Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review

doi:10.1001/jamapediatrics.2018.2847

. 2018 Nov 1;172(11):e182847.

doi: 10.1001/jamapediatrics.2018.2847. Epub 2018 Nov 5.

Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review

Angela Lumba-Brown¹, Keith Owen Yeates², Kelly Sarmiento³, Matthew J Breiding³, Tamara M Haegerich³, Gerard A Gioia⁴, Michael Turner⁵, Edward C Benzel⁶, Stacy J Suskauer^{7

8}, Christopher C Giza^{9

10}, Madeline Joseph¹¹, Catherine Broomand¹², Barbara Weissman¹³, Wayne Gordon¹⁴, David W Wright¹³, Rosemarie Scolaro Moser¹⁵, Karen McAvoy¹⁶, Linda Ewing-Cobbs¹⁷, Ann-Christine Duhaime¹⁸, Margot Putukian¹⁹, Barbara Holshouser²⁰, David Paulk¹², Shari L Wade²¹, Stanley A Herring²², Mark Halstead²³, Heather T Keenan²⁴, Meeryo Choe^{9

10}, Cindy W Christian^{25

26}, Kevin Guskiewicz²⁷, P B Raksin²⁸, Andrew Gregory²⁹, Anne Mucha³⁰, H Gerry Taylor³¹, James M Callahan^{25

26}, John DeWitt³², Michael W Collins³⁰, Michael W Kirkwood³³, John Ragheb³⁴, Richard G Ellenbogen²², T J Spinks³⁵, Theodore G Ganiats³⁶, Linda J Sabelhaus³⁷, Katrina Altenhofen³⁸, Rosanne Hoffman³⁹, Tom Getchius⁴⁰, Gary Gronseth⁴¹, Zoe Donnell³⁹, Robert E O'Connor⁴², Shelly D Timmons⁴³

Affiliations

¹ Stanford University School of Medicine, Stanford, California.
² University of Calgary, Calgary, Alberta, Canada.
³ Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.
⁴ Children's National Health System, George Washington University School of Medicine, Washington, DC.
⁵ Goodman Campbell Brain and Spine, Indianapolis, Indiana.
⁶ Cleveland Clinic, Cleveland, Ohio.
⁷ Kennedy Krieger Institute, Johns Hopkins University , Baltimore, Maryland.
⁸ Johns Hopkins University School of Medicine, Baltimore, Maryland.
⁹ UCLA Steve Tisch BrainSPORT Program, University of California, Los Angeles, Mattel Children's Hospital, Los Angeles.
¹⁰ David Geffen School of Medicine at University of California, Los Angeles.
¹¹ University of Florida Health Science Center, Jacksonville.
¹² Kaiser Permanente, Center for Neuropsychological Services, Roseville, California.
¹³ Emory University School of Medicine, Atlanta, Georgia.
¹⁴ Icahn School of Medicine at Mount Sinai, New York, New York.
¹⁵ Sports Concussion Center of New Jersey, Princeton.
¹⁶ Rocky Mountain Hospital for Children, Denver, Colorado.
¹⁷ Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston.
¹⁸ Massachusetts General Hospital, Harvard University, Boston.
¹⁹ Princeton University, University Health Service, Princeton, New Jersey.
²⁰ Loma Linda University Health, Loma Linda, California.
²¹ Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
²² University of Washington School of Medicine, Seattle.
²³ St Louis Children's Hospital, St Louis, Missouri.
²⁴ University of Utah, Salt Lake City.
²⁵ Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
²⁶ Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
²⁷ University of North Carolina, Chapel Hill.
²⁸ John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois.
²⁹ Vanderbilt University School of Medicine, Nashville, Tennessee.
³⁰ University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania.
³¹ Nationwide Children's Hospital Research Institute, Columbus, Ohio.
³² Jameson Crane Sports Medicine Institute and School of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus.
³³ Children's Hospital Colorado, Aurora.
³⁴ Nicklaus Children's Hospital, University of Miami Miller School of Medicine, Miami, Florida.
³⁵ St. Joseph's Children's Hospital, Department of Pediatric Neurosurgery, Tampa, Florida.
³⁶ University of California, San Diego.
³⁷ Vanguard Communications, Washington, DC.
³⁸ National Association of State EMS Officials, Washington, Iowa.
³⁹ ICF, Social Marketing Group, Rockville, Maryland.
⁴⁰ American Academy of Neurology, Minneapolis, Minnesota.
⁴¹ University of Kansas Medical Center, Kansas City.
⁴² University of Virginia School of Medicine, Charlottesville.
⁴³ Penn State University, Milton S. Hershey Medical Center, Hershey.

