Postconcussive Symptoms After Early Childhood Concussion.

Importance: Research on postconcussive symptoms (PCS) following early childhood concussion has been hindered by a lack of measures suitable for this age group, resulting in a limited understanding of their evolution in young children. Objective: To document PCS in the first 3 months after early childhood concussion using a developmentally appropriate measure. Design, Setting, and Participants: This cohort study used data collected at 3 Canadian and 1 US urban pediatric emergency departments (EDs) and 8 Canadian daycares from December 2018 to December 2022 as part of the Kids' Outcomes and Long-Term Abilities (KOALA) project, a prospective, multicenter, longitudinal cohort study. Participants included children aged 6 to 72 months with early childhood concussion or orthopedic injury (OI) or uninjured children from the community to serve as controls. Data were analyzed from March 2023 to January 2024. Exposure: Concussion sustained between ages 6 and 72 months. Main Outcomes and Measures: Primary outcomes were cognitive, physical, behavioral and total PCS assessed prior to injury (retrospectively), acutely (within 48 hours), and at 10 days, 1 month, and 3 months after injury or recruitment through caregiver observations using the Report of Early Childhood Traumatic Injury Observations & Symptoms inventory. Group comparisons were analyzed using ordinal regression models. Results: The study included 303 children (mean [SD] age, 35.8 [20.2] months; 152 [50.2%] male). Of these, 174 children had a concussion (mean [SD] age, 33.3 [19.9] months), 60 children had an OI (mean [SD] age, 38.4 [19.8] months) and 69 children were uninjured controls (mean [SD] age, 39.7 [20.8] months). No meaningful differences were found between the concussion and comparison groups in retrospective preinjury PCS. Significant group differences were found for total PCS at the initial ED visit (concussion vs OI: odds ratio [OR], 4.33 [95% CI, 2.44-7.69]; concussion vs control: OR, 7.28 [95% CI, 3.80-13.93]), 10 days (concussion vs OI: OR, 4.44 [95% CI, 2.17-9.06]; concussion vs control: OR, 5.94 [95% CI, 3.22-10.94]), 1 month (concussion vs OI: OR, 2.70 [95% CI, 1.56-4.68]; concussion vs control: OR, 4.32 [95% CI, 2.36-7.92]), and 3 months (concussion vs OI: OR, 2.61 [95% CI, 1.30-5.25]; concussion vs control: OR, 2.40 [95% CI, 1.36-4.24]). Significant group differences were also found for domain-level scores (cognitive, physical, behavioral) at various time points. Conclusions and Relevance: In this early childhood cohort study, concussion was associated with more PCS than OIs or typical development up to 3 months after injury. Given the limited verbal and cognitive abilities typical of early childhood, using developmentally appropriate manifestations and behaviors is a valuable way of tracking PCS and could aid in concussion diagnosis in young children.

Improving outcome after paediatric concussion: challenges and possibilities.

The term concussion has permeated mainstream media and household vocabulary mainly due to awareness regarding the risks of concussion in professional contact sports, yet it occurs across a variety of settings and ages. Concussion is prevalent in infants, preschoolers, children, and adolescents, and is a common presentation or reason for referral to primary care providers, emergency departments, and specialised trauma clinics. Its broad range of symptoms and sequelae vary according to multiple individual, environmental, and clinical factors and can lead to health and economic burden. More than 20 years of research into risk factors and consequences of paediatric concussion has revealed as many questions as answers, and scientific work and clinical cases continue to expose its complexity and heterogeneity. In this Review, we present empirical evidence for improving outcome after paediatric concussion. We consider work pertaining to both sports and other injury mechanisms to provide a perspective that should be viewed as complementary to publications focused specifically on sports concussion. Contemporary challenges in prevention, diagnosis, prognosis, and intervention are discussed alongside pathways and future directions for improving outcome.

"What If?": Caregivers' Experiences Following Early Childhood Concussion.

