Update on Pediatric Concussions
AUTHORS
Cameron Callipari, MD, Department of Emergency Medicine, Columbia University Medical Center, New York
Adria Simon, MD, Assistant Professor of Emergency Medicine, Columbia University Medical Center, New York
PEER REVIEWER
Aaron Leetch, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Arizona College of Medicine, Tucson
The authors provide a current summary of the best practices for diagnosis and management of pediatric concussions.
— Ann M. Dietrich, MD, Editor
Introduction
Pediatric concussions pose a challenge for emergency providers to evaluate and manage, not necessarily because of their complexity, but rather because of the nuanced and dynamic recommendations that follow these injuries. Accurate and timely diagnosis is the first vital step in initiating treatment, guidance, and counseling that could help prevent potentially debilitating sequelae. The emergency department (ED) clinician plays an important role within the vulnerable time period where re-injury could result in prolonged post-concussive symptoms or, in rare instances, catastrophic brain swelling.1 Therefore, it is important for emergency providers to sort through the plethora of guidelines and recommendations to put forth a practical treatment plan in real time.
There are numerous recommendations and guidelines in the medical literature on the approach to pediatric concussions aimed at symptom management and mitigating the risk of re-injury and its associated sequelae. The Centers for Disease Control and Prevention (CDC) Pediatric Mild Traumatic Brain Injury (mTBI) guideline is one of the more prominent and frequently referenced resources to guide management of pediatric mTBI across a variety of care settings from the emergency department to outpatient follow-up care. The CDC’s guideline on mTBIs in pediatric patients includes 19 sets of recommendations that span the breadth of clinical management from initial diagnosis to supportive treatment and will be referenced as a central component of this article’s updated recommendations.
Definition
Concussions, or mTBIs, are trauma-induced physiologic disruptions in brain function resulting from a blunt impact force and/or an acceleration-deceleration event. Many nuanced and heterogeneous definitions have been put forth previously; as a result, in 2004, the World Health Organization Collaborating Centre Task Force on mTBI, along with the mTBI Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine and the CDC mTBI Working Group Report to Congress, came together to develop a comprehensive consensus definition of mTBI based on several criteria.
- First, there must be an acute brain injury as the result of a mechanical force to the head from an external physical entity.
- Next, this injury must involve one or more of the following symptoms: disorientation, loss of consciousness for less than 30 minutes, post-traumatic amnesia for 24 hours or less, or other transient neurological abnormalities.
- Last, the criteria mandate a Glasgow Coma Scale score of 13-15 within 30 minutes of the initial injury or at the time of presentation in the ED.2
In 2017, the 5th International Conference on Concussion in Sport revisited the previously accepted definition stating that a concussion is the short-lived neurological impairment resulting from either an indirect or direct impulsive force to the head.3-5 Although the definitions vary in degree of specificity, they are unified in the presence of some transient degree of neurological impairment from an external force to the head as the defining features of mTBI.
Epidemiology
Both the incidence and increasing prevalence of mTBI in children present a significant public health concern. Currently, it is estimated that 1.1 million to 1.9 million children younger than 18 years of age in the United States experience recreational and sports-related concussions annually.6 This results in a substantial number of visits to both the ED and outpatient providers, as data from 2005 to 2009 showed that children made more than 2 million outpatient visits and almost 3 million ED visits for initial workup of mTBI symptoms.5 The rates of pediatric visits for minor head injuries to outpatient offices and EDs over the last decade have increased between two- to fourfold in Canada and the United States.7-9
Increasing rates of diagnosis are likely multifactorial in nature and can be attributed to both improved provider and coaching staff education as well as increased media exposure. Additionally, as gender equity in sport continues to improve, the number of athletes at risk for mTBI increases commensurately. With the increasing number of children participating in athletics, along with increased speed, strength, and size of young athletes, the likelihood of head injury is becoming more significant.10 This is especially true for female children; as has been demonstrated epidemiologically, more female athletes are diagnosed with a concussion compared to their male counterparts, likely for multifactorial reasons.11 Still, these increased estimates may be underreported, given that many athletes choose to downplay or not report their injuries. A recent study of high school athletes showed that only 40% to 45% reported their sports-related concussion.12 Therefore, it is important for the emergency provider to maintain a high index of suspicion for mTBI.
This suspicion for an mTBI can be heightened depending on the mechanism of injury the patient is reporting. Various studies have been published in an attempt to assess the most high-risk etiologies of pediatric concussions, although variations exist in these data sets. One such observational study conducted by Yaramothu et al reviewed the medical records of 1,408 patients who were diagnosed with a concussion and found that mTBIs were most prevalent in organized sports, specifically with soccer and football recording the highest incidences of concussion.11 (See Figure 1.) Although sports may be a top contributor of concussions, it is important for ED providers to keep mTBI on the differential diagnosis regardless of the mechanism of injury.
