How Concussion Management differs in Children and Adolescents

What is the difference in concussion management in children as compared with adults? A systematic review. Gavin A Davis, Vicki Anderson, Franz E Babl, Gerard A Gioia, Christopher C Giza, William Meehan, Rosemarie Scolaro Moser, Laura Purcell, Philip Schatz, Kathryn J Schneider, Michael Takagi, Keith Owen Yeates, Roger Zemek. British Journal of Sports Medicine 2017;51:949-957.

The true incidence of sports related concussion is not know because it is often underreported. This is because the injury may not be identified at the time or the injury is down played or there are not healthcare facilities available. The current estimate is that 4 million children worldwide present to emergency departments for concussion. However, these studies suggests that 4 million child concussion presentations represents only 12% of the true number. So the real number may be as high as 33 million worldwide.

The International Concussion in Sport Group, (CISG) consensus report recommends the Sport Concussion Assessment Tool, (SCAT), now in its third edition for individuals 12 years and above, while there is a Child Sports Concussion Assessment Tool, (ChildSCAT3) for children ages 5 - 12 years. Additionally, the latest consensus report recommends a separate tract for children’s cognitive requirements, the need for school accommodations, the use of neuropsychological testing in children, and specific considerations for children with learning disabilities and attention deficit hyperactivity disorder (ADHD). The post concussion treatment or return to play and school requires a different approach in children and adults.

Age has been evaluated in the following five categories 1) developmentally (eg, using categories of 5–7 years vs 8–9 years vs 10–12 years, etc); (2) educationally (eg, high school vs middle school); (3) based on sport level (eg, little league vs. pee wee); (4) using age as a continuous variable; or (5) using an age grouping due to sample convenience.

While the vast majority of children recover from sports related concussion and return to play or school within 4 weeks, and, similar to adolescent and collegiate athletes, a proportion of children experience concussion-related symptoms beyond 1 month after injury. Some evidence suggests that adolescents may take longer to recover than young children and college students. There is a 12-point risk score model, which had modest discrimination to stratify PPCS, (persistent post concussion symptoms), risk at 28 days (area under the curve 0.71), and was significantly better than physician judgement in predicting PPCS. The nine variables found to predict the risk of developing PPCS in this selected population were: female sex, age 13 years or older, prior physician diagnosis of migraine, prior concussion with symptoms lasting longer than 1 week, headache, sensitivity to noise, fatigue, answering questions slowly and four or more errors on the Balance Error Scoring System tandem stance.

Across the studies reviewed, recurring predictor variables of PPCS were acute headache, migraine and dizziness (all when higher than pre-injury levels), as well as female sex and history of receiving multiple concussions.

When deciding on when a child should return to school following concussion the parent and healthcare professional should take into account age, symptom severity, school accommodations, medical follow-up, and school subjects the child has to contend. Similarly, there are differences at which children can return to play when compared to adults.

So what is recommended:

AGE - Child-specific paradigms for sports related concussion management should apply to children ages 5–12 years and adolescent-specific paradigms should apply to those ages 13–18 years.

SIGNS & SYMPTOMS - An age-appropriate, validated symptom rating scale should be used as a component of the diagnostic evaluation in children presenting with suspected sport related concussion. An age-appropriate, validated symptom rating scale should be used to assess recovery in children with sport related concussion.

COMPUTERIZED NEUROPSYCHOLOGICAL TESTS - The widespread use of CNT (eg, immediate post-concussion assessment and cognitive test (ImPACT), CogSport) has been adopted in some countries as a mainstay of concussion management in children but have not been shown to consistently properly access post concussion outcome. In children and adolescents with SRC, CNT should not be used in isolation in concussion management, but, if used, should be combined with a multimodal clinical assessment.

NORMAL RECOVERY TIME - Expected duration of symptoms in children with sport related concussion should be defined as up to 4 weeks. Prolonged duration of symptoms in children with sport related concussion should be defined as greater than 4 weeks.

RETURN TO SCHOOL/PLAY - Children and adolescents should not return to sport until they have successfully returned to school, however early introduction of symptom-limited physical activity is appropriate.