OBJECTIVE: Little is known about the symptoms, signs, and management guidelines for children under the age of 6 years after they sustain a concussion. Caregivers of such young children may have unique concerns and encounter different challenges from those of school-age children given the distinctive developmental characteristics of the early childhood period. This study aimed to explore the experience of caregivers through semistructured interviews to inform clinical practice. METHODS: Fifty caregivers of children aged 6 months to 5.99 years were interviewed 3 months postinjury for this qualitative study to document their experience in relation to their child's accident, recovery, and healthcare provisions. RESULTS: Four main themes were identified: (1) visible changes associated with caregiver concerns, (2) a roller-coaster of emotions after the injury, (3) healthcare providers' role in addressing the need for reassurance, and (4) the need for better information after the injury. CONCLUSION: The findings provide critical insight into the unique experiences and information needs of caregivers of young children who sustain concussion. The challenges identified can inform healthcare professionals regarding the needs of caregivers after early concussion and contribute to building a knowledge base for the development of age-appropriate anticipatory guidance for caregiver mental health and child recovery.

Using Billing Codes to Create a Pediatric Functional Status e-Score for Children Receiving Inpatient Rehabilitation.

OBJECTIVE: Provide proof-of-concept for development of a Pediatric Functional Status eScore (PFSeS). Demonstrate that expert clinicians rank billing codes as relevant to patient functional status and identify the domains that codes inform in a way that reliably matches analytical modeling. DESIGN: Retrospective chart review, modified Delphi, and nominal group techniques. SETTING: Large, urban, quaternary care children's hospital in the Midwestern United States. PARTICIPANTS: Data from 1955 unique patients and 2029 hospital admissions (2000-2020); 12 expert consultants representing the continuum of rehabilitation care reviewed 2893 codes (procedural, diagnostic, pharmaceutical, durable medical equipment). MAIN OUTCOME MEASURES: Consensus voting to determine whether codes were associated with functional status at discharge and, if so, what domains they informed (self-care, mobility, cognition/ communication). RESULTS: The top 250 and 500 codes identified by statistical modeling were mostly composed of codes selected by the consultant panel (78%-80% of the top 250 and 71%-78% of the top 500). The results provide evidence that clinical experts' selection of functionally meaningful codes corresponds with codes selected by statistical modeling as most strongly associated with WeeFIM domain scores. The top 5 codes most strongly related to functional independence ratings from a domain-specific assessment indicate clinically sensible relationships, further supporting the use of billing data in modeling to create a PFSeS. CONCLUSIONS: Development of a PFSeS that is predicated on billing data would improve researchers' ability to assess the functional status of children who receive inpatient rehabilitation care for a neurologic injury or illness. An expert clinician panel, representing the spectrum of medical and rehabilitative care, indicated that proposed statistical modeling identifies relevant codes mapped to 3 important domains: self-care, mobility, and cognition/communication.

Emergency department visits for mild traumatic brain injury in early childhood.

BACKGROUND: Brain injury during early childhood may disrupt key periods of neurodevelopment. Most research regarding mild traumatic brain injury (mTBI) has focused on school-age children. We sought to characterize the incidence and healthcare utilization for mTBI in young children presenting to U.S. emergency departments (ED). METHODS: The Nationwide Emergency Department Sample was queried for children age 0-6 years with mTBI from 2016 to 2019. Patients were excluded for focal or diffuse TBI, drowning or abuse mechanism, death in the ED or hospital, Injury Severity Score > 15, neurosurgical intervention, intubation, or blood product transfusion. RESULTS: National estimates included 1,372,291 patient visits: 63.5% were two years or younger, 57.5% were male, and 69.4% were injured in falls. The most common head injury diagnosis was "unspecified injury of head" (83%); this diagnosis decreased in frequency as age increased, in favor of a concussion diagnosis. Most patients were seen at low pediatric volume EDs (64.5%) and non-children's hospital EDs (86.2%), and 64.9% were seen at a non-teaching hospital. Over 98% were treated in the ED and discharged home. Computed tomography of the head and cervical spine were performed in 18.7% and 1.6% of patients, respectively, less often at children's hospitals (OR = 0.55, 95%CI = 0.41-0.76 for head and OR = 0.19, 95%CI = 0.11-0.34 for cervical spine). ED charges resulted in $540-681 million annually, and more than half of patients utilized Medicaid. CONCLUSIONS: Early childhood mTBI is prevalent and results in high financial burden in the U.S. There is wide variation in diagnostic coding and computed tomography scanning amongst EDs. More focused research is needed to identify optimal diagnostic tools and management strategies.

