Mild traumatic brain injury (mTBI) in children is a rapidly growing public health concern that impacts the emergency physician’s daily practice. The number of emergency department visits for mTBI has been on the rise over the past decade. In 2007, there were 461,000 emergency department visits for TBI among children 14 years and younger; in 2013, that number was up to 642,000.^1,2

Although the terms “concussion,” “minor head injury,” and “mTBI” often are used interchangeably, they have different connotations and could lead to misinterpretation if not used correctly. Therefore, the Centers for Disease Control and Prevention (CDC) guideline recommends the clinical use of the single term “mild traumatic brain injury.” The recently published CDC pediatric mTBI guideline identifies the best practices based on the current evidence for health care professionals in various settings, including the emergency department.^3-4 The guideline was developed through a rigorous process guided by the American Academy of Neurology and 2010 National Academy of Sciences methodologies. An extensive review of scientific literature, spanning 25 years of research, formed the basis of the guideline. Importantly, research pertaining to the assessment and management of mTBI in children is rapidly evolving and advancing, and guidelines should be revised periodically to reflect new evidence.

The CDC pediatric mTBI 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. The vast majority of these recommendations are very useful for emergency physicians as they are the frontline providers to care for most children with mTBI in the emergency department.

The CDC pediatric mTBI 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 and Tools

Routine neuroimaging in the acute care setting is not recommended for mTBI in children. CT imaging should be considered when there is a suspicion of more severe forms of TBI supported by validated clinical decision instruments that evaluate a variety of risk factors (eg, Pediatric Emergency Care Applied Research Network [PECARN] head CT rules).⁵ The CDC has developed guideline implementation tools, such as postconcussion symptom rating scales for emergency physicians to document their patients’ presenting symptoms. These tools assist emergency physicians in making the accurate diagnosis of concussion and contribute to prognostic counseling of children and their families. In addition, based on best evidence, the guideline identifies premorbid history and other risk factors for prolonged recovery that can be easily assessed in the acute care setting. These include older children/adolescents, Hispanic ethnicity, lower socioeconomic status, severe presentation of mTBI including intracranial hemorrhage, and higher levels of postconcussive symptoms. The guideline also emphasizes the unique recovery trajectory for individual patients.

In addition, the guideline provides recommendations on return to cognitive and physical activity. The guideline provides specific recommendations for emergency department counseling, including the use of discharge instructions for return to activity. The guide will allow patients and families to better implement a plan for recovery. This includes more restrictive physical and cognitive activity during the first two to three days, followed by a gradual return to activity/play that does not significantly exacerbate symptoms, and monitoring of symptom number and severity. Follow-up instructions related to longer-term activity integration cannot be determined from an emergency department setting, and joint medical (primary care physicians, neurologists, etc.) and school-based teams should address these specific issues, including “clearance” for full activity. Emergency department clinicians may also recommend sleep hygiene to facilitate recovery.

Key Recommendations

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

To learn more about the guideline and the methodology for developing the guideline, visit HEADSUP.

Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the CDC.

---

Dr. Joseph is professor of emergency medicine and pediatrics and assistant chair of pediatric emergency medicine quality improvement in the department of emergency medicine at the University of Florida College of Medicine–Jacksonville.

Dr. Lumba-Brown is clinical assistant professor in the departments of emergency medicine and pediatrics and co-director of the Stanford Concussion and Brain Performance Center at Stanford University School of Medicine in Palo Alto, California.

Dr. Yeates is Ronald and Irene Ward Chair in pediatric brain injury and professor and head of the department of psychology at the University of Calgary in Alberta.

Dr. Wright is professor and interim chair of emergency medicine in the department of emergency medicine at Emory University School of Medicine in Atlanta.

References

1. Bryan MA, Rowhani-Rahbar A, Comstock RD, et al. Sports and recreation-related concussions in US youth. Pediatrics. 2016;138(1):e20154635.
2. Taylor CA, Bell JM, Breiding MJ, et al. Traumatic brain injury-related emergency department visits, hospitalizations, and deaths—United States, 2007 and 2013. MMWR Surveill Summ. 2017;66(9):1-16.
3. 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. JAMA Pediatr. 2018;172(11):e182853.
4. Lumba-Brown A, Wright DW, Sarmiento K, et al. Emergency department implementation of the Centers for Disease Control and Prevention pediatric mild traumatic brain injury guideline recommendations. Ann Emerg Med. 2018;72(5):581-585.
5. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170.