Parents, coaches, physicians and athletes today are more acutely aware of the danger of concussions and mild traumatic brain injuries (mTBI). The Centers for Disease Control (CDC) notes that more than 800,000 children seek care related to traumatic brain injuries in U.S. emergency departments each year, and about 2.5 million reported having a sports/activity-related concussion within the last 12 months.
In an effort to improve mTBI recovery outcomes for patients 18 years and younger, the CDC recently released updated guidelines — built from a comprehensive review of 25 years of research — intended to guide health-care professionals in diagnosis, prognosis, management and treatment. Dr. Stacy J. Suskauer, co-director of Kennedy Krieger Institute’s Center for Brain Injury Recovery, served as a co-author of the guidelines. Here, Suskauer answers some questions to help parents better understand pediatric mTBI and the implications of the new guidelines.
What are the most common causes of concussion in children?
The frequency and cause of concussion varies depending on what population is studied. In the youngest children (baby to 4 years old), falls are typically the leading cause of concussion. For older children, sports-related injuries are often more numerous that non-sports-related injuries, though non-sports-related falls and other trauma, such as assault and motor vehicle collisions, are also important causes of concussion in older children. With regard to sports, contact sports, including football, soccer, lacrosse, ice hockey and basketball, are the most frequent causes of concussion.
Which ages are most often affected?
This is a great example of a statistic that differs considerably based on the setting where research is conducted. Children 4 years and younger have the highest rate of emergency department visits for concussion; this may reflect a bias toward having young children examined acutely because they cannot give as much information about the symptoms they are experiencing. In contrast, studies that examine visits for concussion across an entire health system (including outpatient settings) show a substantially higher number of children from 5 to 17 years of age receiving care for concussion compared to younger children.
How does pediatric mTBI differ from adult mTBI?
We still are learning about concussion/mTBI in young children (birth to 5 years). We have contributed to some of the research regarding preschoolers with mTBI, and we know that parents of children in this age group often report symptoms that are not considered common in older children or adults with concussion, such as a regression in toilet training. For all children, recovery after concussion commonly takes longer compared to adults, though there is a great deal of variability in the timeline to recovery overall. In addition, for children, the developmental stage of the child and impact of natural transitions (i.e., adjustment to middle school or high school) need to be considered when teasing apart contributions to symptoms. Management of the return-to-learn process is also largely specific to the care of children.
What are the biggest risk factors if a concussion is missed or improperly treated?
The biggest risk with missing or mistreating a concussion is exposing the child to ongoing impact to the head, such that additional hits to the head may be incurred prior to recovery. This most typically occurs during sports activities. While fortunately catastrophic injury from “second impact syndrome” is rare, we see that children who continued to receive hits to the head after incurring a concussion often have more severe symptoms and a longer time to recovery. This is why it’s so important that a child be removed from play if there is any concern that a concussion may have been sustained.
In the 25 years of research that went into this study, were there more or fewer concussions among children at various points of time?
Research studies show an increasing rate of concussion among children. There has certainly been increased attention to concussion in recent years, resulting in better identification and reporting of concussion as well as leading more people to seek care for concussion. In addition, studies are now capturing children treated for concussion not only in emergency departments, but also in outpatient clinics and by school-based athletic trainers as well as those who are not seen in any medical setting.
How has the approach to treating concussions changed in recent years?
One major source of variability in treatment has been with regard to how much rest is recommended after a concussion. The guidelines reflect recent studies on how rest impacts recovery in children, providing the recommendation that a child have a few days of rest after concussion and then start to get back to safe (non-contact) activities, with modifications as needed for symptom management.
It seems that many youth sports teams now have their own concussion plans in effect. Many require that athletes and parents view videos and/or read information and acknowledge that they will comply. Is this becoming mandated practice? Do health providers assist in creating these team protocols?
All states, including Maryland, have laws regarding youth concussion. These laws typically include education for athletes, parents and coaches on concussion. Some, but not all, school and sports programs have health providers assisting with their development and oversight.
Much research has been done to date, but what other aspects are still in need of further study?
There is still a lot that we don’t know about concussion in children and the impact of mild traumatic brain injuries on the developing brain, which is why it is so important for the research community to continue engaging in high-quality research studies on this topic. One area of need is how to best determine which child may have more difficulty following a subsequent concussion. As one approach to this question, I am running a research study designed to evaluate how the brain may be functioning differently even after a child appears to be recovered from concussion. At the Center for Brain Injury and Recovery, we are committed to continuing our research and expanding our knowledge of pediatric concussions and brain injuries, so we can ensure patients have the best opportunity for a positive outcome.
The guidelines are written for providers, but what can parents take away from these important study findings?
It is important for parents to know that the guidelines exist and represent recommendations for care across all settings. When evaluating where to seek care for a child with concussion, parents can ask if the provider follows the guidelines in their practice. Parents should also know that multidisciplinary evaluation is recommended if symptoms continue to be problematic four to six weeks post-injury. The CDC has the guidelines posted on its website, along with educational materials for parents related to what to expect after a concussion and how to help their child feel better.