Currently there are no consensus guidelines for evaluation and management of pediatric mild TBI outside of the sports arena.

The Loophole of Pediatric Concussion / Mild TBI

Traumatic Brain Injury (TBI) is, by far, the leading cause of pediatric death in the U.S. For every child that dies from TBI, many more survive. This cannot be minimized by the old belief that children recover better from TBI than adults because they are more “plastic.” On the contrary, often these children cannot progress through a normal developmental continuum, so even a comparatively mild TBI can have devastating long-term effects.

We know from epidemiological studies done by the CDC that toddlers and teenagers are at the highest risk. These studies also suggest that 75% of all TBIs are concussions / mild TBI. In fact, these studies based on ER visits probably underestimate the problem due to the number of cases that never even seek medical attention. This is a common scenario since a young toddler who has subtle initial symptoms may seem intact to their parents and even their pediatrician.

In a system where medical education falls short on teaching nuances of development, age-specific cognition and functional neurological evaluation, mild pediatric traumatic brain injury becomes a perfect storm for both assessment and management. Currently there are no consensus guidelines for evaluation and management of pediatric mild TBI outside of the sports arena. Because of the priority our country places on sports and the recent media attention to Second Impact Syndrome and early onset dementia in NFL players, many states have legislated return-to-play guidelines to protect their adolescent school athletes. These guidelines are based on the basic principle that the patient should be protected from re-injury via physician monitored, graduated return to activities (both physical and cognitive.)

School athletes have the luxury of pre-injury baseline computerized testing (IMPACT) that measures some cognitive domains and reaction time. Along with standardized point-based balance testing, this offers a fairly cookie cutter option for managing these patients. What about all of those toddlers and non-athlete children (i.e., the overwhelming majority)? If the children’s injuries merit admission to the hospital, they are typically admitted to a surgical service — usually Trauma but possibly Neurosurgery if there is an isolated skull fracture / head bleed. These busy services are focused on addressing surgical needs and as soon as patients have cleared from a surgical standpoint, they are discharged.

These teams do not have formal training in neurodevelopment, age-specific multi-domain cognitive evaluation, behavioral issues and other long-term sequelae of TBI. Often, they may not recognize subtle deficits or the need to consult a specialist, therapist or school services. In fact, there are few specialists with this training in the country (mainly pediatric physiatrists) and, contrary to popular belief, pediatric neurologists have not traditionally been very involved with TBI. Follow-up from the hospital admitting teams is limited, if any, and focused on surgical issues. This often leaves children in a lurch whose deficits were subtle enough to be missed in the hospital, but later make a huge impact on school performance, social skills, behavior, and self-esteem. Furthermore, distractibility, fatigue, visuospatial problems and delayed response times place these children at very high risk for re-injury. Sadly, they often miss out on school services that are rightly theirs since treating physicians do not link the patients to their diagnosis of TBI.

Wendy E. Goodwin, MDW. E. Goodwin is a physician who is board certified in both (adult) Physical Medicine & Rehabilitation and Pediatric Rehabilitation Medicine. She consults and testifies in cases regarding children who are injured, severely ill, or are mentally challenged.