Mild TBI in Children: Guidance from the CDC for Diagnosis and Treatment
Am Fam Physician. 2019 Apr 1;99(7):462-464.
Related article: Current Concepts in Concussion
Author disclosure: No relevant financial affiliations.
Key Points for Practice
• Head CT should not be routinely performed to assess patients with mild TBI.
• Most symptoms resolve within one to three months after TBI, with significant difficulties rarely lasting longer.
• Full return to activity is appropriate only after the patient is without symptoms at rest and gradually increased activity.
From the AFP Editors
Mild traumatic brain injury (TBI) in children is a major problem in the United States, causing pathophysiologic injuries and associated symptoms that can result in poor physical, cognitive, or psychological function. Although guidelines exist for adults and specifically for sports-related concussions in children, there has been no guidance provided on diagnosing and treating mild TBI in children. Based on a systematic literature review, the Centers for Disease Control and Prevention (CDC) released recommendations specific to children with Glasgow Coma Scale scores of 13 to 15. It should be noted that because the terms concussion, minor head injury, and mild TBI are often used with the same intended meaning, but actually have different connotations that can result in misinterpretation, the CDC recommends using the term mild TBI.
Head computed tomography (CT) should not be routinely performed to assess patients with mild TBI. Clinical decision rules, such as the Pediatric Emergency Care Applied Research Network decision rule (https://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm), should be used instead to differentiate patients with a low risk of intracranial injury from those at higher risk of clinically important intracranial injury to determine the necessity of CT. Such decision rules assess a combination of risk factors that include age younger than two years, amnesia, Glasgow Coma Scale score, loss of consciousness, nonfrontal scalp hematoma, severe headache, significant mechanism of injury, suspicion of scalp fracture, and vomiting. Symptom rating scales and computerized cognitive testing specific to the patient's age are additional options to aid in diagnostic assessment of mild TBI; however, it should be noted that the Standardized Assessment of Concussion is not appropriate as a stand-alone diagnostic tool in patients six to 18 years of age. A discussion of the risks associated with head CT (e.g., radiation, sedation) should occur to help provide families with greater insight into the care process and decision-making.
Although magnetic resonance imaging is more sensitive than CT and avoids radiation, it should not be routinely performed in the acute setting because of the lack of adequate study in magnetic resonance imaging trials, increased need for sedation, and expense. Single-photon emission CT (SPECT) also should not be performed in evaluations of suspected or confirmed
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This series is coordinated by Sumi Sexton, MD, Editor-in-Chief.
A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.
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