New Guidelines on Pediatric Mild Traumatic Brain Injury

First US Evidence-based Guidelines on Pediatric Diagnosing, Managing mTBI.¹ The first US evidence-based guidelines on pediatric mTBI was developed by a CDC expert work group and is the most comprehensive literature review to date.² The guidelines include 19 recommendations on the diagnosis, prognosis, and management of pediatric mTBI with 5 key practice-changing recommendations. 

1. Do Not Routinely Image When Diagnosing mTBI. The first practice-changing recommendation is do not routinely image pediatric patients to diagnose acute mTBI including head CT scans, MRI, single photen emission CT scans, and skull radiographs. Clinical decision rules are more accurate for identifying patients and should be used instead. 

2. Use Validated Symptom Scales. The second recommendation is to use validated, age appropriate symptom scales to diagnose mTBI. Validated, age-appropriate computerized cognitive testing may be used in diagnostic workup of acute mTBI. Risk factors for serious injury include patients aged <2 years, vomiting, loss of consciousness, severe mechanism of injury, severe/worsening headache, amnesia, nonfrontal scalp hematoma, a Glasgow coma scale <15, and clinical suspicion of skull fracture. 

3. Screen for Risk Factors. Physicians should screen patients for risk factors for prolonged recovery which include patients who are older in age/teens, children of Hispanic ethnicity, lower socioeconomic status, history of mTBI/other brain injury, more severe presentation, more acute postconcussion symptoms, personal characteristics, and family history. Validated prediction rules may be used to provide prognostic counseling to patients and family. 

4. Give Customized Instructions on Returning to Normal Activity. Patients and caregivers should receive customized instructions on returning to normal activities. Advise a gradual increase in activity that does not increase symptoms with close monitoring. If that is successful, advise progressive reintroduction of noncontact aerobic activity that does not increase symptoms with close monitoring. Also, advise patients to return to full activity when back to baseline and symptom-free at rest with increased exertion.

5. Prescribe Rest Before Patients Return to Activity. Advise patients and caregivers about a gradual return to non-sports activities after 2-3 days of rest. If the patient wants to return to school, they should have an individualized protocol and collaborate between medical, school, and family.