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