January 28, 2019
Pediatric Concussion…Why is it such a headache?!
Diagnosis and management of concussion in children is part of our everyday bread and butter in the Emergency Department. Given the estimated 1.1 million – 1.9 million pediatric concussions we see annually in the United States, it is no wonder why.  We are well aware that pediatric concussions (more accurately termed mild traumatic brain injury, mTBI) occur most commonly from direct blunt head trauma, but they can also occur via indirect forces. Regardless of mechanism, concussions result in temporary neurologic and/or cognitive impairment that can last hours to days, with long-term sequelae potentially lasting weeks to months.
In the ED setting, we use clinical presentation and well validated PECARN criteria to determine the need for advanced imaging in children.  Ruling out intracranial hemorrhage is only part of the initial evaluation. Managing the patient’s myriad of symptoms can be the tricky part. Symptoms can be classified into five categories [3,4,5,6]:
- Somatic (headache, nausea, photophobia, phonophobia)
- Cognitive (confusion, feeling “foggy”, repetitive questioning)
- Vestibular/Oculomotor (hearing problems, dizziness)
- Emotional (irritability, emotional lability)
- Sleep dysfunction (drowsiness, insomnia)
The severity of the patient’s clinical presentation dictates their disposition. The vast majority of patients, however, can be discharged home after receiving supportive care in the ED.
Perhaps our most important intervention in the care of a concussion patient is the conversation with patient and family just prior to discharge. We know that second impact syndrome, though rare, is a real and appropriately feared complication. Balancing patient education with the anxiousness most young athletes feel to return to their competitive sport requires finesse. Ironically, this is where OUR headache as clinicians begins. Throughout the last decade, recommendations for post-concussion care and return-to-play/life have been ever-changing, and at times even contradictory! Rest…don’t rest. Sleep…don’t sleep. Lie in a dark room…get going with your day. No screen time…some types of screens are probably ok?
The reason for this evolution in recommendations is multifactorial. First, our understanding of the pathophysiology of mTBI has been progressing slowly over the last twenty years. Second, there are numerous organizations (i.e.: American College of Sports Medicine, American Medical Society for Sports Medicine, American Academy of Neurology, American Academy of Pediatrics, National Athletic Trainers Association etc.) who publish position statements and recommendations. However, there is not a single body or organization which reigns as the ultimate expert when it comes to concussion management. Even the largest collaborative body of experts for sports-related concussion, the International Conference on Concussion in Sports, which has been publishing expert consensus-based guidelines since 2002 admits in their most recent consensus statement, “This consensus document reflects the current state of knowledge and will need to be modified as new knowledge develops.”[3,4] To be quite frank, the literature is not strong, and to make matters even more complicated, each specialty (Sports Medicine, Pediatrics, Neurology) has its own opinions on the matter. Suddenly, you find yourself struggling to keep up as the needle moves back and forth.
Regardless of relatively weak evidence, it is vital that we keep up on the latest recommendations. In late 2018, both the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) published their newest guidelines on management of concussion/mTBI in children. Given these are the most up to date recommendations, they are worth reviewing.
The CDC’s Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children was published in JAMA Pediatrics in September 2018 by Lumba-Brown A et al.
Methods: The CDC collaborated with the ‘National Center for Injury Prevention and Control Board of Scientific Counselors’ to establish the ‘Pediatric Mild Traumatic Brain Injury Guideline Workgroup’. This workgroup then reviewed previously published recommendations in a systematic review of literature from 1990 – 2015. From this collective review, the CDC published 19 sets of new recommendations on the management and treatment of pediatric mTBI. Clinicians have already adopted many of these recommendations regarding imaging and use of PECARN practice patterns. Of these nineteen recommendations, the ones that are most new or noteworthy include:
- Clinicians should not use biomarkers (i.e.: SB100 calcium binding protein, serum tau, serum potassium, ubiquitin carboxyl-terminal-hydrolase L1 and glial fibrillary acid protein) to diagnose children with mTBI, as there is currently insufficient evidence to support their use outside research settings. (Recommendation 6, high; level R recommendation) 
- Families should be counseled that most concussions (70-80%) are self-limited and typically resolve within 1-3 months. (Recommendation 7A: moderate; level B recommendation) 
- We need to explain to patients and families that each child’s recovery from mTBI is unique and variable. No single factor can predict symptom resolution or outcome. Each child will follow his/her own trajectory at his/her own speed. (Recommendation 7B: moderate; level B recommendation) 
- After discharge parents should follow up with their pediatrician, school staff, and coach to create a graduated plan for recovery. Multiple tools should be used to assess the individual patient’s recovery, as a single test has not proven to be superior. Symptoms scales and cognitive testing have demonstrated the strongest correlation in predicting outcomes and assessing recovery. (Recommendation 10 A-C: moderate; level B-C recommendations) 
When a child can return to sports and resume aerobic activity after mTBI has not been well established. We do know, however, that extensive inactivity (> 72 hours) has been shown to worsen self-reported symptoms of recovery. [3,4,5,6] So what should we advise?
