New guidelines for traumatic brain injuries in children

It used to be that when a child suffered a traumatic brain injury from playing sports or falling, the doctor would order several weeks of rest. But that’s not the case anymore.

A recent work group appointed by the Centers for Disease Control & Prevention recently came up with new guidelines to treat such injuries.

Dr. Stacy J. Suskauer, co-director of the Center for Brain Injury Recovery at Kennedy Krieger Institute, helped develop the guidelines. She tells parents what they need to know about traumatic brain injuries in children.

What is a traumatic brain injury?

A mild traumatic brain injury is an injury to the brain caused by a bump, blow, or jolt to the head that does not result in prolonged alteration in consciousness. The injuries may or may not be associated with a short period of loss of consciousness or period of confusion and typically result in symptoms such as headache and dizziness. “Concussion” and traumatic brain injury are often used synonymously.

How do most kids get these injuries?

Sports are one cause in youth. In particular, contact sports such as football, ice hockey, soccer and lacrosse are among the leading causes of sport-related traumatic brain injuries in children. Falls are another frequent cause in children, including falls from playground equipment, bicycles and skateboards, as well as falls down stairs. Children also incur the injuries from motor vehicle collisions and assault.

Why do you think new guidelines were needed to treat these injuries?

The guidelines were needed to standardize the approach to evaluation and management of traumatic brain injuries in children based on evidence that exists from research studies. For example, in recent years there has been a great deal of variability in recommendations made regarding rest as a treatment for such injuries.

Some providers were recommending that a child be restricted from participating in school and other typical activities until all symptoms resolved, even if that required missing school and other activities for many months.

Research studies have shown that this type of prolonged rest can actually delay recovery from symptoms and may contribute to more problems with mood and stress. Thus, it was critical to create a guideline document summarizing best practices for care related to traumatic brain injuries in children.

Who are these guidelines aimed at?

The guidelines were created to provide guidance for any health provider who cares for children with traumatic brain injuries. The information on evaluation and management of these injuries in children applies to healthcare providers who work in emergency department and inpatient hospital settings, as well as primary care providers and outpatient specialists.

To help with dissemination of the recommendations contained in the guideline document, the Centers for Disease Control and Prevention has created additional resources, both for healthcare providers and for parents, which are available on their website.

For providers, additional materials include a checklist on evaluation and management and a letter to facilitate a child’s return to school. For parents, there is educational information, including what to expect after an injury as well as a list of common symptoms and tips for managing them.

Who helped come up with the new guidelines?

The guidelines were developed by a group of pediatric traumatic brain injury experts invited by the CDC to form a work group. Members from the group represented pediatric rehabilitation medicine, emergency medicine, sports medicine, neurology and neuropsychology. Before the guidelines could be developed, the work group completed an extensive review of the scientific literature. Following the literature review, clinical recommendations were developed and subsequently finalized through a consensus process.

What are some of the key recommendations included in the guidelines?

The guidelines include 19 sets of recommendations. There are a few that are key for parents to know.

1. Parents should be aware that brain imaging is not recommended as part of routine care for a child with a traumatic brain injury. This is due to the low likelihood of identifying an abnormality on the scan, as well as the risk associated with scans, such as radiation from a CT scan. Instead, healthcare providers should consider whether a child has specific risk factors for a more severe traumatic brain injury, such as loss of consciousness, amnesia, confusion, vomiting, and/or severe and worsening headache, to determine whether brain imaging is necessary.

2. Restrictive limitations on thinking and low-risk physical activities should be limited to just the first few days after an injury. After that time, children should begin to gradually return to typical daily activities, such as attending school, with accommodations as needed to help with managing ongoing symptoms. Using electronics and participating in non-contact physical activity is okay if it doesn’t make the child feel worse.

3. Children whose symptoms don’t resolve within four to six weeks after a traumatic brain injury should receive additional assessment and/or interventions. In particular, the guidelines identify the importance of multidisciplinary evaluation and treatment due to the multifactorial nature of symptoms such as ongoing headaches, sleep difficulties and cognitive concerns. The guidelines highlight the importance of seeking care from providers who can formally assess a child’s physical, cognitive, and emotional symptoms and direct related care.

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