CDC Creates New Guidelines for Addressing Mild TBI, Concussions in Children

The US Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and its federal advisory committee Control Board of Scientific Counselors has released a new set of guidelines for the comprehensive care of pediatric mild traumatic brain injury (mTBI).

The guidelines, which were drafted and finalized by an amalgamation of the 2 agencies titled the Pediatric Mild Traumatic Brain Injury Guideline Workgroup, is a set of 19 recommendations pertaining to the diagnosis, prognosis, and management or treatment of pediatric mTBI. The recommendations are based on initial literature research spanning from 1990-2012, and an updated search from December 2012 to July 2015.

According to the workgroup investigators, more than 2 million US outpatient visits and 3 million emergency department (ED) visits from 2005-2009 were accounted to children seeking care for mTBI. The need to address this rate, as well as update guidelines in response to recent developments in sports-related concussion research, drove the formulation of these guidelines.

“To date, no broad, evidence-based clinical guidelines have been developed in the United States for the purposes of diagnosis, prognosis, and management/treatment of pediatric mTBI,” investigators wrote. “Clinical guidance for health care professionals is critical to improving the health and safety of this vulnerable population.”

Because of the interchangeable use of the terms “concussion” and “minor head injury” along with mTBI—despite their conflicting clinical implications—the investigators recommended the sole use of the term mTBI. A “wide clinical and functional definition of pediatric mTBI” intended to assure that heterogeneous presentations and outcomes of children with the condition are not excluded was adopted by investigators. In their systematic review, pediatric patients with Glasgow Coma Scale (GCS) scores of 13-15 with or without intracranial injury (ICI) complication were included for assessment.

The 19 recommendations address the following subjects:

• Risk Factors for ICI and Computed Tomography
• Brain Magnetic Resonance Imaging
• Single-Photon Emission CT
• Skull Radiograph
• Neuropsychological Tools, Including Symptom Scales, Computerized Cognitive Testing, and Standardized Assessment of Concussion
• Serum Markers
• General Health Care Professional Counseling of Prognosis
• Prognosis Related to the Premorbid Conditions
• Assessment of Cumulative Risk Factors and Prognosis
• Assessment Tools and Prognosis
• Interventions for mTBI With Poor Prognosis
• Patient/Family Education and Reassurance
• Cognitive/Physical Rest and Aerobic Treatment
• Psychosocial/Emotional Support
• Return to School
• Posttraumatic Headache Management/Treatment
• Vestibulo-Oculomotor Dysfunction Management/Treatment
• Sleep Management/ Treatment
• Cognitive Impairment Management/ Treatment

Investigators also presented multifaceted approaches to each recommendation, determining the strength and prioritization of each recommendation based on the importance of the outcome, benefit relative to harm, expected variation in patient preferences, financial burden relative to benefit expected, and the feasibility of each intervention.

For example, in addressing cognitive and physical rest and aerobic treatment for pediatric mTBI patients, the investigators recommend that healthcare providers counsel patients on observing restrictive activity during the first several days after the injury. The recommendation is graded as “B”, meaning it should usually be followed, whereas a stronger recommendation that should almost always be followed is graded as “A.”

Among its most interesting recommendations is the investigators’ stance on limiting computed tomography (CT) scans in children with mTBI. According to their analysis, up to 7.5% of children reporting to the ED with mTBI will have ICI. But a variety of factors in patients without the use of CT make patients at greater risk of ICI or more severe TBI are prevalent in assessment. Researchers concede, though, that head CT is still the preferred diagnostic tool to rapidly identify ICI in acute care settings.

“However, higher doses of radiation attributable to this type of imaging in children have been associated in studies with an increase in the lifetime cancer risk, although the cumulative absolute risk appears small,” investigators wrote. “Furthermore, certain pediatric populations will require sedation to obtain adequate neuroimaging, increasing the overall risk related to imaging processes.”

Investigators also made the recommendation that children returning to school following mTBI be assisted by medical and school-based teams, who should both counsel the child and their family on the process of increasing academic activities at a gradual rate. The goal, they note, is to increase school participation without exacerbating patient symptoms.

“Because postconcussive symptoms resolve at different rates in different children after mTBI, individualization of return-to-school programming is necessary,” investigators wrote. “To protect their legal right to an appropriate education, children with mTBI who have a greater symptom burden and prolonged recoveries may require formal educational planning incorporating protections under federal statutes.”

Along with these updated recommendations, investigators advocated for a multifaceted approach to their implementation. They noted that materials such a screening tool, online courses, fact sheets, and patient discharge literature have been created by the CDC, who will also support guideline distribution through its HEADS UP campaign.

As the guidelines are based on the recent development of new and critical neurological findings, the investigators call for a similarly updated and critical assessment of the recommendations as they are practiced.

“The science of managing mTBI in children is rapidly evolving and expanding,” they concluded. “This guideline identifies the best practices based on the current evidence for health care professionals in primary care, outpatient specialty, inpatient, and emergency care settings; updates may be made as the body of evidence grows.”

The guidelines, "Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children," were published in JAMA Pediatrics on Tuesday.