Pediatric TBI Guidelines from the CDC

Written by Clay Smith

Spoon Feed
Taking care of children with mild traumatic brain injury (mTBI) is not easy. This guideline states clearly, based on compiled evidence, what you should and should not do.  It’s helpful.

Why does this matter?
So much is being written on mTBI in children.  What should we do to take care of these kids?  Should we CT or observe?  Should we have them rest or resume light activity?  Here are the guidelines.

The CDC Guidelines can help
Each statement was listed as a level of obligation: “must,” “should,” or “may” based on the level and quality of the evidence.

Diagnosis

  • “Health care professionals (HCP) should not routinely obtain head CT for diagnostic purposes in children with mTBI [this also includes MRI and SPECT].”  Rather, they should use clinical decision instruments, such as PECARN, to guide imaging decisions and discuss the risk/benefit with families.  Level B evidence

  • “Skull radiographs should not be used in the diagnosis of pediatric mTBI.”  Level B evidence

  • “HCPs should use an age appropriate, validated symptom rating scale as a component of the diagnostic evaluation in children seen with acute mTBI,” such as the Graded Symptom Checklist.  They may use computerized testing and should not use the Standardized Assessment of Concussion. Level B evidence

  • “HCPs should not use biomarkers outside of a research setting for the diagnosis of children with mTBI.”  Level R evidence (R = only in research setting).

Prognosis

  • “HCPs should counsel patients and families that most (70%-80%) children with mTBI do not show significant difficulties that last more than 1 to 3 months after injury” and “each child’s recovery from mTBI is unique.” Level B

  • “HCPs should assess the premorbid history of children either before injury as a part of preparticipation athletic examinations or as soon as possible after injury in children with mTBI to assist in determining prognosis.”  They should screen kids for known risk factors and use validated tools to assess recovery.  Kids with more cognitive or learning comorbidities or prior mTBI do worse in recovery and need to be monitored more closely. There are several recovery assessment tools. Level B.

Management and Treatment

  • Give anticipatory guidance: “Warning signs of more serious injury; Description of injury and expected course of symptoms and recovery; Instructions on how to monitor postconcussive symptoms; Prevention of further injury; Management of cognitive and physical activity/rest; Instructions regarding return to play/recreation and school; Clear clinician follow-up instructions.”

  • Injured children should rest more in the days after mTBI, though complete rest is not helpful.  They should gradually resume activity and have supervised return to contact play.  Level B

  • Injured children also may need emotional support (Level C) and should have gradual return to school and academics (Level B).

  • “Children undergoing observation periods for headache with acutely worsening symptoms should undergo emergent neuroimaging.” Level B.  Ibuprofen or acetaminophen should be used for headache.  Level B.  They should not get 3% saline for mTBI (who is doing this?).  Level B.

  • Children may need referral for persistent vestibulooculomotor dysfunction after mTBI.  Level C

  • HCPs should instruct on, “proper sleep hygiene methods to facilitate recovery from pediatric mTBI” and should pursue treatment for persistent cognitive dysfunction after mTBI.  Level B

Another Spoonful
The CDC has created a website to house all this information, called HEADS UP, so you can find and reference the latest mTBI guidelines.

Source
Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children.  JAMA Pediatr. 2018 Sep 4:e182853. doi: 10.1001/jamapediatrics.2018.2853. [Epub ahead of print]

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