Figure 1. Etiology of Concussions
MVC: motor vehicle collision
Data from: Yaramothu C, Goodman AM, Alvarez TL. Epidemiology and incidence of pediatric concussions in general aspects of life. Brain Sci 2019;9:257.Pathophysiology
The pathophysiology of concussions is a complex and multifactorial phenomenon that has been researched extensively without a clearly elucidated mechanism. Several proposed theories have been studied and accepted as potential pathophysiological mechanisms that focus on the various neurotransmitter fluctuations, energy deficits, and structural changes that accompany a concussive injury.
Ionic and Neurotransmitter Flux
When the brain suffers a mechanical injury, there is a cascade of ionic, metabolic, inflammatory, and neurovascular changes that occur within the central nervous system that lead to both the acute and chronic neurologic sequelae that are seen following mTBIs. This cascade is initiated when a mechanical force to the external cranium leads to the excitatory neurotransmitter glutamate being released from the injured neurons. This substantial increase in extracellular glutamate, in turn, causes a potassium efflux from the neurons through stimulation of ligand-gated potassium channels. Glutamate also activates the N-methyl-D-aspartate (NMDA) receptor, leading to neuronal depolarization, which furthers potassium efflux from the neuron. As the potassium leaves the neuron, calcium and sodium enter, causing depression of neuronal activity.13 In an attempt to restore balanced homeostasis, the body upregulates sodium-potassium ion pumps, which depletes intracellular energy reserves, resulting in less ATP available for use. Increased energy demand and associated ATP depletion results in a compensatory increase in glucose metabolism, leading to further dwindling of energy stores.
Energy Crisis
The energy crisis theory suggests that following a mechanical injury to the brain, the body cannot adequately restore homeostasis as it intends, secondary to the flux of neurotransmitters depleting its energy reserves and reduced cerebral blood flow limiting restorative potential.13 This decrease in flow is thought to be from structural vessel damage as well as vasoreactive disturbances, which can take around 10 days to return to baseline.13 The hypothesis follows that when this decrease in blood flow is coupled with the increase in energy demand from the ionic shifts, an “energy crisis” results.13 Further worsening this energy crisis is the response to the increased levels of intracellular calcium. As neurons sequester calcium into the mitochondria, it leads to mitochondrial dysfunction and impaired oxidative metabolism, exacerbating the energy crisis.13 As previously mentioned, glucose is initially hypermetabolized in an attempt to compensate for the increased energy demand, before creating a subsequent compensatory hypometabolic state that can persist for up to several weeks.12 This hypometabolic state is another proposed component of the energy crisis theory that attempts to explain the etiology of prolonged post-concussive symptoms.10
Structural Changes
There are several anatomic changes that occur post-concussion that possibly can account for prolonged symptoms following an mTBI. Structurally, the calcium influx from the ionic shifts causes damage to the cytoskeleton of the neuronal axons and impairs mitochondrial function for up to three to four days post-injury.13 The most damage done to the axons still is believed to be primarily from the initial shear and tensile forces of the mechanical head trauma. The resulting neuronal damage reduces conductive velocity, manifesting as the cognitive impairment commonly seen in mTBI.10 Axonal myelination is an ongoing process throughout brain development, which may explain the increased vulnerability to axonal injury associated with mTBI in the pediatric population. Conversely, the ongoing myelination process also may explain the better long-term prognosis of mTBI in children as compared to their adult counterparts.
Clinical Features
Although symptoms of mTBI vary greatly, they can be divided into four overarching categories: somatic, cognitive, emotional, and sleep-related disturbances. Table 1 provides examples within each category of symptoms that caregivers can screen for following a head injury that would prompt further evaluation by a healthcare provider. (See Table 1.)
Table 1. Common Symptoms of Concussion
Physical
- Bothered by light or noise
- Dizziness or balance problems
- Feeling tired, no energy
- Headaches
- Nausea or vomiting (early on)
- Vision problems
Thinking or Remembering
- Attention or concentration problems
- Feeling slowed down
- Foggy or groggy
- Problems with short- or long-term memory
- Trouble thinking clearly
Social or Emotional
- Anxiety or nervousness
- Irritability or easily angered
- Feeling more emotional
- Sadness
Sleep
- Sleeping less than usual
- Sleeping more than usual
- Trouble falling asleep
Source: Centers for Disease Control and Prevention
Symptom onset, progression, and recovery vary between individual patients. Although there are studies evaluating general patterns, these time lines vary greatly among pediatric patients. Signs and symptoms that immediately follow the traumatic event commonly include nausea, dizziness, headaches, and confusion. Other symptoms in the early phases that may indicate cerebral dysfunction include confusion, amnesia (retrograde or anterograde), disequilibrium, vomiting, and, rarely, seizures.4,8 Symptoms that have a more delayed onset, presenting hours to days after injury, typically involve mood symptoms such as depression, and cognitive symptoms, such as impaired concentration. It is important to recognize that these symptoms are not mutually exclusive and often may reflect synergistic effects of other symptoms. These delayed symptoms can contribute to the perceived morbidity associated with concussions, since often by the time a patient is experiencing cognitive symptoms, they are likely to have experienced one or more physical symptoms from their injury as well.
