Data collection and sample size:
In this cross sectional study, pediatrics in the age range of 5-15 years old with mild to moderate TBI referred to the pediatric neurosurgery clinic affiliated with Shiraz University of Medical Sciences were enrolled. The sample size was calculated to be 50 patients based on the energy intake value in pelizzo et al. study with the power of 80% and α=5%:(19). This study was approved by ethics committee of Shiraz University of Medical Sciences. (No. IR.SUMS.REC.1397.708) and followed the principles of the Declaration of Helsinki.
Inclusion criteria:
children of 5-15 years old with mild to moderate TBI who were injured within the past 3-6 months without any other illnesses that could affect their food intake, such as cancer, liver and kidney failure, thyroid disorders, and diabetes were recruited.
Exclusion criteria:
Patients who were on parenteral nutrition, suffered multiple injuries or had a history of neurological or psychiatric problems, used any medications or supplements that could affect appetite and also were reluctant to participate in the study, were excluded.
After explaining the research objectives to the childrens’ parents, they were asked to complete the consent form and the following steps were performed for each patient: Completing the demographic information (age, gender, medications, medical disorders), dietary intake assessment, taking blood samples for biochemical evaluations, assessing psychological disorders using the “Rutter Children Behavior Questionnaire” (the parent’s form) and doing CT scan for determining the main area of brain injury (frontal, temporal, occipital, or other sites of brain).
Dietary intake assessment:
to assess the children’s dietary intake, data from three 24 h dietary recalls were taken. Two assessments were made on weekdays and a third one during the weekends. The data were assessed under the guidance of a skilled dietitian. The reported values were then entered into the Nutritionist 4 software. The average energy intake was then compared with the RDA values for each individual (4). Adequate energy intake was defined as intake 75 to 110% of the RDA, while inadequate and excess intake were considered as intakes less than 75% and more than 110% of the RDA, respectively (20).
Evaluation of behavioral disorders:
Children were assessed for behavioral disorders using the “Rutter Children Behavior Questionnaire” (the parent form), which was provided to the child's parents to answer the questions. It should be noted that the Rutter Behavioral Problems Questionnaire was developed by Michael Rutter in 1975, which is consisted of 31 items including 13 questions related to general health, habits and lifestyle (including complaints of headache, stomach pain with nausea, shortness of breath, urinary or fecal incontinency, refusal to go to school, speech problems, stealing behaviors, and eating and sleeping problems) and 18 questions related to child behavioral disorders (including behaviors such as restlessness, aggression, irritability, depression, disobedience, concentration problems, and lying) and is completed by parents. A score of 13 is the cut-off point, and children with a score of 13 or higher are considered as having behavioral disorders. (21).
CT scan evaluation:
evaluation and interpretation of the patients' CT scan was done by the neurosurgeon to determine where the affected region of the brain was (frontal, temporal, parietal, occipital lobe, or other sites of brain) and if the cerebral hemorrhage existed. By referring to the patient's medical history, information on the day that the trauma had occurred, the length of hospitalization, the cause of trauma, the GCS at admission and also the therapeutic strategies were recorded.
Biochemical assessment:
Fasting blood samples were taken from each participant. The serums were prepared by centrifuging at 3000 rpm for 15 minutes and were stored at -70 °C until further analysis. Serum leptin was measured by ELISA method, using German Mediagnost kit, serum Ghrelin was measured by ELISA method, using Chinese Crystallday kit, and serum Orexin A was measured by ELISA method, using Chinese Crystallday kit.
Statistical Analysis:
Data analysis was done, using SPSS software (version 24). Quantitative variables were reported as mean ± SD. The normality of quantitative variables was evaluated by Kolmogorov-Smirnov test. To compare the mean ± SD of normal quantitative variables by multivariate qualitative variables, one-way ANOVA was used and Kruskal-Wallis test, if the variables were not normal. Additional post-hoc tests were also used to compare the groups two by two. Comparison of variables in two groups according to Rutter test score were done by independent sample t-test (for normal data) and Mann Whitney test for nonparametric ones. P< 0.05 was considered to be statistically significant.