Predictors of Treatment Response to Multidisciplinary Care for Persistent Symptoms after Pediatric Concussion.

PURPOSE: To assess which pediatric patients experiencing persistent post-concussive symptoms (PCS) benefit most from multidisciplinary treatment including specialists in Neurology, Neuropsychology, Physical Therapy, and Athletic Training, and to explore the effectiveness of this approach. METHODS: A retrospective chart review of 56 adolescents 10-20 years old (M = 15.0 ± 2.1) receiving multidisciplinary care for PCS (>30 days) was conducted. RESULTS: Systolic blood pressure and Body Mass Index predicted time to concussion resolution (p < .05), such that higher values were associated with slower resolution. PCS scores significantly decreased between participants' initial and final clinic visits, p < .01, and among the 25 participants for whom pre-intervention PCS scores were available, symptom severity scores significantly declined following multidisciplinary intervention compared to pre-referral values (p < .01). CONCLUSIONS: Exploratory analyses reveal that multidisciplinary treatment is a promising approach for reducing symptoms among adolescents with PCS, and that those with greater levels of physical fitness may benefit most.

Exposure to Head Impacts and Cognitive and Behavioral Outcomes in Youth Tackle Football Players Across 4 Seasons.

Importance: Repetitive head impacts have been posited to contribute to neurocognitive and behavioral difficulties in contact sport athletes. Objective: To identify associations between cognitive and behavioral outcomes and head impacts measured in youth tackle football players over 4 seasons of play. Design, Setting, and Participants: This prospective cohort study was conducted from July 2016 through January 2020, spanning 4 football seasons. The setting was a youth tackle football program and outpatient medical clinic. Players were recruited from 4 football teams composed of fifth and sixth graders, and all interested players who volunteered to participate were enrolled. Data analysis was performed from March 2020 to June 2021. Exposures: Impacts were measured using helmet-based sensors during practices and games throughout 4 consecutive seasons of play. Impacts were summed to yield cumulative head impact gravitational force equivalents per season. Main Outcomes and Measures: Ten cognitive and behavioral measures were completed before and after each football season. Results: There were 70 male participants aged 9 to 12 years (mean [SD] age, 10.6 [0.64] years), with 18 completing all 4 years of the study. At the post-season 1 time point, higher cumulative impacts were associated with lower self-reported symptom burden (ß = -0.6; 95% CI, -1.0 to -0.2; P = .004). After correcting for multiple comparisons, no other associations were found between impacts and outcome measures. At multiple times throughout the study, premorbid attention-deficit/hyperactivity disorder, anxiety, and depression were associated with worse cognitive or behavioral scores, whereas a premorbid headache disorder or history of concussion was less often associated with outcomes. Conclusions and Relevance: In this cohort of youth tackle football players, premorbid conditions, including attention-deficit/hyperactivity disorder, anxiety, and depression, were associated with cognitive and behavioral outcomes more often than cumulative impact.

Treatment of Post-traumatic Headaches in Children: A Systematic Review.

Post-traumatic headache is a secondary headache disorder beginning within 7 days of head injury. We conducted a systematic review of the evidence for treatment of post-traumatic headache in children. Of 2169 unique articles screened, 12 were included. Most studies pertained to headaches after concussion. The authors of seven studies examined the effect of medications, 4 studied nonpharmacological therapies, and 1 studied the reduction of medication usage. Much of the evidence came from retrospective chart reviews, had low level of evidence, and had fair risk of bias. High-quality randomized controlled treatment trials are needed to guide the clinical management of this condition.

Subconcussive Head Impacts and Neurocognitive Function Over 3 Seasons of Youth Football.