The time line of symptom improvement is varied on an individual basis, but a typical pattern of recovery can be estimated by age. In 2019, Ledoux and Teng et al found that children 5-7 years of age tended to resolve symptoms within the first two weeks following a concussion, whereas, in preadolescents ages 8-12 years and male adolescents, this usually occurred within the first four weeks.8 Adolescent females seem to have a more prolonged recovery compared to their male counterparts based on observational studies.8 Although a majority of patients will recover fully within the first month post-injury, Zemek et al published a multicenter study demonstrating that as much as 30% of children treated in the ED may have symptoms exceeding this time course.14 Although it is impossible to predict how a child’s symptoms will progress, documented prognostic factors that may suggest a prolonged recovery are older age, female sex, high number of previous concussions, and a greater initial symptom burden.8 If a patient has any of these risk factors, closer monitoring should be undertaken, since they may benefit from recommendations for subspecialty referral.
Imaging
When deciding to pursue imaging in pediatric patients presenting with mTBI, providers must balance the benefits of finding a clinically significant injury with the risk of radiation exposure. The ionizing radiation dose that is delivered from a head computed tomography (CT) is as much as 20 times more radiation than a plain chest radiograph.15 Calculations done by Pearce et al determined that based on typical doses of cumulative ionizing radiation from two to three head CTs (i.e., ∼ 60 mGy), the risk of malignancy development nearly tripled for children 15 years of age or younger.16 As a result of the associated radiation risk, the CDC emphasized in their guidelines that healthcare professionals should not routinely obtain head CTs for the diagnosis of mTBI in children, instead recommending the use of validated clinical decision rules to identify which children with head trauma are at low risk for intracranial injury and in whom head CT could be forgone.2
The Pediatric Emergency Care Applied Research Network (PECARN) decision rule is one of the most widely used validated algorithms to help identify which children are at low risk of serious intracranial injury and obviate the need for CT scan. This decision tool is important for all ED providers to be familiar with, since many parents or caregivers often will ask about obtaining advanced imaging for their children after a head injury. Therefore, providers need to have a reliable tool that is supported by evidence to reassure families that advanced technology is not always needed after a head injury. The PECARN clinical decision rule has a negative predictive value of 99.95% for those older than the age of 2 years and 100% for those younger than 2 years of age who present with none of the predicted risk factors, making the decision tool one of the most useful when it comes to determining which patients can safely forgo advanced imaging.17 A recent study aimed at determining the risk of clinically important TBI in children younger than 3 months old using PECARN criteria suggested that this clinical decision rule also could accurately identify infants at low risk of clinically important TBIs.18 While there is hope that this algorithm can be used in an even younger cohort of patients presenting with a pediatric head injury, there still is the need for a cautious approach in these infants. (See Figure 2.)
Figure 2. PECARN Algorithm
Suggested CT algorithm for children younger than 2 years (A) and for those aged 2 years and older (B) with GCS scores of 14-15 after head trauma.
PECARN: Pediatric Emergency Care Applied Research Network; GCS: Glasgow Coma Scale; ciTBI: clinically important traumatic brain injury; CT: computed tomography; LOC: loss of consciousness
Reprinted with permission from: Kuppermann N, Holmes JF, Dayan PS, et al; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: A prospective cohort study. Lancet 2009;374:1160-1170.
In the management of pediatric mTBIs, parents and patients alike may inquire about obtaining other types of advanced imaging in the ED. Although magnetic resonance imaging (MRI) may be the diagnostic modality of choice in other acute conditions, given limited radiation exposure, drawbacks include prolonged study time and an associated need for sedation, which carries its own risks. In light of these constraints, the current CDC guidelines do not recommend the routine use of MRI in the acute evaluation of suspected or diagnosed mTBI.2 Ongoing research has focused on advanced neuroimaging modalities, such as functional MRI (fMRI), susceptibility-weighted imaging (SWI), and diffusion tensor imaging (DTI), as promising future modalities for evaluating the associated morbidity of concussions. DTI is a form of imaging that measures the diffusion of water molecules within the brain to assess for functional damage and recently has shown promising correlations with reported symptoms, emotional issues, arithmetic problem-solving, and concussion outcome scores, making it a likely useful option in the future.19 Although various tests are promising, they are not yet recommended for use in the diagnosis of mTBI, and the role of CT imaging remains limited to evaluation of clinically significant brain injuries, such as intracranial hemorrhage.
