Friday, September 7, 2018

CDC guideline identifies the best practices for pediatric mild traumatic brain injury

Angela Lumba-Brown, Keith Owen Yeates, Kelly Sarmiento, et al.  Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children.  JAMA Pediatr. Published online September 4, 2018. doi:10.1001/jamapediatrics.2018.2853

Key Points
Question  Based on current evidence, what are best practices for diagnosis, prognosis, and management/treatment of pediatric mild traumatic brain injury (mTBI)?

Findings  Based on a previous systematic review of the literature, this guideline includes 19 sets of recommendations on diagnosis, prognosis, and management/treatment of pediatric mTBI. Each recommendation was assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence.

Meaning  Clinical guidance for health care professionals is critical to improving health and safety of this vulnerable population; the recommendations represent current best practices and comprise the first evidence-based clinical guideline to date for diagnosing and managing pediatric mTBI in the United States.

Importance  Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States.

Objective  To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI.

Evidence Review  The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015.

Findings  The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment.

Conclusions and Relevance  This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.

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…

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.

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.

[See:  McCrea M, Manley G. State of the Science on Pediatric Mild Traumatic Brain InjuryProgress Toward Clinical Translation. JAMA Pediatr. Published online September 04, 2018. doi:10.1001/jamapediatrics.2018.2846]

1 comment:

  1. The guideline, which is the first from the C.D.C. that is specific to mild brain injury in children, advises against the long recovery period, isolated in a dark, quiet room, that has sometimes been used in treatment…

    Dr. Christopher C. Giza, professor of pediatric neurology and neurosurgery at the University of California, Los Angeles, who worked on the guidelines, said that even though there are many situations in which it might be helpful to have more extensive evidence, practicing physicians have to treat children with head trauma all the time, so “we can’t wait for the perfect study.” By following the evidence we have and being careful about the return to play for athletes, he said, “you are reducing the long-term risk.”

    The key recommendations from the guideline, all aimed at the clinicians taking care of these children, are also of interest to parents, because they help explain what will — and should — happen when a child suffers a head injury. First, the guideline tells medical providers that imaging studies — CT scans and X-rays — are not necessary for diagnosing mild traumatic brain injury, and avoiding these tests helps minimize children’s exposure to radiation. There is also no blood test for mild traumatic brain injury; the diagnosis is made by clinical examination and observation…

    “When I was a kid, people tended to blow off concussions,” Dr. Giza said. Then the pendulum swung the other way, and we began worrying that “any cognitive activity might put your brain at risk,” so injured kids ended up in “cocoon therapy,” in a dark room with no stimulation. But the evidence shows that extending that can be detrimental, he said, with kids developing anxiety symptoms about their schoolwork, or depression from being completely deprived of contact with friends — which may be wrongly attributed to the head trauma.