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.
Abstract
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]
https://www.medscape.com/viewarticle/901517
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…
ReplyDeleteDr. 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.
https://www.nytimes.com/2018/09/17/well/family/children-concussions-brain-injuries-cdc-guidelines.html