Decision-Making Tools
Validated symptom checklists exist to help risk stratify pediatric head injuries and determine which patients may need further evaluation and treatment. The systematic review conducted by the CDC supports the use of several age-appropriate symptom checklists, including the Graded Symptom Checklist, Post-Concussion Symptom Scale, Health and Behavior Inventory, and Post-Concussion Symptom Inventory for risk stratification and symptom observation in the evaluation of mTBI.2 While emergency medical providers may not be the ones conducting these neurocognitive tests, they should be aware of their validity and role in follow-up care as part of routine mTBI discharge counseling. For example, the Graded Symptom Checklist is useful for children 6 years of age and older in distinguishing those with mTBI from those without one within the first two days following an injury.2 Parents or patients rate symptoms on a scale of 0-6 on the checklist at various points in time post-injury to evaluate disease progression or improvement.
The Post-Concussion Symptom Scale is another validated, age-appropriate tool that is commonly used in computerized neurocognitive testing that may be recommended for outpatient use by the emergency medical provider. Computerized neurocognitive testing involves comparing a baseline evaluation of an athlete’s premorbid function prior to the school year or season to establish a baseline level of function that can be compared later to post-suspected-mTBI results. There is no definitive score on these exams at which one diagnoses an mTBI, but the higher the score, the more indicative it is of a higher severity concussion a patient may have incurred.
For example, this Post-Concussion Symptom Scale has been shown to distinguish high school athletes with mTBI from those without within the first four days after injury, adding another resource that emergency medical professionals can recommend to parents or patients in the acute period of injury to aid in the diagnosis of mTBI. Although they are inexpensive and quick, these clinical scales are not meant to be used in isolation for the diagnosis of mTBI, but rather in conjunction with a physician’s medical decision-making to help determine which patients may require further supportive care following injury.
Laboratory Tests
There are a variety of blood tests, both novel and old, that are actively being studied for possible use in the diagnosis of mTBI. These laboratory tests include various serum biomarkers, such as S100B, tau proteins, serum potassium, glucose, white blood cell count, glutamate autoantibodies, oxide metabolites, and multiplex bead arrays. Although there is the potential for future use of some of these laboratory tests, the current evidence is not robust enough to support the routine use of these assays in either children or adults for diagnostic purposes in relation to mTBI. The CDC agrees with this consensus and asserts that providers should not use these biomarkers outside of a research setting until there is more sufficient evidence for their use in the diagnosis of pediatric mTBI.2
Discharge Instructions
After a diagnosis of mTBI is established in a pediatric patient, the next steps in management include comprehensive discharge counseling for both caregiver reassurance and education regarding any concerning symptoms that should prompt a return visit or specialist evaluation. Routine education and discharge counseling should include a brief description of the injury, management of expected symptoms, recommendations on an appropriate rest period, instructions regarding returning to both cognitive and physical activity, warning signs of more serious injury, and clear clinician follow-up instructions. An example of a brief discharge summary with instructions is provided in Table 2.
Table 2. Discharge Instructions
Summary of Visit
- Your child was seen in the ED today for their head injury. We evaluated them and, based on validated clinical tools, we forewent advanced imaging and clinically diagnosed a mild traumatic brain injury (mTBI) or concussion. We gave your child symptomatic treatment in the ED and observed them for a predetermined period.
Symptom Management
- We recommend a short course of acetaminophen or ibuprofen for headache symptoms with alternating use every four to six hours as needed using weight-based dosing.
- Ondansetron may have been prescribed to your child if nausea was a significant symptom at this visit.
- We recommend limiting use of electronic screens to avoid exacerbating your child’s symptoms.
Recommendation of Rest
- Based on clinical guidelines for pediatric concussions, we recommend cognitive and physical rest for 24-48 hours, after which the child may gradually begin light physical activity, driving, and schoolwork under the guidance of their outpatient primary provider. We have attached a school note to these discharge instructions for your convenience.
Follow-Up Plans
- Please schedule an appointment with your primary physician or pediatrician within the next 48 hours for reassessment and further symptom management along with return-to-activity planning.
Return Criteria
- Please return to the ED for any worsening headaches, intractable vomiting, seizures, change in mental status, new unsteadiness, or any other acute change in health.