PMID: 30193325
PMCID: PMC11811836
DOI: 10.1001/jamapediatrics.2018.2847

Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review

Angela Lumba-Brown et al. JAMA Pediatr. 2018.

. 2018 Nov 1;172(11):e182847.

doi: 10.1001/jamapediatrics.2018.2847. Epub 2018 Nov 5.

Authors

Affiliations

¹ Stanford University School of Medicine, Stanford, California.
² University of Calgary, Calgary, Alberta, Canada.
³ Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.
⁴ Children's National Health System, George Washington University School of Medicine, Washington, DC.
⁵ Goodman Campbell Brain and Spine, Indianapolis, Indiana.
⁶ Cleveland Clinic, Cleveland, Ohio.
⁷ Kennedy Krieger Institute, Johns Hopkins University , Baltimore, Maryland.
⁸ Johns Hopkins University School of Medicine, Baltimore, Maryland.
⁹ UCLA Steve Tisch BrainSPORT Program, University of California, Los Angeles, Mattel Children's Hospital, Los Angeles.
¹⁰ David Geffen School of Medicine at University of California, Los Angeles.
¹¹ University of Florida Health Science Center, Jacksonville.
¹² Kaiser Permanente, Center for Neuropsychological Services, Roseville, California.
¹³ Emory University School of Medicine, Atlanta, Georgia.
¹⁴ Icahn School of Medicine at Mount Sinai, New York, New York.
¹⁵ Sports Concussion Center of New Jersey, Princeton.
¹⁶ Rocky Mountain Hospital for Children, Denver, Colorado.
¹⁷ Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston.
¹⁸ Massachusetts General Hospital, Harvard University, Boston.
¹⁹ Princeton University, University Health Service, Princeton, New Jersey.
²⁰ Loma Linda University Health, Loma Linda, California.
²¹ Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
²² University of Washington School of Medicine, Seattle.
²³ St Louis Children's Hospital, St Louis, Missouri.
²⁴ University of Utah, Salt Lake City.
²⁵ Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
²⁶ Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
²⁷ University of North Carolina, Chapel Hill.
²⁸ John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois.
²⁹ Vanderbilt University School of Medicine, Nashville, Tennessee.
³⁰ University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania.
³¹ Nationwide Children's Hospital Research Institute, Columbus, Ohio.
³² Jameson Crane Sports Medicine Institute and School of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus.
³³ Children's Hospital Colorado, Aurora.
³⁴ Nicklaus Children's Hospital, University of Miami Miller School of Medicine, Miami, Florida.
³⁵ St. Joseph's Children's Hospital, Department of Pediatric Neurosurgery, Tampa, Florida.
³⁶ University of California, San Diego.
³⁷ Vanguard Communications, Washington, DC.
³⁸ National Association of State EMS Officials, Washington, Iowa.
³⁹ ICF, Social Marketing Group, Rockville, Maryland.
⁴⁰ American Academy of Neurology, Minneapolis, Minnesota.
⁴¹ University of Kansas Medical Center, Kansas City.
⁴² University of Virginia School of Medicine, Charlottesville.
⁴³ Penn State University, Milton S. Hershey Medical Center, Hershey.

PMID: 30193325
PMCID: PMC11811836
DOI: 10.1001/jamapediatrics.2018.2847

Erratum in

Error in End Matter.
[No authors listed] [No authors listed] JAMA Pediatr. 2018 Nov 1;172(11):1104. doi: 10.1001/jamapediatrics.2018.3879. JAMA Pediatr. 2018. PMID: 30398577 No abstract available.

