What are the guidelines for managing traumatic brain injury (TBI), specifically concussion, in pediatric patients?

From the Guidelines

Concussion management in children requires a careful, stepwise approach to ensure proper recovery, with the most recent guidelines from 2018 recommending a gradual return to activities after 24-48 hours of cognitive and physical rest 1. The guidelines emphasize the importance of evaluating children with suspected concussions by a healthcare provider and providing medical clearance before returning to play 1. Key aspects of concussion management in children include:

• Immediate cessation of physical activity and evaluation by a healthcare provider
• 24-48 hours of cognitive and physical rest, followed by a gradual return to activities
• Avoidance of screens, reading, and mentally demanding tasks during early recovery
• Gradual reintroduction of physical activity using a 5-step protocol: light aerobic activity, moderate activity, non-contact training drills, practice, and finally full competition, with each step taking at least 24 hours and requiring symptom-free status before progression
• Limited medication use, with acetaminophen preferred over NSAIDs for headache management
• No return to sports until completely symptom-free at rest and with exertion, and cleared by a healthcare provider
• Monitoring for persistent symptoms, as recovery typically takes longer in children than adults, often 2-4 weeks 1. It is essential to prioritize a cautious approach, as children's developing brains are more vulnerable to second impact syndrome and long-term consequences from concussions 1. The Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children provides evidence-based recommendations for healthcare professionals, emphasizing the need for individualized return-to-school programming and collaboration among medical, school, and family systems to minimize cognitive and physical overexertion 1.

From the Research

Guidelines for Managing Traumatic Brain Injury (TBI) in Pediatric Patients

• The management of concussion in pediatric patients should be tailored to the individual's symptoms and focus on an early and gradual return to both cognitive and noncontact low-risk physical activity 2.
• A multidisciplinary approach is often helpful in addressing specific symptoms, which fall into the somatic, cognitive, vestibular, emotional, and sleep domains 2.
• The cornerstones of initial management are cognitive and physical rest, with a graded return-to-play protocol implemented once the patient has recovered in all affected domains 3.
• Children, adolescents, and those with a history of concussions may require a longer recovery period, and a more conservative approach to management is appropriate in these patients 3.

Return to Activity (RTA) and Return to School (RTS) Protocols

• New protocols highlight differences from earlier versions, including symptom strata to allow quicker progression for those who recover most quickly, a shortened rest period (24-48 hours) accompanied by symptom-guided activity, and the recommendation that children progress through the stages before they are symptom-free 4.
• Specific activity suggestions at each stage of the RTA protocol and recommendations for the amount of time to spend per stage are also included in the new protocols 4.
• Integration of RTS and RTA is important, with a focus on gradual progression and symptom management 4.

Role of Physical Activity in Recovery

• Current guidelines recommend a period of physical and cognitive rest with a gradual progressive return to activity, and most studies report a positive impact of exercise in facilitating recovery after concussion 5.
• Physical therapists should be aware that current neuroimaging evidence supports participation in physical activity after an initial and brief period of rest, and consider how best to incorporate exercise into rehabilitation to enhance recovery following concussion 5.

Evaluation and Management in Emergency Departments

• Emergency medicine physicians routinely use medications to treat the symptoms of concussion and often refer patients to primary care physicians as well as designated sports concussion clinics for follow-up 6.
• Most clinicians use a published guideline in their management of concussions, and the symptoms most likely to prompt head imaging in the ED include a focal neurological deficit, altered mental status, and intractable vomiting 6.