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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.

Importance: Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States., Objective: To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI., Evidence Review: The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015., Findings: The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment., Conclusions and Relevance: This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.

Primary Objective: To assess feasibility and utility of neurocognitive testing of children evaluated and discharged from the ED with mild traumatic brain injury (MTBI)., Methods: Paediatric blunt trauma patients (aged 11-18 years) evaluated in the ED for MTBI and control patients with isolated lower extremity injury were prospectively enrolled. All patients were administered a validated neurocognitive test (ImPACT(©)). Wilcoxon sign rank tests were used to compare reported symptoms and neurocognitive performance between subjects and controls, as well as to matched normative data., Results: Thirty-nine subjects and 46 controls were enrolled. The MTBI patients had a mean age of 13.9 years (53.8% male). An abnormal symptom score was reported in 89.7% of MTBI subjects (mean score = 29.4, normal ≤ 8), differing significantly (p < 0.05) from controls, in whom 39.1% demonstrated an abnormal score (mean score = 8.7). In all neurocognitive test domains, visual motor speed and reaction time, MTBI patients demonstrated lower scores than normative data (p < 0.05)., Conclusions: Patients with MTBI were more likely than control subjects to have scores on any or all neurocognitive domains below the 25th percentile and 10th percentile. In the ED setting, acute neurocognitive testing of MTBI in children is feasible. This highlights the importance of structured follow-up for this treated and released population.

Background: This study examined symptom reports and neurocognitive outcomes in children (8-17 years) with mild traumatic brain injury (mTBI) or orthopaedic injury (OI)., Method: Children and parents were initially assessed upon presentation in the Emergency Department of a local hospital and again at 3 months. Children completed the Immediate Post-Concussion Assessment and Cognitive Testing battery (ImPACT) and parents completed the Behavior Rating Inventory of Executive Function (BRIEF). The Peabody Picture Vocabulary Test, 3rd edition (PPVT-III) was completed by the children at the 3-month assessment., Results: Children with mTBI reported more symptoms than the OI group initially, but did not differ from the OI group at 3 months. Both groups reported a higher than expected number of symptoms at 3 months. On the ImPACT, children with mTBI performed significantly worse than the OI on a visual memory test at both assessments. The OI group had higher levels of parent-reported executive dysfunction on the BRIEF at initial and 3-month assessments., Discussion: As expected, more post-concussion symptoms were initially reported by children and adolescents with mTBI vs orthopaedic injury, but there was no difference at 3 months. The BRIEF and ImPACT cognitive measures did not differentiate concussed subjects from controls, with the exception of concussed subjects' lower performance on a visual memory test at both initial assessment and at 3 months.

Objective: To determine the self-reported practices and attitudes surrounding concussion diagnosis and management in a single, large pediatric care network., Methods: A cross-sectional survey was distributed to pediatric primary care and emergency medicine providers in a single, large pediatric care network. For all survey participants, practices and attitudes about concussion diagnosis and treatment were queried., Results: There were 145 responses from 276 eligible providers, resulting in a 53% response rate, of which 91% (95% confidence interval [CI]: 86%-95%) had cared for at least 1 concussion patient in the previous 3 months. A Likert scale from 1 "not a barrier" to 5 "significant barrier" was used to assess providers' barriers to educating families about the diagnosis of concussion. Providers selected 4 or 5 on the scale for the following barriers and frequencies: inadequate training to educate 16% (95% CI: 11%-23%), inadequate time to educate 15% (95% CI: 12%-24%), and not my role to educate 1% (95% CI: 0.4%-5%). Ninety-six percent (95% CI: 91%-98%) of providers without a provider decision support tool (such as a clinical pathway or protocol) specific to concussion, and 100% (95% CI: 94%-100%) of providers without discharge instructions specific to concussion believed these resources would be helpful., Conclusions: Although pediatric primary care and emergency medicine providers regularly care for concussion patients, they may not have adequate training or infrastructure to systematically diagnose and manage these patients. Specific provider education, decision support tools, and patient information could help enhance and standardize concussion management.

The article focuses on a study which identified children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom computed tomography (CT) might be unnecessary. Age-specific prediction rules for ciTBI were derived and validated by the researchers in a large, diverse population of children with minor head trauma. The study noted the importance of CT reduction in children younger than 2 years old because they are sensitive to radiation. The limitations of the study are also cited.