Abstract

Importance: In recent years, there has been an exponential increase in the research guiding pediatric mild traumatic brain injury (mTBI) clinical management, in large part because of heightened concerns about the consequences of mTBI, also known as concussion, in children. The CDC National Center for Injury Prevention and Control's (NCIPC) Board of Scientific Counselors (BSC), a federal advisory committee, established the Pediatric Mild TBI Guideline workgroup to complete this systematic review summarizing the first 25 years of literature in this field of study.

Objective: To conduct a systematic review of the pediatric mTBI literature to serve as the foundation for an evidence-based guideline with clinical recommendations associated with the diagnosis and management of pediatric mTBI.

Evidence review: Using a modified Delphi process, the authors selected 6 clinical questions on diagnosis, prognosis, and management or treatment of pediatric mTBI. Two consecutive searches were conducted on PubMed, Embase, ERIC, CINAHL, and SportDiscus. The first included the dates January 1, 1990, to November 30, 2012, and an updated search included December 1, 2012, to July 31, 2015. The initial search was completed from December 2012 to January 2013; the updated search, from July 2015 to August 2015. Two authors worked in pairs to abstract study characteristics independently for each article selected for inclusion. A third author adjudicated disagreements. The risk of bias in each study was determined using the American Academy of Neurology Classification of Evidence Scheme. Conclusion statements were developed regarding the evidence within each clinical question, and a level of confidence in the evidence was assigned to each conclusion using a modified GRADE methodology. Data analysis was completed from October 2014 to May 2015 for the initial search and from November 2015 to April 2016 for the updated search.

Findings: Validated tools are available to assist clinicians in the diagnosis and management of pediatric mTBI. A significant body of research exists to identify features that are associated with more serious TBI-associated intracranial injury, delayed recovery from mTBI, and long-term sequelae. However, high-quality studies of treatments meant to improve mTBI outcomes are currently lacking.

Conclusions and relevance: This systematic review was used to develop an evidence-based clinical guideline for the diagnosis and management of pediatric mTBI. While an increasing amount of research provides clinically useful information, this systematic review identified key gaps in diagnosis, prognosis, and management.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Benzel reports receiving funding from the Orthopedic Research and Education Foundation. Dr Gioia reports receiving royalties for the Behavior Rating Inventory of Executive Function from Psychological Assessment Resources Inc. Dr Giza reports receiving fees as a consultant to the National Football League Neurological Care Program, National Hockey League Players’ Association, National Hockey League, Major League Soccer, National Basketball Association, US Soccer Federation, and the National Collegiate Athletic Association; medicolegal work on 1 or 2 cases annually; and research support from the National Football League and General Electric. Dr Halstead reports being a lead author on the American Academy of Pediatrics policy statement on concussion. Dr Herring reports past service on a medical advisory board for X2Biosystems and payment from Vicis, a helmet manufacturer. Dr Turner reports receiving financial support from Medtronic Corporation and NICO Corporation. Dr Wright reports receiving speaker and consultant fees from Astrocyte Pharmaceuticals Inc (Scientific Advisory Board), LPath Inc, and Biogen Inc and receiving commercial support from Astrocyte Pharmaceuticals Inc, LPath, and OneMind. Dr Choe reports serving as a consultant for the World Boxing Council, USA Swimming, and Neural Analytics. Dr Christian reports serving as a medical-legal expert in child abuse cases. Dr Collins reports Board Membership and role as codeveloper for ImPACT applications; he also serves as a consultant to the Pittsburgh Steelers and Pittsburgh Penguins, and he reports medical-legal work as an expert on mTBI cases. Dr Ellenbogen reports participating in General Electric scientific board review. Dr Mucha reports receiving speaker fees from American Physical Therapy Association, Medbridge Education, Impact Applications, and several healthcare organizations. Dr Paulk reports receiving fees for legal consulting for a Pennsylvania practice. Dr Putukian reports working as a consultant for the USA Football Medical Advisory Committee, National Football League Head Neck and Spine Committee, US Lacrosse Sports Science & Safety Committee, National Collegiate Athletics Association Concussion Task Force, and the US Soccer medical advisory committee and serving as a medical consultant for Major League Soccer; she also reports receiving a research grant support from the National Collegiate Athletics Association–Department of Defense Grand Alliance and the National Operating Committee on Standards for Athletic Equipment. Drs Gronesth, Getchius, Hoffman, and Donnell were compensated through a contract with the CDC (200–2007-20003 [019]) for their contributions to this study. No other disclosures were reported.

