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  • Updated 08.29.2020
  • Released 07.21.2012
  • Expires For CME 08.29.2023

Cerebral concussion in childhood

Introduction

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 or body inducing a series of neurometabolic changes that reflect a functional disturbance rather than a structural injury (71). 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 at the time of injury is essential given the risk of second impact syndrome or diffuse cerebral swelling, unique to the younger population.

Key points

• Concussion results from biomechanical forces leading to temporary neurometabolic alterations that reflect a functional disturbance rather than a structural injury.

• 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, or sleep domains; however, resolution of symptoms is often longer in children.

• Management of pediatric concussion includes a brief period of 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 (84). 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 (71), sports-related concussion was defined as

“A traumatic brain injury induced by 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 signs and symptoms largely reflect a functional disturbance rather than a structural injury, and, as such, no abnormality is seen on standard structural neuroimaging studies. Concussion results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical symptoms typically follows a sequential course. However, 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, including online concussion training for health care providers 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/headsup/providers/index.html.

Concussion “grading scales” attempting to stratify concussion severity were utilized in the past, but are no longer recommended (72). The SCAT5 (Sports Concussion Assessment Tool, Version 5) is utilized at most sidelines if there is a concern for a concussion in a player. This tool utilizes Maddocks’ questions as well as the Standardized Assessment of Concussion (SAC) (58; 59; 71).

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. Many individual states have their own legislation regarding removal from play and return to play that healthcare providers should become familiar with.

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