Source: Centers for Disease Control and Prevention
Prognosis
It also is important to remind parents that every patient’s recovery is unique and, while there are some risk factors that can predict prolonged symptoms, pediatric concussions generally are well-tolerated and will resolve without significant intervention.20 Most children (70% to 80%) who experience an mTBI will not show significant symptoms past one to three months post-injury.2 (See Table 3.) Premorbid factors that confer an elevated risk for prolonged symptoms and a slower recovery include history of previous mTBI, learning disability or lower cognitive ability at baseline, underlying psychological or neurological condition, attention deficit hyperactivity disorder (ADHD), history of headaches or migraines, family and social stressors, lower socioeconomic status, Hispanic ethnicity, older age, and an initial severe symptom burden.2 These risk factors should be relayed to parents, since they do increase the risk of re-injury in children with mTBI.
Table 3. Symptom Progression Data in Pediatric Mild Traumatic Brain Injury (mTBI)
Symptoms of mTBI generally fall into four categories:
- Somatic
- Cognitive
- Mood/affective
- Sleep
Symptom resolution:
- 30% experience symptoms one month post-injury
- 10% experience symptoms three months post-injury
- 5% experience symptoms one year post-injury
Source: Centers for Disease Control and Prevention
A retrospective study from the Children’s Hospital of Philadelphia evaluating 87 patients ages 5 to 15 years who had their first visit for an index concussion found that nearly one in six would go on to develop at least one subsequent concussion within two years.21 The risk of repeat concussion increased with patient age, greater symptom burden, and longer course of recovery during their index concussion.21 Many of these risk factors are non-modifiable; therefore, discharge instructions should focus on those factors, which can be addressed by patients and their families, including adherence to proper sleep guidelines, screen time recommendations, driving suggestions, and return to play and school protocols to mitigate the risk of prolonged symptoms or worsening outcomes after an mTBI.
Sleep
Sleep is one of the most important modifiable factors that can either positively or adversely affect the health of a patient. Recent studies on the importance of quality sleep post-concussion run contrary to the previously dogmatic practice of awakening children throughout the night. This practice of repeated awakenings may exacerbate and prolong concussion symptoms. Instead, caregivers should be encouraged to focus on a consistent sleep schedule with an appropriate amount of sleep per night based on the child’s age. The American Academy of Sleep Medicine put forth recommendations that school-age children (between 6 and 12 years of age) require about nine to 12 hours of sleep per night, whereas adolescents (13-18 years of age) should have eight to 10 hours of sleep.22 Sleep deficiency post-concussion is a predictor of post-concussive symptom duration, and insomnia and poor sleep quality are shown to be key factors dictating recovery following an mTBI.23
While there is a paucity of studies on the specific topic of sleep affecting pediatric mTBI patients, there is well-documented evidence in the adult populace that suggests adequate and undisrupted sleep may be imperative to the treatment of pediatric mTBI cases.2 A 2019 review of sports-related concussions in children younger than 18 years of age by Chung et al demonstrated that patients who were categorized as having good-quality sleep based on their Pittsburgh Sleep Quality Index composite scores had lower median symptom scores during a three-month follow-up compared to patients with poor-quality sleep (3.0 vs. 0.0; P < 0.01).24 The study went on to show that the poor-quality sleep group also took more than two weeks longer to recover from their reported symptoms as compared to their good-quality sleep counterparts (35.0 days vs. 20.0 days; P < 0.01), helping to emphasize the importance of sleep in leading to a faster and more pronounced recovery.24 This is a critical area where providers can intervene with recommendations for proper sleep hygiene to reduce symptom severity and prolonged duration of mTBI symptoms.
Screen Time
Given the rapid rise of electronics use, there are prominent concerns about the theoretical harms associated with constant screen time following a head injury. However, data remain limited on the effects of screen time during mTBI recovery. The previously rigid notion of removing electronics altogether until complete symptom resolution has fallen out of favor in light of evidence suggesting a potentially beneficial role for social media and cellular phones as an important point of social connection for many children. Therefore, recommendations for complete and prolonged avoidance of electronics should be discouraged, and instead providers should recommend an initial rest period with a gradual increase in electronics use as tolerated. This mirrors similar recommendations for returning to other activities, where an initial rest period followed by a gradual increase in exposure may be beneficial to recovery.
Studies evaluating this concept have aimed to compare how patients fared when doing an initial screen abstinence period vs. those who continued active use during the first two days post-injury. A randomized clinical trial that followed 125 concussion patients (ages 12 to 25 years) comparing those with an initial screen holiday vs. no initial screen restrictions found that there was a statistically significant decrease in symptom duration (3.5 days) in the group who abstained from screen time in the first 48 hours of recovery with a gradual increase in use compared to those who were permitted initial screen time (eight days).25
This notion of gradually increasing electronics use is supported further by the CDC’s recommendation for professionals to emphasize social support as a key element in the recovery process of mTBI for the pediatric patient.2 Screen time recommendations should be symptom-driven, focusing on mitigating specific symptoms, such as light sensitivity or nausea from fast-moving graphics, and slowly increasing use at a sub-symptom pace. Although more data from multicenter studies need to be gathered, instead of removing all electronics completely, caregivers can use a variety of techniques, such as promoting an initial screen time break, adjusting brightness levels on devices, or increasing font sizes, to help mitigate oculomotor symptoms after an mTBI to promote recovery.
