Pediatric concussion

Sarah R Risen MD (Dr. Risen of Baylor College of Medicine has no relevant financial relationships to disclose.)
Michael V Johnston MD, editor. (Dr. Johnston of Johns Hopkins University School of Medicine and Chief Medical Officer at Kennedy Krieger Institute has no relevant financial relationships to disclose.)
Originally released July 21, 2012; last updated April 7, 2015; expires April 7, 2018

This article includes discussion of pediatric concussion, mild traumatic brain injury, closed head injury, and minor head trauma. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

The incidence of concussion, or mild traumatic brain injury, has reached epidemic proportions. The author describes features of concussion in the pediatric population, noting that these injuries occur in the context of the developing brain. Concussion results from a biomechanical force to the head inducing a series of neurometabolic changes. Differences in stature and nervous system physiology of children lead to unique susceptibility to concussive injury. Similar to adults, symptoms indicate disruption of global brain function, including cognitive, emotional, physical, and sleep dysfunction; however, the recovery time is often prolonged in the pediatric population. Management of pediatric concussion is also distinctive given the cognitive demands of children in school. Management of pediatric concussion includes immediate removal from play, a brief period of cognitive and physical rest, evaluation by a provider trained in concussion management, return to learning with appropriate academic accommodations, and, once clearance is provided, return to sports/physical activities following a supervised gradual return to play program. Proper management is essential given the risk of second impact syndrome or diffuse cerebral swelling, unique to the younger population.

Key points

 

• Concussion results from biomechanical injury leading to temporary neurometabolic alterations.

 

• Concussion in children is unique, occurring within the context of neurodevelopment.

 

• Core symptoms of concussion in children are similar to adults, including abnormalities in physical, cognitive, emotional, and/or sleep domains; however, resolution of symptoms is often longer in children.

 

• Management of pediatric concussion emphasizes physical and cognitive rest. If involved in sports, immediate removal from play is essential followed by a supervised, gradual return to physical activity when cleared by a provider.

 

• Assessment and management should be individualized in pediatric concussion.

Historical note and terminology

The term “concussion” is derived from the Latin concutere meaning “to dash together, shake violently,” and the terminology has been noted back to times of Ancient Greece in 1 short Hippocratic text (Pearce 2008). Current definitions of concussion vary in both literature and practice. Mild traumatic brain injury (mTBI), minor head trauma, closed head injury, and concussion are often used to describe similar constructs, though currently no consensus exists on which 1 term, or precise definition, to use. In the most recent Consensus Statement on Concussion in Sport (McCrory et al 2013), concussion was defined as

“A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces… may be caused by a direct blow to the head, face, neck or elsewhere on the body with an ‘impulsive' force transmitted to the head. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously… the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged.”

The Centers for Disease Control and Prevention (CDC) has developed a website devoted to traumatic brain injury, including concussion in sports. This website provides concussion-related educational material and clinical documentation forms (Heads Up and the Acute Concussion Evaluation (ACE) checklist and care plan). This material can be accessed for free at www.cdc.gov/concussion.

Concussion “grading scales” attempting to stratify concussion severity were utilized in the past, but are no longer recommended (McCrory et al 2008).

The management of concussion in young athletes has reached the public health domain, with all 50 states and the District of Columbia passing legislation modeled after the “Lystedt Law” (Washington State, House Bill 1824, 2009). This legislation mandates the following: concussion education for coaches, athletes, and parents; immediate removal of a child from play if a concussion is suspected; same-day return to play is prohibited; and written clearance from a medical professional with expertise in brain injury for return to play.

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