September 4, 2018: JAMA Pediatrics (Journal of the American Medical Association, Pediatrics) publishes new guidelines on evaluation of mild traumatic brain injury in children. One purpose of this blog is to provide up-to-date expert information on Traumatic Brain Injury (TBI). The reader of this blog can refer directly to this material as it appears on-line, usually free of charge.
The CDC (Center for Disease Control) has used 25 years of accumulated data to gather a panel of specialists to make clinical recommendations. Most health care providers are simply too busy to stay up-to-date on many aspects of clinical medicine. These expert recommendations provide a consensus review of the literature emphasizing its strengths and weaknesses.
I have previously discussed mild TBI in children. Pediatric head trauma patients are a difficult group to study because they have difficulty communicating symptoms of head injury and they are dependent on adults to find care. One recommendation is that children only occasionally need CT scans of the brain in the ER. Kids rarely require acute neurosurgical intervention. CT scans in adults are often routine. They expose young people to needless radiation.
Also, children must often be sedated to get an accurate scan. The last thing a clinician wants to do is sedate a child that has experienced head trauma. Mental alertness is critical in determining severity of injury. MRI scans are almost impossible in children as they require prolonged absence of movement.
Cognitive testing is important as age-related norms on testing are important in children. Any pre-injury problems in school places the child at higher risk. The close integration of the educational system and the health care system is critical. Teachers are often the first observers of deviation from pre-trauma behavior and learning. Thus, teachers should be alerted to any history of significant head trauma.
Vision can be involved. Specific recommendations are made in relation to vestibular-oculomotor function in children. The evaluation and treatment by a vestibular oculomotor specialist is made. The ophthalmologist is left out of the equation, but oculomotor specialist indicates the importance of eyesight. I see many pediatric patients in my practice.
Children often return to physical environments where they are at risk for repeat head injury (often mild). Adults after an automobile accident are unlikely to experience another collision soon after the initial trauma, and returning to a desk and a computer terminal does not present the likelihood of a second impact. Children return to school and physical education, older children return to high school sports teams. Children routinely engage in more bumping and banging behavior than sedentary adults. Every parent knows this to be true. The literature on mild TBI is clear, the second head knock can do long-term damage if the brain has not fully recovered. Children and concussions is a blog subject that is also worth a second look.
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Steven H. Rauchman, M.D. is an eye physician and surgeon who has been in private practice for 30 years. He has served as a Traumatic Brain Injury (TBI) medical/legal expert for the last 6 years specializing in the area of personal injury and related traumatic brain injuries.