Return to Driving
Although there are widely accepted stepwise protocols for guiding adolescents back into the classroom and onto the athletic field, no such universal guidelines currently exist for returning to driving.26 A large portion of pediatric concussions occur in the 14- to 17-year-old age range, warranting specific guidance for this age group on driving when discussing post-injury recommendations.27 A generally accepted consensus is that driving should be restricted for the first 24-48 hours post-injury in conjunction with the patient’s initial rest period.
The importance of a post-concussive pause from driving is highlighted by various studies looking into the neurocognitive effects immediately following an mTBI and the effect this has on driving ability. While pediatric studies still are limited, some have demonstrated both acute and chronic deficits in neurocognitive functioning affecting driving abilities.10,28,29 Although it was performed in adults, one such study demonstrated deficits in reaction times and decision-making capabilities of adults diagnosed with concussion who were put through a driving simulator within the first 24 hours of their mTBI recovery. It found that these adults had deficits in their reaction time to road hazards as compared to those without mTBI.10 It is not unreasonable to extrapolate that similar deficits may exist in adolescents following an mTBI, and providers may consider recommending restrictions on driving for the first 24-48 hours after injury.29 These recommendations are critical, given that a 2018 survey from Schmidt et al showed that of athletes who did refrain from driving post-concussion, it was the advice of their medical provider that prompted them to do so.30 A simple and quick intervention, such as giving a brief recommendation on an initial 24-48 hour break period from driving in the post-concussive patient, may help prevent potential devastating motor vehicle accidents in the future.31 Notably, evidence supporting restrictions beyond this time point currently is lacking.32
Return to Play
With the media coverage of increasing numbers of prominent athletes now experiencing devastating consequences of repeated head injuries, there is a renewed focus on limiting sports-related concussions starting at an early age, particularly in sports with repetitive head impacts.
One of the most severe consequences of repeated head injury is chronic traumatic encephalopathy (CTE), a neurodegenerative condition thought to be a long-term sequela of repeated head trauma. Various neuroimaging studies of retired professional football and ice hockey players reveal structural changes to the brain itself, including reduced white matter integrity and gray matter atrophy, following repeated traumatic impacts.1 A recent autopsy study evaluated the donated brains of former football players and found that of those who participated in high school athletics, 21% had some evidence of CTE, and nearly all of the professional athletes were found to have signs of CTE on exam, with the majority having findings consistent with severe pathology.33 There is a misconception in the public sphere that there is a “magic number” of concussions that an individual can sustain before developing serious consequences. Unfortunately, this perception is not validated by current evidence. There is no number that can be used to determine when an athlete should limit or permanently stop playing a particular sport for safety reasons.10 With CTE as a disease entity becoming more prominent and studied, return-to-play protocols for youth athletes have become increasingly more important to help limit the risk of long-term neurologic injury.