OBJECTIVE: To determine the association between repetitive subconcussive head impacts and neurobehavioral outcomes in youth tackle football players. METHODS: Using helmet-based sensors, we measured head impacts for 3 consecutive seasons of play in 29 male players age 9-11. Cumulative impact g's were calculated. Players completed a battery of outcome measures before and after each season, including neuropsychological testing, vestibular-ocular sensitivity, and self- and parent-reported measures of symptoms and attention-deficit hyperactivity disorder (ADHD). RESULTS: Average cumulative impact over 3 seasons was 13 900g. High-intensity hits predicted worse change for self-reported social adjustment (P = .001). Cumulative impact did not predict change in any of the outcome measures. History of ADHD, anxiety, and depression predicted worse change for self-reported symptoms and social adjustment, independent of head impacts. When players were stratified into 3 groups based on cumulative impact across all 3 seasons, differences in outcome measures existed prior to the start of the first season. These differences did not further increase over the course of the 3 seasons. CONCLUSION: Over 3 consecutive seasons of youth tackle football, we found no association between cumulative head impacts and neurobehavioral outcomes. Larger sample sizes and longer follow-up times would further assist in characterizing this relationship.

Proposal of a Functional Impairment Symptom Scale for Concussion.

Clinicians currently administer patient-reported symptom scales to quantify and track concussion symptoms. These scales are based on subjective ratings without reference to the degree of functional impairment caused by the symptoms. Our objective was to develop a concussion symptom scale based on functional impairment and compare it to a widely used concussion symptom checklist. We conducted a retrospective chart review evaluating 133 patients age 9-22 with an acute concussion who completed 2 symptom checklists at their initial visit-the Sport Concussion Assessment Tool (SCAT-3) symptom evaluation (22 symptoms, 0-6 scale) and the proposed Functional Impairment Scale (22 symptoms, 0-3 scale related to degree of functional impairment). Mean total symptom score was 27.2±22.9 for Sport Concussion Assessment Tool-3 and 14.7±11.9 for the Functional Impairment Scale. Pearson correlation between the scales was 0.98 (P < .001). Mean time from concussion to first visit was 6.9±6.2 days, and median clearance time after injury was 19 (95% CI 16-21) days. After adjusting for patient and injury characteristics, an increased score on each scale was associated with longer time to clearance (5-point increase in Sport Concussion Assessment Tool-3 hazard ratio 0.885, 95% CI 0.835-0.938, P < .001; 2.5-point increase in Functional Impairment Scale hazard ratio 0.851, 95% CI 0.802-0.902, P < .001). We propose a concussion symptom scale based on functional impairment that correlates strongly with the Sport Concussion Assessment Tool-3 scale, demonstrates a similar association with time to clearance, and may provide a more intuitive approach to monitoring how symptoms are affecting patients recovering from concussion. Future research should aim to validate this scale through a prospective longitudinal study.

Head Impact Burden Differs Between Seasons in Youth and High School US Football Players.

Retrospective estimates of head impact burden in contact sports are often used in studies assessing for correlation of head impact exposure with neurocognitive outcomes later in life. These estimations assume a consistent impact burden from year to year. We monitored head impacts in youth tackle football players in the 6th-8th grades and high school varsity players using helmet-based sensors during two consecutive seasons. Helmet-based pressure sensors were used to measure head impacts, and estimates of peak linear acceleration (g's) were then grouped and summed for cumulative impact. After each season, players estimated whether they experienced an average, below average, or above average head impact burden in relation to their teammates. Of the 98 players who participated, 54 played in both seasons and sustained a median of 102.5 impacts (2206 cumulative g's) in season 1 and 161 impacts (3682 cumulative g's) in season 2. Using pairwise comparisons, number of impacts and cumulative g's increased in the youth players from season 1 to season 2 (p = 0.0021 and p = 0.0018, respectively), but there was a trend towards a decrease in number of impacts and g's at the high school level. In an exploratory analysis, perceived cumulative head impact and measured cumulative g's weakly correlated (Pearson's correlation coefficient = 0.26 for season 1 and 0.02 for season 2). In conclusion, cumulative head impacts differ significantly from one season to the next, and players have difficulty estimating their cumulative head impacts in relation to their team mates, especially at the youth level. Retrospective estimations of head impact burden should account for this variability.

Neurocognitive Function and Head Impact Burden over Two Seasons of Youth Tackle Football.

