The Centers for Disease Control and Prevention (CDC) has issued the first evidence-based clinical guideline in the United States for diagnosing and managing concussion or mild traumatic brain injury (mTBI) from all causes in children.
The guidance includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI.
Several previous guidelines in the field have been consensus-based and some have focused on only sports concussion or only adults.
Co-author Matthew J. Breiding, PhD, team lead, Division of Unintentional Injury Prevention, CDC, Atlanta, Georgia, told Medscape Medical News that limiting the duration of rest in the first days after an injury is one of the most important messages of the guideline. Providers should counsel patients "to return gradually to nonsports activities after no more than 2 to 3 days of rest," he said.
Rest has been central to treating mTBI and a way to prevent another, potentially worse, TBI. But there is little evidence on the best time to start rest and optimal duration, he explained.
"While some scientific findings indicate that rest or reduction in cognitive and physical activity is beneficial immediately following mTBI, there is also evidence to suggest that limiting cognitive and physical activity beyond several days can worsen symptoms," Breiding said.
The guideline was published online September 4 in JAMA Pediatrics.
Most Comprehensive Review of Pediatric mTBI
The guideline, called for by Congress and written by lead author Angela Lumba-Brown, MD, and the Pediatric Mild Traumatic Brain Injury Guideline Workgroup of the CDC, was based on a systematic literature review that covered 25 years of research. Recommendations were drafted using American Academy of Neurology methods.
Researchers used a broad definition of mTBI for the guideline.
"Specifically, pediatric patients were included with Glasgow Coma Scale scores of 13 to 15 with or without the complication of intracranial injury on neuroimaging and regardless of potentially requiring a hospital admission and/or neurosurgical intervention," they write.
Breiding says the guideline "represents the most comprehensive review of pediatric mTBI scientific evidence to date and provides evidence-based recommendations for healthcare professionals caring for children."
It also applies to patients, caregivers, school professionals, and sports programs, he added.
He prioritized these key recommendations for providers:
Refrain from routinely imaging children to diagnose mTBI. Clinical evaluation of the child with possible mTBI should weigh multiple risk factors for further injury against the risks associated with radiation exposure and possible sedation, according to the guidelines.
Use validated, age-appropriate symptom scales in diagnosis. For instance, the Standardized Assessment of Concussion should not be the only one used to diagnose mTBI for children aged 6 to 18 years.
Assess risks for sustained recovery, including history of mTBI or other brain injury, severe symptoms immediately after the injury, and personal characteristics and family history, such as learning difficulties and family and social stressors.
Provide instructions about returning to activity appropriate for patients' symptoms. For example, providers should advise patients to resume full activity "when they return to premorbid performance if they have remained symptom-free at rest and with increasing levels of physical exertion," the guideline states.
Mild Traumatic Brain Injury in Kids Is Not Benign, Needs Follow-Up
Two neurosurgery experts praise the authors but write in an accompanying editorial that widespread adoption of the CDC guideline faces a major hurdle in the United States without a standardized system of care for adults or kids who have had a TBI.
Michael McCrea, PhD, ABPP, Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, and Geoff Manley, MD, PhD, Department of Neurosurgery, University of California in San Francisco, note: "A 2018 report indicated that nearly half of patients with mTBI treated at major level I trauma centers had no medical follow-up following discharge, even those with persistent symptomatology."
"Our ultimate goal, both in pediatric and adult populations, should be the deployment of a precision medicine approach to TBI that accounts for all factors known to influence the acute, subacute, and chronic phases of mTBI and which is harnessed to a multidisciplinary care delivery system."
The guidelines come in light of a gradual understanding over two decades by providers and the public that mTBI is not a benign condition as once thought, but has lasting physical, neuropsychiatric, and cognitive effects that affect quality of life and functional ability, McCrea and Manley write.
They note, "Pediatric mTBI is now recognized as a major public health problem, bringing nearly 1 million children to US emergency departments annually."
Healthcare providers, parents, and others can learn more about mTBI, including signs and symptoms and how to safely return to school and sports, at the CDC HEADS UP website.
The guideline was funded by the CDC. Disclosures for the authors are listed in the guideline. The editorialists have reported no relevant financial relationships.
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Cite this: CDC Issues First Pediatric Concussion Treatment Guidelines - Medscape - Sep 04, 2018.