Given the paucity of currently available treatments for mTBI, prevention seems to be the best management. The question then becomes “When can the child return to play?” following a sports-related head injury without greatly increasing their risk of serious neurological consequences. Early activity initiation must be balanced with the theoretical risk of re-injury or second-impact syndrome. The threshold for re-injury may be lower during this vulnerable initial period of recovery, and the symptom burden following a second impact during this time may be greater than the initial burden.2 While still a contested condition within the medical community, second-impact syndrome is a theoretical risk, and precautions should be exercised. It is theorized that the initial injury leads to cerebral vascular congestion, which in turn can progress to cerebral edema. It is this diffuse edema that then leads to brain herniation and possibly death.34 Fortunately, this is believed to be a rare condition, but nonetheless one that supports the recommendation of immediate removal of an athlete following a suspected sports-related head injury and not allowing the premature return to play, especially while the patient is symptomatic.10
This immediate pause from play should be distinguished from the old adage of strict, prolonged rest following a concussion, as dogma has been challenged by several authors and there is more recent evidence suggesting that return to physical activity within seven days of the injury, if not sooner, actually may improve recovery.35 A randomized controlled trial evaluating strict rest for youth post-mTBI showed no improvement in symptom burden, neurocognitive testing, and balance outcomes in patients randomized to strict rest. In fact, this group of patients reported more symptoms over the course of the study.36 Although the optimal duration of rest has yet to be determined, the 2017 International Conference on Concussion in Sport recommends cognitive and physical rest during the first 24 to 48 hours, followed by gradual return to activity.3 This gradual increase in activity is intended to be sub-symptom in quality, described as a limited intensity that does not provoke or worsen any symptoms.6,37,38 The CDC recommends progressive reintroduction of non-contact aerobic activity first, followed by a gradual return to full activity when an athlete has remained symptom free with increasing levels of physical exertion.2
Return to School
In addition to the physical burden of returning to activity, providers also must consider the cognitive load associated with school or work when counseling patients regarding expected recovery from mTBI. It is important to educate parents and caregivers properly on when children can return to school. Managing symptoms like headaches, fatigue, mood changes, and concentration difficulties must be balanced with the potentially detrimental effects of falling far behind in school and disrupting social support structures. Delayed reintroduction to school can worsen stress levels, increase caregiver burden, and exacerbate emotional or depressive symptoms from the mTBI, supporting a need for safe and early return to school efforts.39 Initial cognitive rest can provide some benefit to the overall injury course, but as with prolonged restrictions on physical exertion, delayed return to school can have paradoxical negative effects on a patient’s recovery.40 Therefore, guidance should be based on symptom burden and gradual progression toward pre-injury academic performance.10
The overarching theme of the CDC recommendations regarding return to school is an emphasis on collaboration between physicians and school-based teams to counsel the student and their family on how to safely increase the intensity and duration of academic activities. These protocols ideally should be customized by both medical and school personnel based on the severity of post-concussion symptoms, and requires continuous reassessment. Given that recovery is gradual and unique to the individual, any student with prolonged symptoms interfering with academic performance should be evaluated further for additional educational support, including that which falls under the purview of certain federal statutes like the Individuals With Disabilities Education Act §504.2 The end goal of this process should be to slowly advance cognitive activity, progressing toward the premorbid level of the student’s academic performance.41 Therefore, the ED provider’s role should be to impart guidance on when children can return to school in conjunction with the child’s pediatrician, who can follow their symptoms and academic progress more closely.
Symptom Management
Symptomatic management of pediatric concussion requires a focus on both the acute pain following the initial injury and the subsequent physical, cognitive, and emotional symptoms that occur during the recovery process. Because of the difficulty and broad presentation of mTBI injuries, emergency providers should be prepared with a variety of pain-relieving strategies for symptomatic relief.
There is no current consensus on which medications perform better for acute pain management in mTBI, especially in the pediatric population. A 2021 systematic review of the literature on symptomatic treatment of mTBI found limited quality pediatric studies that compared various medications against one another in a clinically significant manner.42 While this particular study by Feinberg et al could not perform an evidence-based analysis, it did draw some secondary conclusions from the data. The group noted that, of the 20 pharmacological interventions that were examined in the review, certain medications appeared more than others. Sertraline, methylphenidate, ondansetron, amitriptyline, and melatonin were some of the only medications that appeared across multiple studies, suggesting more common use and preference among medical providers.42
Another multicenter study published in 2019 by Mannix et al surveyed various specialty providers across Canada and the United States, assessing the frequency with which certain medication classes were prescribed for pediatric mTBIs. In the responses, nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen were recommended most commonly for overall symptom relief, followed by amitriptyline for headache symptoms.43 The most common non-pharmacological interventions seen across the study were rest, recommended by 83% of the 107 respondents, exercise recommended by 59%, vestibular therapy by 42%, and cervical spine exercises suggested by 29%.43 The CDC echoes these findings, recommending that emergency providers should be offering non-opioid analgesic options to children with acute mTBI presenting with pain from headaches (for example, ibuprofen or acetaminophen).2,38 ED providers also should feel comfortable counseling family members on the side effects of medications, the risk of rebound headaches and overuse, and the dangers of overdose as potential issues.
Aside from headache, other symptoms with an mTBI can include vertigo, dizziness, tinnitus, and other vestibule-oculomotor symptoms. Providers may use medications that they are comfortable prescribing, such as ondansetron and meclizine, for symptomatic treatment. The CDC also suggests that pediatric mTBI patients with persistent vestibule-oculomotor dysfunction can benefit from referral to vestibular rehabilitation, since there may be some benefit of this physical therapy.2,20
Physicians and other healthcare providers may encounter questions from patients and caregivers regarding alternative treatment options for mTBI management. One hypothetical treatment regimen that has been suggested includes the use of 3% hypertonic saline to reduce theoretical swelling associated with concussions, but the CDC makes it clear in their recommendations that providers should not be administering this to children for mTBI treatment outside of a research setting.2
There are numerous other alternative medicine regimens touted as potential preventative and therapeutic options for mTBI, including various nutritional supplements, vitamins, and herbal remedies. Examples include omega-3 fatty acids, curcumin, resveratrol, melatonin, creatine, Scutellaria baicalensis, green tea, caffeine, and vitamins C, D, and E. Although some animal studies show promising results for the use of these alternative remedies in the management of concussions, there currently are not sufficient data to support the use in humans with mTBI at this time.10
Follow-Up
While care in the ED is focused on diagnosis and initial treatment of mTBI, many patients still will ask about subspecialty referral for further management and follow-up care. After initial ED evaluation, most patients with mTBI can be referred to their primary care physician or pediatrician for a follow-up assessment, since these providers should have a better understanding of the child’s baseline cognitive and physical functioning. If patients do return to the ED, the ED clinician should discern which children and families may benefit from help navigating further subspecialty referrals and care.
