In a special communication article published in JAMA Pediatrics, the Centers for Disease Control (CDC) and Prevention presented a new guideline comprised of evidence-based recommendations for the diagnosis and management of mild traumatic brain injury (mTBI) in pediatric patients.
The guideline was compiled by the Pediatric Mild Traumatic Brain Injury Guideline Workgroup, which created evidence-based recommendations for healthcare professionals who diagnose and treat pediatric mTBI. Recommendations were based on a systematic literature review, scientific principles, expert knowledge, and related evidence. Potential recommendations were reviewed and voted on by each workgroup member, with an 80% response required prior to tabulation of each recommendation. Following a total of 4 voting rounds, a consensus was reached on 46 recommendations relating to diagnosis (n=11), prognosis (n=12), and management/treatment (n=23) of pediatric mTBI.
Recommendation levels were categorized by letter, with A, B, C, U, and R representing recommendations that should always be followed, usually should be followed, sometimes be followed, those that have insufficient evidence to create a recommendation, and those that should not be followed outside a research setting, respectively.
The first recommendations made by the committee suggest head computed tomography (CT) should not be routinely used to identify and diagnose children with mTBI. Additionally, single-photon emission CT (SPECT) and magnetic resonance imaging (MRI) should not be used in the acute assessment of suspected or diagnosed mTBI. Clinical decision rules, including the Pediatric Emergency Care Applied Research Network (PECARN) rules, should be used to identify pediatric patients with mTBI patients at low risk for intracranial injury.
Evidenced-based recommendations also indicate that healthcare professionals should routinely screen for known risk factors of persistent symptoms in this patient population. According to the committee, the evidence suggests that non-injury as well as injury-related risk factors can often predict prognosis in pediatric mTBI. A combination of symptom scales and cognitive testing is also recommended for their ability to predict outcomes and evaluate recovery.
A level B recommendation notes that patients should be counseled to restrict physical and cognitive activities during the first few days following mTBI, with evidence suggesting that rest in the first few days of the event is helpful for supporting recovery. In addition, the committee recommends assessment of patients’ social support, suggesting that a strong social support network may be helpful for promoting recovery in pediatric patients with mTBI who present with cognitive deficits. Gradually increasing the duration as well as intensity of school-related activities is also recommended as a means of eluding the exacerbation of mTBI symptoms. The action of gradually increasing academic pursuits requires careful planning among the medical, school, and family units that enables prompt return and avoidance of prolonging school absence.
“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 committee wrote. “Evaluation is crucial for understanding the influence of the recommendations, both intended and unintended, and for revising future recommendations and implementation materials.”
Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children [published online September 4, 2018]. JAMA Pediatr. doi:10.1001/jamapediatrics.2018.2853