The Journal of the Arkansas Medical Society Med Journal June 2019 Final | Page 12

EDITORIAL PANEL: Chad T. Rodgers, MD, FAAP | Elena M. Davis, MD, MPH | William L. Mason, MD | Michael Moody, MD | J. Gary Wheeler, MD, MPS
Management and Treatment Options
for Pediatric Traumatic Brain Injury
LAURA J. HOBART-PORTER, DO, FAAPMR
EDITOR’S NOTE: In the May issue,
Dr. Hobart-Porter discussed the
diagnosis and prognosis for pediatric
mild traumatic brain injury. She
continues this month with its
management and treatment.
P
ediatric mild traumatic brain
injury (mTBI) is a common but
complex and potentially seri-
ous condition, which affects
millions of children each year. 1 Most
recover in one to three months, but
some patients have persistent and
functionally impairing symptoms
that require additional management.
The Centers for Disease Control
and Prevention (CDC) presented a
consensus guideline in November
2018 on the management of child-
hood mTBI, based on a systemic
review of articles published between
1990-2015. 2 Use of the term mild
traumatic brain injury in place of
concussion is now recommended.
Mild TBI is “an acute brain
injury from mechanical energy to
the head from external physical
forces including: (1) one 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 (GCS) score of 13-15 after
30 minutes post-injury or later upon
presentation for healthcare.” 3
Recommendations regarding
prognosis, diagnostics, manage-
ment and treatment options were
rated according to the CDC commit-
tee’s level of confidence as well as
strength of recommendation. Level
of confidence included High, Mod-
erate, Low and Very Low. Strength of
recommendation included Level A
(should always be followed), Level B
(usually should be followed), Level
C (may sometimes be followed),
Level U (insufficient evidence to
make recommendation), and Level R
(should not be done outside research
setting). The following is a summary
of committee consensus on manage-
ment and treatment of mTBI.
EDUCATE FAMILY ABOUT
TREATMENT
In addition to providing reas-
surance and education, health care
professionals should provide families
with counseling on warning signs
of more serious injury, instructions
on when to return to play and
276 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
school, injury prevention, and clear
follow-up instructions. In the past,
absolute rest was often prescribed
for those recovering from mTBI.
Inactivity beyond a few days may
worsen self-reported symptoms and
has the potential to prolong recov-
ery. 4,5 It is now recommended that
after the first several days, children
gradually resume both physical
and cognitive activities that do not
exacerbate their symptoms (Mod-
erate level of confidence, Level B
strength of recommendation). After
a gradual return to activity is success-
ful, providers should offer an active
rehabilitation program of progressive
reintroduction of noncontact aerobic
activity (High, Level B).
As with any return-to-activity
recommendation in mTBI, it is vital that
providers closely monitor symptom
expression and that mTBI patients stop
activity that exacerbates symptoms.
Children should return to full activity
when they return to premorbid perfor-
mance and are symptom free at rest
and with increased levels of exertion
(Moderate, Level B). For instance, a
child who has symptoms with jogging
should be returned to the prior level of
symptom-free activity — light activ-
ity or walking. Activity level may be
VOLUME 115