This prospective cohort study sought to determine the association of repetitive sub-concussive head impacts with neurocognitive outcomes in youth tackle football players. The study sample included 166 youth tackle football players over two seasons: 70 primary school players ages 9-12 and 96 high school players ages 15-18. Helmet-based sensors recorded head impacts during practices and games, and impacts were summed to provide a cumulative measure of impact for each season. Participants also were stratified by "high intensity" and "low intensity" groups based on whether they sustained high or low g-force impacts. Participants completed assessments on a variety of neurologic, cognitive, and behavioral outcomes before and after each football season. In the subgroup of 55 players who participated in both seasons, the average combined cumulative impact for primary school and high school players was 7127 (standard deviation [SD] 4670) and 6558 (SD 4438) g-forces, respectively. Neither cumulative impact nor impact intensity predicted change scores from pre-season 1 to post-season 2 on any outcome measures. Instead, younger age group and history of attention deficit hyperactivity disorder (ADHD) predicted worse change scores on several cognitive measures and an ADHD symptom reporting scale. In the full 166-player cohort, a computerized test of processing speed declined over time, while the remaining 22 outcome measures either did not change or improved over time. Minimal changes were observed in neurocognitive outcomes associated with participation in youth tackle football over the course of two seasons, and there was no correlation with the number and severity of head impacts sustained over that time. However, longer prospective follow-up times will be beneficial.

Head Impact Burden and Change in Neurocognitive Function During a Season of Youth Football.

OBJECTIVE: To determine the association of repetitive subconcussive head impacts with functional outcomes in primary and high school tackle football players. SETTING: Youth football fields and an outpatient sports neurology clinic. PARTICIPANTS: A total of 112 primary school (n = 55, age 9-12 years) and high school (n = 57, age 15-18 years) football players. DESIGN: A prospective cohort study. MAIN MEASURES: Helmet-based sensors were used to record head impacts during practices and games during the 2016 football season. Impact g-forces were summed to yield a measure of cumulative impact. History of self-reported premorbid medical diagnoses was obtained preseason. Players completed assessments of a variety of outcomes both pre- and postseason: neuropsychological test performance, symptoms, vestibular and ocular-motor screening, balance, parent-completed attention-deficit hyperactivity disorder (ADHD) symptoms, and self-reported behavioral adjustment. RESULTS: Average cumulative impact was 3700 (standard deviation = 2700) g-forces for the season and did not differ between age groups (P = .594). Cumulative impact did not predict pre- to postseason change scores on any outcome measures (all P > .05). Instead, younger age group and reported history of premorbid ADHD predicted change scores on several cognitive testing measures and parent-reported ADHD symptoms, while reported history of premorbid anxiety and depression predicted change scores on symptom reporting. CONCLUSIONS: In youth tackle football, subconcussive head impacts sustained over the course of a single season may not be associated with neurocognitive functional outcomes. The absence of a significant association may reflect the relatively short follow-up interval, and signals the need for studies across multiple seasons.

Utilization of conventional neuroimaging following youth concussion.

BACKGROUND/OBJECTIVE: Conventional neuroimaging is not recommended for the routine diagnosis of concussion, but some patients with concussion undergo computed tomography (CT) or magnetic resonance imaging (MRI). The objective of this study was to explore the clinical factors that predict neuroimaging utilization in concussion. METHODS: Concussion-related CT and MRI data were analysed from 1953 patients, aged 10-19 years, who presented to a sports concussion clinic within 30 days of injury. RESULTS: The majority of CT scans (n = 193) were obtained during the acute concussion period (mean = 2.7 days post-concussion), whereas MRI scans (n = 134) were ordered later during recovery (mean = 39.4 days post-concussion). Predictors of CT utilization included loss of consciousness, amnesia and vomiting (all p < 0.001). Prior concussion (p = 0.002) and continued participation in activity after injury (p = 0.03) predicted greater MRI utilization. Neuroimaging with either CT (p = 0.024, hazard ratio = 1.2) or MRI (p < 0.001, hazard ratio = 2.75) was associated with prolonged symptoms. Only 3.1% of CTs and 1.5% of MRIs demonstrated signs of traumatic brain injury. CONCLUSION: Several clinical factors predict neuroimaging utilization in patients with concussion. CT is generally used acutely, while MRI is used in the sub-acute and chronic post-concussion periods. In a sports concussion clinic, delayed neuroimaging has limited clinical yield.