Figures

**Figure 1.**
Flow of Article Selection Process

See this image and copyright information in PMC

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References

1. National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/traumaticbraininjury/pdf/mtbireport-a.pdf. Published 2003. Accessed February 14, 2018.
1. Gaw CE, Zonfrillo MR. Emergency department visits for head trauma in the United States. BMC Emerg Med. 2016;16(5):5. doi:10.1186/s12873-016-0071-8 - DOI - PMC - PubMed
1. Coronado VG, Thurman DJ, Greenspan AI, Weissman BM. Epidemiology. In: Jallo J, Loftus CM, eds. Neurotrauma and Critical Care of the Brain. New York, NY: Thieme; 2009:3–19.
1. Zaloshnja E, Miller T, Langlois JA, Selassie AW. Prevalence of long-term disability from traumatic brain injury in the civilian population of the United States, 2005. J Head Trauma Rehabil. 2008;23(6):394–400. doi:10.1097/01.HTR.0000341435.52004.ac - DOI - PubMed
1. Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic brain injury–related emergency department visits, hospitalizations, and deaths—United States, 2007 and 2013. MMWR Surveill Summ 2017;66(9):1–16. doi:10.15585/mmwr.ss6609a1 - DOI - PMC - PubMed

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[1] National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/traumaticbraininjury/pdf/mtbireport-a.pdf. Published 2003. Accessed February 14, 2018.

[2] National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/traumaticbraininjury/pdf/mtbireport-a.pdf. Published 2003. Accessed February 14, 2018.

[3] Gaw CE, Zonfrillo MR. Emergency department visits for head trauma in the United States. BMC Emerg Med. 2016;16(5):5. doi:10.1186/s12873-016-0071-8 - DOI - PMC - PubMed

[4] Gaw CE, Zonfrillo MR. Emergency department visits for head trauma in the United States. BMC Emerg Med. 2016;16(5):5. doi:10.1186/s12873-016-0071-8 - DOI - PMC - PubMed

[5] Coronado VG, Thurman DJ, Greenspan AI, Weissman BM. Epidemiology. In: Jallo J, Loftus CM, eds. Neurotrauma and Critical Care of the Brain. New York, NY: Thieme; 2009:3–19.

[6] Coronado VG, Thurman DJ, Greenspan AI, Weissman BM. Epidemiology. In: Jallo J, Loftus CM, eds. Neurotrauma and Critical Care of the Brain. New York, NY: Thieme; 2009:3–19.

[7] Zaloshnja E, Miller T, Langlois JA, Selassie AW. Prevalence of long-term disability from traumatic brain injury in the civilian population of the United States, 2005. J Head Trauma Rehabil. 2008;23(6):394–400. doi:10.1097/01.HTR.0000341435.52004.ac - DOI - PubMed

[8] Zaloshnja E, Miller T, Langlois JA, Selassie AW. Prevalence of long-term disability from traumatic brain injury in the civilian population of the United States, 2005. J Head Trauma Rehabil. 2008;23(6):394–400. doi:10.1097/01.HTR.0000341435.52004.ac - DOI - PubMed

[9] Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic brain injury–related emergency department visits, hospitalizations, and deaths—United States, 2007 and 2013. MMWR Surveill Summ 2017;66(9):1–16. doi:10.15585/mmwr.ss6609a1 - DOI - PMC - PubMed

[10] Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic brain injury–related emergency department visits, hospitalizations, and deaths—United States, 2007 and 2013. MMWR Surveill Summ 2017;66(9):1–16. doi:10.15585/mmwr.ss6609a1 - DOI - PMC - PubMed

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Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review

Affiliations

Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review

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