Indications for referral in the outpatient setting include prolonged symptoms of more than four to six weeks after standard care, a history of multiple concussions, difficulty recovering from previous concussions, known risk factors for prolonged recovery, prominent or severe vestibular or visual symptoms, or an uncertain diagnosis of mTBI.2 Any of these aforementioned characteristics should prompt the ED provider to consider recommending further evaluation by a neurologist, sports medicine specialist, or even pediatric psychiatrist if mood disturbance symptoms persist. The CDC agrees that children at high risk for persistent symptoms based on their premorbid characteristics should be monitored closely.2 As such, those with previous diagnoses of ADHD, migraines, learning disabilities, or mood disorders should have close follow-up to observe for a protracted recovery.2
Children with persistent cognitive deficits should be referred for a formal neuropsychological evaluation.41 Cognitive impairment is a relatively common symptom following mTBI and is broadly defined to include difficulties with attention, memory, learning, response speed, and some aspects of executive functions. These symptoms can confer significant morbidity, so it is important to recognize these and refer patients for further help and more long-term outpatient treatment.2
Summary
The approach to pediatric concussions should be a multimodal one, with various tools used for the initial evaluation and diagnosis of mTBI. Clinical assessment and risk-stratifying tools are the most useful in the diagnosis of mTBI, since laboratory tests and advanced imaging have not yet been validated for diagnostic purposes. Symptom management in the ED and outpatient setting should be focused on non-opioid analgesia and reducing symptom burden, with an emphasis on discharge counseling regarding rest, return to activity, and screen use. It also is important to focus on reassurance, in that most pediatric patients with mTBIs will have a resolution of the symptoms within four weeks from the time of injury. Offering guidance on proper sleep hygiene, safety recommendations on return to school and activity, and appropriate analgesic treatment are the most beneficial practices that emergency providers can offer patients to mitigate symptoms and improve recovery after an mTBI.
- Follow the PECARN decision rule to assess whether a child with a head injury will need a CT scan as part of their evaluation.
- MRI, single-photon emission computerized tomography (SPECT) novelty imaging, and X-rays should not be used for diagnostic purposes for pediatric mTBI in the ED.
- Symptom rating scales and computerized cognitive function testing are appropriate to use if they are age-correlated and validated, used in conjunction with clinician gestalt, and recommended for outpatient use.
- Laboratory evaluation has a limited role in the evaluation of mTBI. There currently is insufficient clinical evidence to support the role of serum biomarkers in the diagnosis of pediatric mTBI, and use should be limited to the research setting.
- Counsel parents appropriately about the expected course of recovery, with an anticipated resolution of symptoms typically in four to six weeks.
- Encourage pre-participation athletic examinations and repeat neurocognitive evaluations as soon as possible after injury in children with mTBI.
- Screening for the presence of modifiable and non-modifiable risk factors for prolonged mTBI symptoms can help guide appropriate discharge counseling.
- For children with mTBI whose symptoms do not resolve as expected with standard care (i.e., within four to six weeks), refer to appropriate providers for further assessments and/or interventions.
- Create a thorough prompt for discharge instructions that include warning signs that warrant a return trip to the ED.
- Encourage one to two days of rest before gradually increasing both cognitive and physical activity.
- Gradual screen use with appropriate modifications is reasonable during the recovery period to provide social support.
- Start with non-opioid analgesics for pain control and add supplemental medications for vestibular symptoms if nausea or dizziness persists.
- If dizziness is a persistent symptom after mTBI, recommend a vestibular physical therapist for long-term treatment.
- If a child has an mTBI, encourage good sleep hygiene and reassure parents that there are no data to support frequent reawakenings.
- Refer children with persistent symptoms related to cognitive function for a formal neuropsychological evaluation if presenting to the ED with persistent post-concussive symptoms.
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The authors provide a current summary of the best practices for diagnosis and management of pediatric concussions.
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