The U.S. Centers for Disease Control & Prevention (CDC) announced a comprehensive guideline on diagnosing and imaging pediatric mild traumatic brain injury cases. The guideline was published today as a special communication in the journal JAMA Pediatrics. While an adult guideline has been in place for several years, this is the first-ever treatment guideline specific to pediatric patients.
There is no doubt that mild traumatic brain injury in children has been in the news a lot in recent years. Perhaps it started with all of the attention on concussions in the NFL, which gradually filtered down into high school and middle school football and other sports.
In my view, the guideline is needed. According to the CDC, between 2005 and 2009, there were almost 3 million emergency room visits for children complaining of mild traumatic brain injuries.
As an initial matter, the guideline recommends that healthcare providers use the term “mild traumatic brain injury” as opposed to other terms that are sometimes used interchangeably, including concussion and minor head injury.
Definition of mild traumatic brain injury
The guideline defines a mild traumatic brain injury as an acute brain injury resulting from mechanical energy to the head from external forces including:
(1) 1 or more of the following: confusion or disorientation, loss of consciousness for 30 minutes or less, post-traumatic amnesia for less than 24 hours, and/or other transient neurological abnormalities such as focal signs, symptoms, or seizure;
(2) Glasgow Coma Scale score of 13-15 after 30 minutes post-injury or later upon presentation for healthcare.
The new pediatric guideline contains several recommendations. I will summarize some of the significant ones here.
The guideline recommends that physicians, nurse practitioners, and physician’s assistants should not routinely order CT scans to diagnose children with a mild traumatic brain injury.
As a Houston, Texas medical malpractice attorney, I do not find this recommendation surprising. After all, as a growing body of literature discourages the routine use of CT scans because of the potentially-dangerous cumulative effect of radiation exposure. In many cases that I have reviewed, physicians order head CT scans almost reflexively.
The guideline recommends that, before ordering a head CT scan, healthcare providers weigh the benefits versus the risks of causing additional harm, including factors like: (1) patient age of less than two years; (2) vomiting; (3) loss of consciousness; (4) severe mechanism of injury; (5) severe worsening headache; (6) amnesia; (7) non-frontal scalp hematoma; (8) Glasgow Coma Scale score of less than 15; and (8) clinical suspicion for skull fracture. Plus, healthcare providers should discuss the risks of a pediatric CT scan with the patient and family members.
Although MRI scans do not pose radiation risk like CT scans, the guideline also does not recommend routine use of MRIs for the acute evaluation of a suspected or diagnosed mild traumatic brain injury.
The guideline recommends that physicians and other healthcare providers counsel patients and family members that 70-80% of children with a mild traumatic brain injury do not show significant difficulties lasting more than one to three months after the injury. Counseling should also include that each child recovery from a mild traumatic brain injury is unique and will follow its own path.
Given all of the media attention to sports injuries, I found it interesting that the guideline recommends that healthcare providers counsel children and families presenting for sports physicals about the risks of mild traumatic brain injuries. The counseling should include the fact that recovery from a mild traumatic brain injury could be delayed by factors including prior history of such an injury, lower cognitive ability (for children with an intracranial lesion), neurological or psychiatric disorder, learning difficulties, post-concussive symptoms, and family and social stressors.
The guideline includes recommendations that physicians and other healthcare providers screen for factors that could make recovery from a mild traumatic brain injury more difficult, and then closely monitor children who are deemed to be at high risk for persistent symptoms. In addition, for patients whose mild dramatic brain injury symptoms do not resolve within 4-6 weeks, the physician or other provider should order appropriate assessments and interventions.
The research shows that there is a group of pediatric patients whose symptoms last longer than three months. Mild traumatic brain injuries are known to affect the ability of children to function at all levels, including physical, thinking (cognitive), and emotional (psychological).
Overall, I believe that the CDC guideline is a step in the right direction and when healthcare providers educate and cooperate closely with parents, it can lead to better care for children with mild traumatic brain injuries. While the CDC recommends a less-aggressive approach in most circumstances, it also contemplates a collaborate decision-making approach with patients and families.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2017, by H Texas as one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.