concussed child is taken to either St-Justine or the Children’s Hospital in Montreal no work up for endocrine status is available  let alone tested.  If the children’s pititary-adrenal axis is compromised in the concussion, there should be stimulation testing of the adrenal-pituitary axis approximately one month after the concussion incident. For TBI, steroids having mineralcorticoid and glucocorticoid effects can be given which have to be tapered off since treatments are short term, usually for one month. Again for concussions there is no assessment and no treatment. As if to make comparisons scary, in adults, abnormalities in pituitary function occur in23-69% of studied adults, one year after TBI. So shouldn’t we be concerned about children with concussions being checked to be also evaluated for at least pituitary function? There are no existing statistics to go from for children with concussions who may have compromised their normal pituitary function.

Does that mean that puberty is changed with concussed children? I would say depending on the force of deceleration, probably. Yet the current advice is go home and rest. According to the authors many of the endocrine abnormalities found in the first few months after TBI resolve by one year. But that means the system, the neuroendocrine system is off, dysregulated for one entire year. So despite this the endocrine deficiencies can be transient or worse, becoming permanent. For concussions nothing is checked so nothing is known.The issue is here these are children that are expected to grow to progress normally through puberty development. Yet TBI in multiple case reports show children suffering from precocious puberty, accelerated in effect, or delay or failure to progress in puberty, with explicit growth hormone deficiency. Pituitary dysfunctuion may go unrecognized and untreated in children after TBI despite the integral nature of the pituitary’s critical function in growth and development. It seems that at least we should be evaluating endocrine puberty criteria with concussed children now instead of just waiting while they heal? That’s what you should mention to Justin Trudeau, in terms of what needs to be established for concussed youth at risk.

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Montreal Grandmother, Agnes Kent was saved by Raul Wallenberg from certain death, when he provided papers for her and her Mom to escape away from the Nazis. Today when asked what that escape meant, she replied,"Remind people, that while statesmen and whole countries remained silent and did nothing, a single individual chose to act, with ramifications that proved enormous. Similar choices confront us today. Write that simple truth she said, it can never be repeated often enough because the world keeps forgetting it."
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