Between January 2020 and December 2022, a total of 3992 children presented to BMC emergency department due to neurological issues. Among them, 302 children had pTBI and were enrolled in the study. Males were the dominant group of 180 (59.6%), whereas 122 (40.4%) were female. The most affected age group was toddlers 125 (41.4%), followed by preschoolers 120 (39.7%), schoolgoing 51 (16.9%) and 11 - 18 years was 2 (7%) and less than 12 months was 4 (1.3%) as shown in Figure 1. In terms of location, urban comprised 132 (43.7%) whereas rural contributed to 170 (56.3%).

In a cohort of children admitted between 2020 and 2022, the incidence of pTBI increased with time: 2020 39/996 (3.92%), 2021 65/1471 (4.42%), and 2022 198/1525 (13%). The overall percentage of children ever treated at BMC due to pTBI for 3 years was 7.56% among 302 children who are less than or equal 18 years old as shown below in Table 1.

Figure 1. Graph showing the frequency of different modes of injury (MOI) per age group.

Table 1. Showing mechanisms of injury, clinical and radiological characteristics.

Road Traffic Accidents (RTAs) contributed to about 178 (58.9%), falls from height were 77 (25.5%), interpersonal attacks were 25 (8.3%), hit by heavy objects were 18 (6%), and animal kicks and assaults contributed a total of 4 (1.4%). Among the RTAs group, pedestrians contributed 87.6% as compared to passengers (12.4%).

Clinically, most patients presented with mild TBI (GCS 13-15) 159 (52.6 %), followed by moderate TBI (GCS 9-12) 94 (31.1 %) and lastly severe TBI (GCS < 9) 49 (16 %). Most children were clinically diagnosed to have intracerebral injury—227 cases, followed by fracture of the skull—53 cases, then diffuse brain injury—13 cases, intracerebral injury—7 cases, subdural hemorrhage—1 case, and concussion—1 case. After the Non-Enhanced Computed Tomography (NECT) scan, the diagnoses changed drastically. (Table 2)

109 patients did not undergo CT scan due to the mild nature of the head injury and these were discharged as outpatients upon review at the emergency. Among the 193 patients who underwent CT scan, findings are shown in Table 1.

Table 2. Showing clinical diagnoses frequency and the age groups affected.

Most of the children were conservatively managed and 31 (10.3%) were treated surgically.

The morbidity due to pTBI contributed to 7.57% of Visits to all emergency and pediatric neurosurgical admissions and had a mortality rate of 3.97%.

Of the 302 children who attended BMC due to pTBI during the first encounter, 142 (47.01%) were normal, 47 (15.56%) had neurological deficits, 5 (1.66%) had milestone regression, 10 (3.31%) children were already dead, and 98 (32.45%) children had missing information about their health status and preservations of their abilities that were already achieved. On one month follow-up of these children, 168 (55.63%) were normal, 29 (9.6%) had neurological deficits, 3 (0.99%) had milestone regression, and 2 (0.66%) children were dead making a total of 12 (3.97%) deaths due to pTBI and 90 (29.8%) had missing information.

Some children’s pTBI was influenced by other comorbid injuries sustained including 72 (24%) children who had skeletal injuries, 36 (12%) children who sustained visceral injuries, 1 (0.3%) child who had polytrauma, and 193 (64%) children who did not succumb to another injury. Table 3 summarizes the treatment outcome findings.

Table 3. Showing summary of treatment outcomes.

In this study, male patients were the majority, a demographic finding consistent with global reports [16][17]. The median age of this cohort was 4.6 years, and two peak age groups were identified 1 - 3 years and 4 - 6 years, a finding similar to earlier CDC reportson pediatric TBI [18]. The most affected age group was children aged between 1 and 3 years of age, possibly attributed to their reduced ability to anticipate the upcoming danger, similar to the findings of the study done in Soweto, South Africa that also picked an increased rate of childhood pTBI and link it to their poor ability to safeguard themselves[19]. In contrast, a study in Northeastern region of Tanga [20] by RTI showed higher rates among adolescents (13 - 17 years) as compared to children < 5 years (21.5 vs. 14.1 per 1000, p = 0.039).

