Answer: There is no “right” answer.
While the rationale for each of these options may sound flippant, I am exaggerating to help illustrate how varied the approach to pediatric head injury has become. Pediatric emergency physicians routinely see patients like this 14-year-old. In some cases, the child has already been referred to a specialist but a parent thinks they will “get in faster” if they go to the ED.
Here I offer a short review of the primary sources of pediatric concussion and keys to timely assessment. I also discuss emerging research that reminds us to approach “mild traumatic brain injury (TBI)” as more than just a minor injury.
Concussions are on the rise
Pediatric head trauma is one of the most common complaints seen in the ED.1 Sports-related concussions, which can occur in any sport, are on the rise.
Concussion is a mild TBI caused by an impact or jolt to the head, face, neck, or elsewhere where the force is transmitted to the head. It is not defined by loss of consciousness. In fact, fewer than 10% of concussions result in any loss of consciousness.2 More than 1 million ED visits are made annually for concussions. It is estimated that 3 times as many occur as are reported. Most are not treated in a hospital.
Sports-related activities and accidents are the main cause of concussions in children and adolescents. Snow skiing, bicycling, and playground injuries account for the most concussions in non–team-related activities. Among athletes, concussion is the most common head injury in sports. There is a 2:1 male to female predominance. However, girls have a higher rate of concussion than boys in similar sports.3 The reason for this remains unclear.
Football is associated with the highest risk for concussion. In high school football alone, 20% of players have suffered at least 1 concussion. Soccer and basketball have the highest rate of concussion in girls’ sports. Other high-risk sports include horseback riding, boxing, ice hockey, wrestling, gymnastics, lacrosse, and rugby.3 While the highest incidence occurs in football (absolute numbers) the highest rate of concussion (number relative to those who play) is in hockey.3 There is an increased risk for subsequent concussion following an initial injury.
Signs and symptoms fall into 4 categories, as shown in the Table.
Concussions can be difficult to recognize and there is no specific definition or test that can confirm the diagnosis. Clinical judgment and specific symptoms after an injury define concussion. The most common symptom is headache. Although loss of consciousness is infrequent, if it occurs or is accompanied by amnesia, it may signal a more serious injury that may warrant imaging or intervention.3 Symptoms can come on gradually (ie, within 24 hours) but they usually appear immediately or shortly after the injury—headache, dizziness, balance disturbance, and disorientation are the most common. Cognitive defects may include confusion, delayed verbal responses, difficulty in concentrating, and feeling foggy. Mental fogginess may be a good predictor of a slower recovery.
Recovery time varies but typically runs from several days up to a week. In some cases, however, postconcussive symptoms may persist for months after the injury. Of note, the “severity” of concussion—the presence/absence of loss of consciousness—does not correlate with the magnitude of symptoms or their duration.
Most people recover after a concussion without any permanent damage. However, repeated concussions can cause permanent damage. Yeates and colleagues4 describe persistent concussive symptoms in children and young adolescents up to 3 and even 12 months after injury. Children who lost consciousness at the time of injury and who had abnormalities on neuroimaging were more likely to have persistent symptoms and to need educational interventions. Many children with mild traumatic brain injury have postconcussive symptoms that are associated with significant functional impairment in their daily lives.
Among youth with sports-related concussions, persistent symptoms have been shown to be associated with abnormalities on functional MRI scans. These abnormalities can persist for months.
The bottom line
The group of injuries classified as “mild TBI,” including sports-related concussions, should not necessarily be treated as minor injuries that quickly resolve.5 Rather, close follow-up for chronic symptoms and functional difficulties is crucial.6
The brains of young athletes are still developing and may be at greater risk for the effects of a concussion. Even a single concussion can be trouble for an immature brain. Echemendia (see Suggested Readings, below) showed that capacity for learning new information was diminished following a concussion; even short-term impairment can have prolonged consequences in a child’s academic performance.
Second impact syndrome, a strictly pediatric phenomenon, can occur when a second concussive event occurs before total recovery from even a mild first injury. Though rare, it can be catastrophic, resulting in prolonged disability and even death.
• If there is any doubt as to whether an athlete has a concussion, he or she should not return to play. (“When in doubt, sit them out.”)
• Most concussions or mild head injuries do not require CT imaging. A concussion cannot be diagnosed with an MRI.
• Focal neurologic findings, prolonged loss of consciousness, amnesia of the traumatic event, or abnormal examination findings warrant imaging.
• Following a concussion, all physical and cognitive activities should be limited.
• Return to physical activity must be gradual. The child must be completely asymptomatic—both at rest and with exercise—before return is permitted.
• Resting the brain is vital: TV, reading, computers, or playing video games may worsen symptoms.7
• Educational interventions may be necessary following a concussion. These include reduced workload, classroom accommodations, and/or tutorial or remedial services. The teacher must be cognizant of the injury.4
• Postconcussive symptoms—even from mild TBI—are associated with significant functional impairment and diminished quality of life.4
• Recovery from a concussion may be prolonged.7
|Table - Signs and symptoms of a concussion|
|Headache||Feeling mentally “foggy”||Irritability||Sleeping more than usual|
|Nausea or vomiting (early on)||Feeling slowed down||Sadness||Sleeping less than usual|
|Balance problems||Difficulty in concentrating||More emotional||Difficulty in falling asleep|
|Dizziness||Difficulty in remembering||Nervousness or anxiety|
|Fuzzy or blurry vision||Forgetful of recent information|
|Fatigue||Answers questions slowly|
|Sensitivity to light or noise||Repeats questions|
Adapted from www.knowabouthealth.com.
1. Ayalin T. Minor head trauma in pediatric patients. Pediatric Emergency Medicine Reports. 2011;16(2).
2. Kirkwood MW, Yeates KO, Wilson PE. Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population. Pediatrics. 2007;117:1359-1371.
3. Halstead ME, Walter KD. Clinical report—Sport related concussion in children and adolescents. Pediatrics. 2010;126:597-615.
4. Yeates KO, Kaizar E, Rusin J, et al. Reliable change in postconcussive symptoms and its functional consequences among children with mild traumatic brain injury. Arch Pediatr Adolesc Med. Published online March 5, 2012. doi:10.1001/archpediatrics.2011.1082.
5. Rivara FP. Concussion: time to start paying attention. Arch Pediatr Adolesc Med. Published online March 5, 2012. doi:10.1001/archpediatrics.2011.1602
6. Van Niel CW. Long-term effects of mild traumatic brain injury are not so mild. Journal Watch Pediatr Adolesc Med. March 21, 2012. http://pediatrics.jwatch.org/cgi/content/full/2012/321/1
7. Moreno MA, Furtner F, Rivara FP. Youth sports and concussion risk. Arch Pediatr Adolesc Med. 2012;166:396.
Additional Reading and Resources:
• Guskiewicz KM, Echemendia RJ, Cantu R. Assessment and return to play following sports-related concussion. President’s Council on Fitness. Sports and Nutrition. 2011;12(1).
• Nigrovic LE, Lee LK. Prevalence of clinically important traumatic brain injuries in children with minor blunt head trauma and isolated severe injury mechanisms. Arch Pediatr Adolesc Med. 2012;166:356-361.
• Splete H. Concussion rates rising in younger athletes. ACEP News. 2010;29(10).
• Centers for Disease Control and Prevention. Concussion in sports. Available at: http://www.cdc.gov/concussion/sports/resources.html. Accessed April 1, 2012.