Multidisciplinary Team of Clinicians from The Children's Hospital of Philadelphia Develops Guidelines for Treatment of Children with Mild Traumatic Brain Injury

The objective of this project was to expand the scope of existing guidelines to incorporate education, injury prevention as well as the role of rehabilitation and physiatry services in the management of mild traumatic brain injury (MTBI). It addresses the management of children up to age 18 and provides a predetermined pathway for clinicians to follow, from a patient's presentation in the emergency department through discharge.

"This clinical pathway is designed to provide clinicians with a theoretical framework on which to base decision-making," said Susan Kamerling, R.N., M.S.N., C.C.R.N., primary researcher of the guidelines. "It is imperative that clinicians and healthcare workers have a standardized framework to identify risk for injury and to help prevent further re-injury."

Mild traumatic brain injury in children is common and may leave children with long-term consequences if unrecognized. "Current practices often vary with regard to diagnosis, treatment and follow-up. This lack of standardization potentially puts children at increased risk for delayed or undiagnosed learning and behavioral disabilities, as well as raising the danger and consequences of re-injury," said Ms. Kamerling.

The new guidelines provide a pathway designed for healthcare workers to use in following children with MTBI through their treatment regimen at the hospital. The pathway takes into account the child's clinical presentation, medical history and age.

Approximately 1.5 million Americans sustain traumatic brain injuries, ranging from mild to severe, and 50,000 of those die. More than 1 million Americans are treated in EDs for TBI with 300,000 requiring hospitalization. Sports and recreational activities contribute to approximately 21 percent of all traumatic brain injuries among American children.

Patient/family education is essential when a child suffers a MTBI to decrease unnecessary stress and empower families to obtain assistance when needed. The team developed instruction sheets for home management of children with MTBI to provide information in a comprehensive and easy-to-read manner.

The instructions for home management focus on expected symptoms and guidance for when to seek further medical attention, as well as providing parents instructions for injury prevention and suggesting resources for additional information.

One of the most challenging issues for parents and physicians is knowing when to allow children who suffer from MTBI to return to sports or other physical activities. By specifying guidelines based on the effects of the initial injury, the guidelines seek to avoid the cumulative effects of repetitive MTBI as well as the potentially devastating results of "second impact syndrome." Second impact syndrome occurs when an athlete experiences a second concussion closely following a first.

Housing the first level one pediatric trauma center in Pennsylvania, Children's Hospital is recognized for its innovative, interdisciplinary approach to care for children with traumatic brain injury. The Traumatic Brain Injury Rehabilitation Team is considered one of the nation's best, providing a comprehensive, multidisciplinary approach to care that considers the whole child. Specialized services include an inpatient unit, integrated physical, speech and occupational therapy, rehabilitation nursing, neuropsychology and social work intervention, a day hospital program and outpatient unit.

Ms. Kamerling's co-authors on the study were Nicolas Lutz, M.D., formerly a trauma fellow at The Children's Hospital of Philadelphia; Jill C. Posner, M.D., M.S.C.E., an Emergency Department attending physician at Children's Hospital, and Marla Vanore, R.N., M.H.A., trauma program manager at Children's Hospital.

Founded in 1855 as the nation's first pediatric hospital, The Children's Hospital of Philadelphia is ranked in 2003 as the best pediatric hospital in the nation by U.S.News & World Report and Child magazines. Through its long- standing commitment to providing exceptional patient care, training new generations of pediatric healthcare professionals and pioneering major research initiatives, Children's Hospital has fostered many discoveries that have benefited children worldwide. Its pediatric research program is among the largest in the country, ranking second in National Institutes of Health funding among children's hospitals.

In addition, its unique family-centered care and public service programs have brought the 430-bed hospital recognition as a leading advocate for children and adolescents from before birth through age 19. Children's Hospital operates the largest pediatric healthcare system in the U.S. with more than 40 locations in Pennsylvania, New Jersey and Delaware.