The CDC’s New Pediatric Traumatic Brain Guidelines And What It Means For Your Child
The Centers for Disease Control and Prevention (CDC) recently released new pediatric traumatic brain guidelines. Below, please find my fine-tuned list, as well as important recommendations and comments on how adults may differ.
Please note, the five key practice-changing recommendations for treating children with mild traumatic brain injury (mTBI) were originally published by The Centers for Disease Control and Prevention (CDC): https://www.cdc.gov/media/releases/2018/p0904-tbi-guidelines.html
1. Do not routinely image pediatric patients to diagnose mild traumatic brain injury (mTBI).
CT scans entail exposing young brains to ionizing radiation. An MRI does not have the same risk with respect to radiation, but because many children need sedation to tolerate an MRI, a different set of significant risk factors exist.
The take-home message is that the routine use of imaging without clinical reasons to suspect significant injury exposes children to more risk than managing the child based upon clinical exam. The same is true for adults, though adults are more likely to have medical issues that cloud the clinical situation. For instance, a patient on antiplatelet or anticoagulation medications “blood thinners” is more likely to be scanned than a child with the same clinical scenario, but not on such medications. It is important to note that physicians often feel tremendous pressure from patients and family to order images. This recommendation will be helpful in helping our patients and families to understand that over imaging is not good medicine.
2. Use validated, age-appropriate symptom scales to diagnose mTBI.
Expecting all age children and, by extension, adults to present the same way following an injury is wrong. Simply put, strange sentence and language from a 12-year-old child will be concerning whereas from a three-year-old child, might be par for the course. In essence, this states that baseline performance and neurological function are age-dependent. Thus evaluation tools have been developed that take age into account. It is important to use the correct age assessment tool for the patient’s age.
Sadly, I have seen this misapplied to our elderly. Some may look at a senior individual and refer to their diagnosis as, “old age.” However, age is not always the issue. In one case, the cause of the deterioration was chronic bilateral subdural hematomas that were ultimately diagnosed and treated.
3. Assess for risk factors for prolonged recovery, including history of mTBI or other brain injury, severe symptom presentation immediately after the injury, and personal characteristics and family history (such as learning difficulties and family and social stressors).
This recommendation alludes to the limited recuperative ability of the brain. Whether the brain has previously been injured, has pathology unrelated to the injury, as well as the severity of the current injury, all contribute to the prognosis that can be expected. This is equally true for adults, too.
4. Provide patients and their parents/caregivers with instructions on returning to activity customized to their symptoms.
One size does not fit all. Whether discussing a concussion (i.e. mild TBI), or severe traumatic brain injury which results in permanent disability, the physician must constantly reassess the patient’s abilities, current symptoms, and any disabilities. One must make an assessment of what is changing for the better and potentially for the worse. Any activity must then be assessed for its potential impact on continued recovery, as well as any benefit of said activity. Returning to physical play and to school are often questions that need to be addressed in youth. Returning to work, driving, and participating in recreational activities are frequent issues for adults. For both adults and children, there is not a set playbook that will make the decision for all situations.
5. Counsel patients and their parents/caregivers to return gradually to non-sports activities after no more than a 2–3 days of rest.
This recommendation is clear, complete inactivity is risky in itself. Immediate return to demanding activities is also problematic. Careful resumption of activities, with continued assessment of the patient’s response to the changes in demand, is safest. This is true for all age groups.
I hope my additional information is helpful and encourages you and your family to discuss these issues with your physician, as a column cannot do justice to the complexity of these issues and the decisions that need to be made. For more information on traumatic brain injuries, please visit my website at drcharlesrosen.com.
Please note, the information provided throughout this article is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. All content in this article and/or available through this individual’s website is for general information purposes only. If you are experiencing relating symptoms, please visit your doctor or call 9–1–1 in an emergency.