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November 5, 2018

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

Author Affiliations
  • 1Stanford University School of Medicine, Stanford, California
  • 2University of Calgary, Calgary, Alberta, Canada
  • 3Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
  • 4Children's National Health System, George Washington University School of Medicine, Washington, DC
  • 5Goodman Campbell Brain and Spine, Indianapolis, Indiana
  • 6Cleveland Clinic, Cleveland, Ohio
  • 7Kennedy Krieger Institute, Johns Hopkins University , Baltimore, Maryland
  • 8Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 9UCLA Steve Tisch BrainSPORT Program, University of California, Los Angeles, Mattel Children’s Hospital, Los Angeles
  • 10David Geffen School of Medicine at University of California, Los Angeles
  • 11University of Florida Health Science Center, Jacksonville
  • 12Kaiser Permanente, Center for Neuropsychological Services, Roseville, California
  • 13Emory University School of Medicine, Atlanta, Georgia
  • 14Icahn School of Medicine at Mount Sinai, New York, New York
  • 15Sports Concussion Center of New Jersey, Princeton
  • 16Rocky Mountain Hospital for Children, Denver, Colorado
  • 17Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston
  • 18Massachusetts General Hospital, Harvard University, Boston
  • 19Princeton University, University Health Service, Princeton, New Jersey
  • 20Loma Linda University Health, Loma Linda, California
  • 21Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 22University of Washington School of Medicine, Seattle
  • 23St Louis Children’s Hospital, St Louis, Missouri
  • 24University of Utah, Salt Lake City
  • 25Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 26Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania, Philadelphia
  • 27University of North Carolina, Chapel Hill
  • 28John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois
  • 29Vanderbilt University School of Medicine, Nashville, Tennessee
  • 30University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania
  • 31Nationwide Children’s Hospital Research Institute, Columbus, Ohio
  • 32Jameson Crane Sports Medicine Institute and School of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus
  • 33Children's Hospital Colorado, Aurora
  • 34Nicklaus Children’s Hospital, University of Miami Miller School of Medicine, Miami, Florida
  • 35St. Joseph’s Children’s Hospital, Department of Pediatric Neurosurgery, Tampa, Florida
  • 36University of California, San Diego
  • 37Vanguard Communications, Washington, DC
  • 38National Association of State EMS Officials, Washington, Iowa
  • 39ICF, Social Marketing Group, Rockville, Maryland
  • 40American Academy of Neurology, Minneapolis, Minnesota
  • 41University of Kansas Medical Center, Kansas City
  • 42University of Virginia School of Medicine, Charlottesville
  • 43Penn State University, Milton S. Hershey Medical Center, Hershey
JAMA Pediatr. 2018;172(11):e182847. doi:10.1001/jamapediatrics.2018.2847
Key Points

Question  What guidance does existing evidence provide for the diagnosis, prognosis, and management of pediatric mild traumatic brain injury (TBI)?

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

Meaning  Despite a substantial increase in the research related to pediatric mild TBI, a number of key clinical questions remain.


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.