Recent Clinical Guideline Updates: 

Updates to the clinical guideline recommendations in the Living Guideline for Pediatric Concussion Care will be shared in the below table.

Last updated: January 24, 2021

Domain Recommendation Update Evidence % Consensus
15- Telemedicine and Virtual Care New tool 15.2 shared in recommendation 15.1d Tool 15.2: Virtual Care Exam Training Resource: A training manual to assist front-line healthcare professionals who are caring for patients that cannot be seen in person or have already had an in-person assessment and require follow-up.   91% Consensus. 30/33 of experts on the expert panel reviewed and voted to include. Quorum: 87%. 33/38 exert panel members participated in the vote. *Two expert panel members were authors and were not included in the vote. Two project leads (RZ and NR) are also authors and did not participate in the vote or decision making
Domain 1-Concussion Recognition and Directing to Care 1.3 Minor revision (red): If a child/adolescent demonstrates any of the ‘Red Flags’ indicated by the Concussion Recognition Tool 5, a more severe head or spine injury should be suspected and an emergency medical assessment is required. These red flag symptoms may appear immediately or within a few hours or days after injury. Delayed red flag symptoms also require urgent medical assessment as they may indicate a more severe injury. Consider arranging an ambulance service as necessary to facilitate urgent medical assessment at the nearest hospital and execution of the Emergency Action Plan for your organization. When calling an ambulance, describe the specific red flags symptoms over the phone.

Eagle et al 2020

 

Borland et al 2019

100% consensus(Domain 1 and 2 expert panel members voted for this minor revision)
Domain 1-Concussion Recognition and Directing to Care 1.4 Minor revision (red): Concussion should be suspected and diagnosed as soon as possible to maintain health and improve outcomes. Concussion can be suspected in the community by healthcare professionals, parents, teachers, coaches, and peers. Those with a suspected concussion should be assessed by a physician or nurse practitioner to perform a thorough medical assessment to exclude more severe injuries, consider a full differential diagnosis, and confirm the diagnosis of concussion. It is important to note that some patients may experience a delayed onset of concussion symptoms. Delayed concussion symptoms also require medical assessment to exclude more severe injuries.

Eagle et al 2020

 

Borland et al 2019

100% consensus(Domain 1 and 2 expert panel members voted for this minor revision)
Domain 15-Telehealth and Virtual Care

Recommendations 15.1-15.6 Considerations for a virtual medical assessment and follow-up

Tools 15.1 and 15.2 (Algorithm and physical exam)

New set of recommendations. See Domain 15 See Domain 15 Reference list 93% (full expert team vote that included 27/35 of the active panel members (77% quorum)
2- Initial Diagnosis and Management 2.3. Graduated return to physical and cognitive activity New Recommendation:  Update recommendation 2.3 to include a section “d” that shares the suggestion to consider referring select patients (e.g., highly active or competitive athletes and/or those who are not tolerating a graduated return to physical activity) to a medically supervised inter-disciplinary team with the ability to individually assess sub-symptom threshold aerobic exercise tolerance and to prescribe aerobic exercise treatment.

Coclick et al 2020,

Haider et al 2020,

DeMatteo et al 2020Del Rossi et al 2020Root et al 2020Sharma et al 2020Marshall et al 2020Leddy et al 2019Chan et al 2018, See domain 2 reference link for a full list.  . New- Dec 2020 paper under consideration: Langevin et al 2020     .

93% (full expert team vote, that included 36/39 of the active panel team member experts)
2- Initial Diagnosis and Management 2.2 Return to School Minor clarification: Highlight the return to school information from Domain 12 by including information about  Acute academic adjustments for concussion and give examples of academic adjustments to help support students transitioning back to school Master et al 2020 50% (not added)
1-Diagnosis 1.4 When to suspect concussion Minor revision: “It is important to note that some patients may experience a delayed onset of concussion symptoms. Delayed concussion symptoms also require medical assessment to exclude more severe injuries.”

Kontos et al 2020,

Gravel et al 2020Borland et al 2019,

100%
7- Sleep   Minor revision: Add in a star to the melatonin recommendation that includes: “Melatonin was not found to be effective when used for youth with concussion symptoms 4-6 weeks after injury in a single-center double-blinded randomized controlled trial” (Barlow et al 2020. Efficacy of Melatonin in Children With Postconcussive Symptoms: A Randomized Clinical Trial. Pediatrics) Barlow et al 2020 100%
7- Sleep   A review of the timing of the recommended use of Melatonin and the dose has been suggested. Barlow et al 2020 (pediatrics), Iyver et al 2020Barlow et al 2020 (Ped Neurol) Vote in progress
7- Sleep   A minor revision to the introduction, adding in: “Medication use, headaches and mental health conditions (e.g. anxiety, depression) may also affect sleep. Poor sleep may be related to cognitive complaints and worse post-concussion symptoms. “ Ludwig et al, 2020Starkey et al 2016, 100%
2- Initial Diagnosis and Management 2.1b: Note common modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms. Minor Revision: Update the list of modifiers for a prolonged recovery to include: High symptom burden at initial presentation, clinical evidence of vestibular or oculomotor dysfunction, duration of recovery from a previous concussion. Zemek et al 2016, Beauchamp et al 2018, Ellis et al 2018Fehr et al 2019Guerriero et al 2018Howell et al 2018Howell et al 2018Ledoux et al 2019,  Master et al 2018,  Yeates et al 2019 100%
2- Initial Diagnosis and Management 2.2: Provide verbal information and written (electronic) handouts regarding the course of recovery and when the child/adolescent can return to school/activity/sport/work. Minor Revision: Include a sentence sharing that the information that females aged 13-18 years have an increased risk of a prolonged recovery. Ledoux et al 2019 83%
7- Sleep Introduction Minor Revision: Update the 4th sentence of the introduction to include: “Medication use, headaches and mental health conditions (e.g. anxiety, depression) may also affect sleep. Poor sleep may be related to cognitive complaints and worse post-concussion symptoms. A repeat…”

Murdaugh et al 2018

Wiseman-Hakes et al 2019

100%
4- Medical Clearance 4.1: Child/adolescent has successfully returned to all school activities including writing exams without symptoms above their previous pre-injury level or requiring accommodations related to their concussion/post-concussion symptoms.

Minor revision:

Update level of evidence to

Dematteo et al 2019 100%
12- Return to School and Work 12.5: Return-to-school and return-to-sport strategies can be performed simultaneously. Recommend that the child/adolescent return-to-school full-time at a full academic load, including writing exams without accommodations related to their concussion/post-concussion symptoms, before returning to full-contact sport or high-risk activities.

Minor Revision:

Update level of evidence to

Dematteo et al 2019 80%

*Consensus for minor revisions: Minimum three domain experts vote on minor revisions. 75% consensus is required to proceed with a minor revision. Please see the Methodology Living Guideline pdf for more information.

** Consensus for minor revisions: Minimum three domain experts vote on minor revisions. 75% consensus is required to proceed with a minor revision. Please see the Methodology Living Guideline pdf for more information. **Consensus for major revisions: A quorum of 75% of active expert panel members are required to vote on the improvement. 75% consensus is required to proceed with a major revision. A pediatric pharmacist will perform an additional review for any proposed changes in dosing. ** Definitions of the A, B, C level of evidence can be found here: Levels of Evidence