Most children diagnosed with pTBI in this study were from rural areas—170 children (56.3%) as compared to several children from urban areas 132 children (43.7%). This was in contrast to the study in the northeastern Tanzania region of Tanga [20] and findings in Iran [21] where the majority were injured in city areas. This could be related to the fact that children between 13 and 17 years old have an increased curiosity and desire to engage in activities their peers are doing, making them to impulsively engage in risky activities like alcohol and other substance use, predisposing themselves to RTAs and consequently, pediatric Traumatic Brain Injury (pTBI).

Over the three years, we noticed a drastic increase in the incidence of PTBI in resonance with global reports [22]. One possible reason could be due to increase in motorizations, negligence, and poor control of vehicles on the roads [23]. Additionally, the increase could be explained by the improved diagnostics ability both at our institution and nationwide given that all regional hospitals are equipped with CT-scan when compared to the past 5 years, leading to increased early detection, diagnosis, and referrals [24]. Notably, our institution is the only tertiary referral center with cheap neurosurgical-related services within the lake-zone region of Mwanza and plays a potential bias in explaining the three-fold rise in our center amidst other factors.

However, the potential role of the COVID-19 pandemic as a confounding factor that may have influenced access to several health services across the globe [25][26] including disrupting traffic patterns and hospital admission rates during the 2020-2021 period cannot be underestimated.

Similarly, self-referrals following raised awareness for conditions such as concussion, although these figures could be underestimated by home-treated cases of mild TBI who never report to the hospital. However, the relatively low incidence in 2020-2021 could be attributed to underestimated self-referrals for several reasons such as the paucity of concussions due to a lack of uniformly accepted admission guidelines for mild TBI forms such as concussions which tend to be home-treated. Banu et al similarly noted a low incidence in 2000-2021 period in Southern India and this was attributed to the decongestion of roads and regulation of alcohol sales can decrease TBI occurrence [27]. In contrast, a higher incidence of TBI hospitalizations was reported in Rwanda during a similar period [28].

Road traffic accidents were the most common mode of injury 58.9% followed by falls from height 25.5%, a finding in tandem with institutional African pediatric series reported elsewhere in East Africa, West Africa [29] Southern Africa [19]. The increased burden of RTAs could be partly attributed to the economic development which has led to better roads and increased number of vehicles, as reported by the Global status report on road safety [30]. In contrast, Fatma etal. reported falls 63.7% vs 18.3% (RTAs) as the most common cause among 985 PBTI patients in a 5-year single-center study in Lebanon [31]. In this study, pedestrians were 7 times more affected in comparison to passengers and this could be explained by the fact that all children below 18 are not allowed to drive, contrary to findings from a systematic review and meta-analysis by Davies etal. among 15 African countries where they reported a higher mortality rate among passengers in motorized passengers compared to pedestrian [32]. In the East African region, a variety of road transport means exist including motor vehicles, motorcycles, [33] motor tricycles, and bicycles and have reportedly contributed to the burden of RTAs in this region [23]. A study in Dar es Salaam noted that children were injured pedestrians 93% of the time and were more likely to be injured on small, unpaved side streets than adults [34]. Another study conducted among African countries indicated that human-related factors such as over-taking, speed driving, fatigue, reckless driving, drugs, poor-seat belt use, sleeping, drunk driving, cell phone usage while driving among others were responsible for more than three-fourths (¾) of RTAs in Africa [35].

Notably, 36.1% of the patients with PTBI did not do CT scan imaging. Although this figure correlates with the finding that the majority 52.1% of the cohort had mild TBI hence some were clinically cleared for radiological imaging, the reality remains that a certain percentage did not undergo radiological imaging due to financial constraints, a common challenge in our low middle-income setting [36][37]. Perhaps, this resonates with the call for validation of the use of biomarkers in the detection of mild TBI in the clinical setting as a cheaper option, as echoed by Papa and colleagues [38].

