March 7, 2019

Comprehensive clinical recommendations now exist for treating children with mild traumatic brain injury (mTBI). They were published last fall after the Centers for Disease Control and Prevention (CDC) convened an interdisciplinary group of experts, including Stacy Suskauer, a pediatric physiatrist at Johns Hopkins Children’s Center and the co-director of Kennedy Krieger Institute’s Center for Brain Injury Recovery.

Discussing the need for the guideline, Suskauer says, “There has been a lot of variability in how pediatric mTBI, including concussion, has been managed. There was a need to translate recent research findings into best practices for caring for children with mTBI.” According to the CDC, about 2.5 million high school students suffered a physical activity-related concussion in the last year, and more than 800,000 children visit emergency rooms with TBIs each year.

Suskauer and the rest of the group, from specialties as disparate as emergency medicine and neurosurgery, first identified six pressing questions, with subgroups focusing on each. Recommendations were developed after systematically reviewing the last 25 years of relevant research.

The finalized guideline includes 19 sets of recommendations, encompassing diagnosis, prognosis, management and treatment standards for health care providers in all practice settings. Of greatest importance are five key points:

1. Do not routinely image pediatric patients to diagnose mTBI.
2. Do use validated, age-appropriate symptom scales to diagnose mTBI.
3. Do assess for risk factors for prolonged recovery.
4. Do provide patients with instructions on return to activity customized to their symptoms.
5. Do counsel patients to return gradually to non-sports activities after no more than two to three days of rest.

Regarding the first takeaway, which stems from a subgroup Suskauer led, she says that the literature showed a very low probability of head CT scans identifying more severe trauma in pediatric mTBI patients and that validated clinical decision rules can be used to inform decision-making about imaging.  In addition, the group highlighted the importance of discussing with families the potential risks of CT, including those related to radiation and the possible need for sedation.

She was gratified to see the fifth point highlighted since it supports the way PM&R doctors are naturally oriented toward helping patients safely return to function as soon as possible. She notes that this principle also informed an accompanying parent handout on symptom-based recovery tips.

One unexpected outcome of the guideline development process was identification of limitations in the body of research on mTBI that limited inclusion of studies in the systematic review. “As a field, we need to shift how we design studies and publish data to make it more usable,” says Suskauer, the lead author on a related follow-up paper in the Journal of Head Trauma and Rehabilitation. “For example, studies often lump together data from mild through severe TBI, or from high school and college athletes, precluding use in the guideline process.”

Though a big step forward, Suskauer says there is still much work to do, including determining whether children who seem to have recovered from a concussion may still be at risk for other adverse outcomes, which is the focus of her current investigations.

Published in Restore Spring 2019