- During the first few days after a concussion, patients should adhere to restricting physical and cognitive activity. Patients should gradually resume activity that does not exacerbate symptoms, with close monitoring of symptom manifestation (both number and severity of symptoms).  After the successful resumption of activity, offer an “active rehabilitation program of progressive reintroduction of noncontact aerobic activity that does not exacerbate symptoms, with close monitoring of symptoms expression.” 
- Return to full activity should only occur when the patient has returned to pre-injury performance and remains symptom-free at baseline. If they remain asymptomatic, then they can gradually increase their level of physical exertion and be safely returned to play. Graduating their return to activity based on their personal level of symptom involvement is key. (Recommendation 13 A-D, moderate level B) 
- Return-to-school should be a collaborative effort by both the patients’ medical professional and school staff, to create a customized program that allows the child to progressively increase participation without significantly exacerbating symptoms (Recommendation 15 A-B: moderate; level B recommendation).  Again, much like return to physical exertion, post-concussive symptoms resolve at different rates, thus individualization of return-to-school is important. 
The American Academy of Pediatrics, via Halstead ME, et al. echoed similar recommendations in their recently published Council on sports medicine and fitness collaborators, et al. Sport-Related Concussion in Children and Adolescents. Pediatrics. 2018 Nov 12.  They emphasize that:
- “Every concussion has a unique spectrum and severity of symptoms;” thus individualized management is important. “The reduction, not necessarily elimination, of physical and cognitive activity” should be the mainstay of treatment. 
- They strongly advise that all athletes suspected of having a concussion should be removed from play promptly and not allowed to play the same day. As athletes who continued to play despite mTBI were “8 times more likely to have a recovery > 21 days” and more severe symptom burden. 
What about screen time?
- Historically it was advised that all patients avoid “screen time” which included all electronics (i.e.: television, handheld devices, video games, texting etc). However, given that there is no data to support that screen time has direct detrimental effects, the AAP has modified their recommendations.
- The AAP recognizes that young athletes and adolescents in particular, are highly connected through social media and electronics. Removing them completely may actually “result in feeling socially isolated from friends”, which may result in feeling of anxiety and depression.Thus hand-held devices and video games should be limited in patients with particular light sensitivity or oculomotor dysfunction, but otherwise the conservative use of electronics seems to be harmless.
In summary, for both return-to-play and return-to-school after mTBI, “gradually return as tolerated” is a safe rule of thumb. With a collective team approach by the patient, parents, physicians, teachers and coaches alike, a customized plan to gradually return them back to the patient’s functional baseline is the goal.
- Bryan MA et al. Seattle Sports Concussion Research Collaborative. Sports- and recreation-related concussions in US youth. Pediatrics. 2016;138(1): e20154635. PMID:27325635
- Kuppermann N. et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. The Lancet. 2009. 374(9696):1160-1170. PMID:19758692
- Aubry, M. et al. Concussion in Sport (CIS) Group. Summary and agreement statement of the 1st international symposium on concussion in sport, Vienna 2001. Clin J Sport Med 2002; 12:6–11.PMID:11854582
- McCrory et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017 Jun;51(11):838-847.PMID:28446457
- Lumba-Brown A et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr. 2018 Sep 4: e182853.PMID:30193284
- Halstead ME et al. Sport-Related Concussion in Children and Adolescents. 2018; 142(6): e20183074 PMID:30420472
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