Specific Factors Influence Postconcussion Symptom Duration among Youth Referred to a Sports Concussion Clinic.

OBJECTIVE: To identify the clinical factors that influence the duration of postconcussion symptoms among youth referred to a sports concussion clinic. STUDY DESIGN: A retrospective cohort study was conducted to evaluate several potential predictors of symptom duration via a Cox proportional hazards analyses. The individual postconcussion symptom scores were highly correlated, so these symptoms were analyzed in the statistical model as coefficients derived from principal component analyses. RESULTS: Among 1953 youth with concussion, 1755 (89.9%) had dates of reported symptom resolution. The remainder (10.1%) were lost to follow-up and censored. The median time to recovery was 18 days (range 1-353 days). By 30 days, 72.6% had recovered; by 60 days, 91.4% had recovered; and by 90 days, 96.8% had recovered. Several variables in a multivariate Cox model predicted postconcussion symptom duration: female sex (P < .001, hazard ratio [HR] = 1.28), continued activity participation (P = .02, HR = 1.13), loss of consciousness (P = .03, HR = 1.18), anterograde amnesia (P = .04, HR = 1.15), premorbid headaches (P = .03, HR = 1.15), symptom components from the day of concussion (emotion, P = .03, HR = 1.08), and the day of clinic evaluation (cognitive-fatigue, P < .001, HR = 1.22; cephalalgic, P < .001, HR = 1.27; emotional, P = .05, HR = 1.08; arousal-stimulation, P = .003, HR = 1.1). In univariate analyses, greater symptom scores generally predicted longer symptom durations. Worsening of symptoms from the day of concussion to the day of clinic evaluation also predicted longer recovery (P < .001, HR = 1.59). CONCLUSIONS: Several factors help to predict protracted postconcussion symptom durations among youth referred to a sports concussion clinic.

Physicians' Management Practices and Perceived Health Risks When Postconcussion Symptoms Persist.

BACKGROUND: Concussion guidelines recommend physical and cognitive rest until all postconcussion symptoms resolve, in part because of potential health risks, including catastrophic injury related to a second impact. However, when postconcussion symptoms persist for weeks or months, these risks are poorly characterized. HYPOTHESIS: Physicians' perceived health risks and management strategies for patients with persistent postconcussion symptoms will vary. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 3. METHODS: A survey of the physician members of the American College of Sports Medicine assessed the perceived health risks related to advancing activity, the indications for neuroimaging, and the referral patterns for patients with persistent postconcussion symptoms. RESULTS: A total of 572 physicians completed the survey (response rate, 27.2%). The majority of physicians recommended physical rest (97.4%) and cognitive rest (93.8%) within the first week of injury. Perceived health risks related to advancing activity in the symptomatic patient differed at 2 weeks versus 3 months after injury (P < 0.001 for all comparisons). Respondents from the United States were more likely to list second impact syndrome as a potential health risk at 2 weeks compared with respondents from other countries (P = 0.04). The majority (56%) responded that the risk of second impact syndrome remains until all symptoms resolve. When postconcussion symptoms persist beyond 1 month, 61.9% of physicians responded that neuroimaging is indicated. Approximately 60% of respondents had access to a multidisciplinary concussion clinic within 60 miles of their practice. CONCLUSION: When postconcussion symptoms persist, the perceived health risks, management practices, and access to multidisciplinary care vary among physicians.

Returning the student to school after concussion: what do clinicians need to know?

Participation in school is vital to a child's academic and social development. Following concussion, returning the student to school can pose several challenges for families, healthcare providers and school personnel. The complex constellation of postconcussion symptoms can impair learning and can make the school environment intolerable. Research evidence to guide the return to school process is lacking, but protocols have been proposed that outline a gradual reintroduction to school with academic accommodations tailored to the student's specific symptoms. Key medical and school personnel must understand their respective roles to optimize the process. This review of the current literature examines the available data and expert recommendations that can support a student's successful return to school following concussion.