traumatic brain injury ( tbi ) is the most common cause of morbidity and mortality in children .
many scoring systems have been established to predict the neurological outcomes in children with tbi .
clinically , different scoring systems may show different characteristics and various effects in estimating children with tbi .
however , the golden standard scoring system for predicting neurological outcome in children with tbi is still unclear .
also , it is equivocal which clinical scoring system can be the most useful scale in the emergency department .
this concern has led to renewed interest in clinical scoring systems to be better applied clinically and accurately predict neurological outcomes in children with tbi .
tbi is the most common cause of morbidity and mortality in children over 1 year of age and young adults .
clinically , many scoring systems may aid clinicians in evaluating the neurologic conditions and predicting the outcomes in patients with tbi .
however , different scoring systems may show different characteristics for clinicians to evaluate these patients .
on the basis of glasgow coma scale ( gcs ) , the severity of the tbi is graded as mild ( gcs 15 - 13 ) , moderate ( gcs 12 - 9 ) or severe ( gcs 8 - 3 ) . since the glasgow outcome scale ( gos ) published by jennett and bond in 1975 ,
it becomes the most widely used scoring system in evaluating neurological outcome for head injury patients .
the current recommendations are to use the gos at 6 months to measure outcome after severe head injury .
however , it is likely to underestimate morbidity in children and is not always readily applicable in this group . in 2001 ,
crouchman and colleagues developed a pediatric adaptation of the gos , the king 's outcome scale for childhood head injury ( koschi ) .
they expand the five categories of gos to provide more sensitivity at the milder end of the disability range . in the koschi ,
the gos category of  persistent vegetative state  was replaced by  vegetative  . 
severe disability  ,  moderate disability  and  good recovery  were allocated two categories , in acknowledgement of the long - term importance of relatively minor sequelae in a developing child .
in addition , they suggested that the koschi could be used to ( 1 ) document recovery and monitor the burden of disability in individual children ; ( 2 ) plan service and evaluate rehabilitation programs ; and ( 3 ) assess effects of service and research interventions . in a prospective cohort study , calvert et al . reported that koschi scored at hospital discharge correlates with severity of injury and some cognitive , health status and health - related quality of life ( hrql ) outcomes early after tbi .
in addition , another neurological outcome score for children was developed by okada et al . in 2003 such as neurologic outcome scale for infants and children ( nosic ) .
they recommended that the nosic was a practical , reliable , valid , nonproprietary instrument applicable to children with a broad range of ages and neurologic diagnoses .
but the limitations of nosic were relatively low sensitivity to mild deficits , lacking much clinical experience and can not be administered by mail or telephone .
it is really a big challenge for primary clinicians to early predict the outcome of individual patients with severe head injuries .
however , predicting and establishing the prognosis after tbi is an important question for doctors , patients and their families , as well as for health organizations and insurers .
previous studies had shown some important factors associated with poor outcome after pediatric tbi , including : low admission gcs score , poor pupil reflexes recovery , coagulopathy , brain computed tomography ( ct ) results : ( subarachnoid hemorrhage with brain swelling and edema , subdural , intracerebral hemorrhage , and basal ganglion lesions ) , hyperglycemia , hypoxia , impaired cerebral autoregulation and early hypotension.[58 ] in this issue entitled  outcome analysis and outcome predictors of traumatic head injury in childhood - analysis of 454 observations  in journal of emergencies , trauma , and shock , the authors did their effort to evaluate the factors correlated with poor outcome in children with tbi . based on the results of multivariate analysis , they found that factors associated with a bad outcome ( gos<4 : death , persistent vegetative state , severe disability ) were prism 24 ( p=0.03 ; or:5.75 ) ; gcs score 8 ( p=0.04 ; or:2.42 ) ; cerebral edema ( p=0.03 ; or : 2.23 ) ; lesion type vi on ct according to traumatic coma data bank classification ( p=0.002 ; or:55.95 ) ; hypoxemia ( p=0.02 ; or:2.97 ) and sodium level > 145 mmol / l ( p=0.04 ; or:4.41 ) .
the authors concluded that the neurological outcome measure ( gos ) was a very blunt instrument , especially for survivors who were not vegetative or severely disability .
in addition , gos was not only poor - sensitive to children with neurobehavioral impairments but also less sensitive to children with substantial impact on academic , social function and quality of life .
as most of previous studies mentioned,[58 ] gos was commonly used to evaluate patients neurological conditions .
although gos appears to be simple and easy - recorded , the variables of gos involve more physical evaluation than cognitive , emotional and behavior surveys .
this issue may lead clinicians to underestimate the severity and prognosis in tbi . moreover ,
the above study also has provided some important predictive factors associated with poor neurologic outcome .
the results might be helpful for clinicians in further evaluation and management of tbi patients .
however , even in tbi patients with initially good outcome indicators ( good recovery and only mild - to - moderate disability ) , poor learning and poor social behavior functions may occur in 6 months after tbi events . during the recent 30 years
, the survival rate and neurological outcome of tbi in children have improved a lot .
however , the disabled survivors remain a significant financial burden on health , education and social - service budgets not only in developing countries but also in developed countries . in order to adequately evaluate neurological outcomes after tbi
, some studies had used a variety of instruments from complex neuropsychological tests to simple clinical outcome scales . nevertheless , which is the gold standard neurological outcome scoring system in children with tbi remains equivocal .
until now , there have been several particular challenges for clinicians in evaluating outcomes after childhood tbi .
physical , behavioral , emotional and cognitive impairments make various contributions to the overall morbidity , depending on the age at injury , interval since injury and the severity of injury .
in addition , measurements in children need to be considered to age - appropriate expectations , and since the process of development and growth continues after the injury , the shortfall between current functional status and age - dependent  normality  is dynamic .
the dynamic correlation and interaction among the components of the morbidity developed after tbi may lead to dilemma in further management and evaluation .
therefore , we think that to develop a practical , reliable and valid neurological outcome instrument in children is an important issue in forwarding research . furthermore , to achieve early accurate assessment , adequate rehabilitation and long - term follow - up is also the key point of improving neurological outcome in children with tbi .
 traumatic brain injury is the most common cause of morbidity and mortality in children . 
 however , it is still challengeable to early predict the outcome of individual patients with severe head injuries . 
 glasgow outcome scale is the most widely used scoring system in evaluating neurological outcome for head injury patients . 
 moreover , it is likely to underestimate morbidity and is not always readily applicable in children . 
 it is an important issue to develop a practical , reliable and valid neurological outcome instrument in children in forwarding research . 
INTRODUCTION