In this study, following CT scan imaging, most of the patients had skull fractures 65 (21.6%), followed by extracranial hemorrhage (16.6%), contusion (9.9%), and concussion (8.9%) among others. There was generally a low incidence of diffuse axonal injury and diffuse brain edema contrary to findings by Weber etal. [39]. These findings are in line with a study by Sarkar and colleagues who found that Pediatric patients with TBI were more likely to have skull fractures (OR 3.21, p < 0.01) and epidural hematomas (OR 1.96, p < 0.01). They further mentioned that pediatric TBI was less likely to be associated with contusion, subdural hematoma, subarachnoid hemorrhage, or compression of the basal cisterns (p < 0.05) [40]. They offered to explain that perhaps the differences may be related to anatomical characteristics, the biomechanics of injury, and/or differences in injury mechanisms given the supple nature of pediatric brains, as compared to the adult population.

Furthermore, despite having a small number of patients with diffuse axonal injury in this study (14/193) (7.25%), Magnetic Resonance Imaging (MRI) was barely used for further evaluation mainly due to financial constraints, although its role in early management is arguable as mentioned by Janas and group [41] who found that high grades of DAI on early MRI (at 5 days) was associated with worse 6-month functional outcome and with discharge to inpatient rehabilitation in children with acute mild TBI. However, on further univariate analysis, it did not independently correlate with the outcome when controlling for the GCS score.

In this series, 89.7% of the children were managed conservatively, although a certain percentage (10.3%) got treated surgically, mostly due to skull fractures. The role of surgical management in skull fractures has been mentioned by Dewan etal. [42] with good outcomes.

The majority (52.9%) of children in this cohort were in the mild TBI (GCS 13-15) group on admission and perhaps this finding correlated with the favorable outcome across the cohort as it is well known in the literature that outcome is primarily dependent on the severity of PTBI at presentation [43]. 15.5% of the patients had neurological deficits and this could be attributed to inevitable sequela of secondary brain injury along with the presence of concomitant injuries; 24% had skeletal injuries, 12% had visceral injuries, and 0.5% polytrauma which could have impacted the overall clinical outcomes. The mortality rate in this series was relatively low at 4% (12/302) among the patients in the severe TBI group, comparatively similar to the KID study (4%) by Lu etal. [44].

In the one-month follow-up, more than half (55.6%) of the children were clinically stable; however, a few (9.6%) still had resolving neurological deficits and a mortality rate of 0.3%, reports largely similar to findings in the Malawi pediatric TBI series [45].

Regarding preventive public measures, several options have been laid down in different regions across the globe. Cassidy etal. emphasized that the strong evidence supports helmet use to prevent mild traumatic brain injury in motorcyclists and bicyclists [46].

In our earlier study in Nyamagana District, Mwanza, analyzing the perception of civilians on pre-hospital involvement in RTAs among the 151 participants, we found that emergency care before hospitalization was largely acceptable in terms of attitude, willingness with RTAs before hospitalization [47], a finding which could relate to early response and quicker referrals in this region. Chaitanya etal. in their pediatric series in India pointed out that most of these injuries are preventable in infancy and childhood by ensuring proper vigilance, and tender care by the parents and the caretakers [48]. Educational programs are much needed to address the gap in the mothers’ KAP toward child injury prevention. Further studies are recommended to understand the cultural context and examine its key determinants to identify effective strategies and develop tailored interventions for preventing childhood injuries [49].

The need to increase training of neurosurgery-specific medical personnel has been echoed as one of the measures to mitigate this public burden locally by Kahamba etal. [50] and others [52].

In comparison to this 10-year report conducted at our institution [52], our institution has seen inevitable improvements in the scope of TBI management including 2 CT scan machines, MRI, >60-bed intensive care beds, and the recruitment of the associated personnel involved in the management of TBI. The recent enrolment of CT scans [24] in over 40 regional hospitals throughout Tanzania has seen a rapid increase in TBI referrals hence decreasing the rate of delayed referrals.

From an engineering perspective, a study by Jimoku etal. identifying the factors influencing the severity of motorcycle crashes found that speeding, driving under the influence, head-on impact, presence of horizontal curves, reckless riding, off-peak hours, violations, and riding without a helmet were among the influencing factors. They, hence, recommended countermeasures focusing on the fundamental highway safety improvement strategies comprising engineering, education, and traffic law enforcement [53].