Pediatric Concussion

The term mild traumatic brain injury (TBI) is used interchangeably with the term concussion. A mild TBI or concussion is a disruption in the function of the brain as a result of a forceful blow to the head, either direct or indirect. This disturbance of brain function is typically not detected with a normal CT scan or MRI. A concussion results in a set of physical, cognitive emotional and/or sleep-related symptoms and often does not involve a loss of consciousness. Duration of symptoms is highly variable and may last from several minutes to days, weeks, months, or even longer in some cases.

A complete evaluation is important to determine the effects of the concussion and to develop an appropriate treatment plan. This will also be an important tool in deciding when the child is ready to return to normal activities including school, social activities and sports.

Concussions are probably more common than we know because they often go unrecognized. It is estimated that each year more than three million children sustain a traumatic brain injury, 80 to 90% of which are mild. Some of the more common causes of a mild TBI/concussion include:

• Motor vehicle accidents
• Falls
• Pedestrian-motor vehicle accidents
• Bicycle accidents
• Sports and recreation activities
• Assaults

Although we used to think that about 300,000 people in the United States sustained sports and recreation-related mild TBI/concussions every year, new estimates now indicate that up to 3.8 million people sustain a concussion each year. Most of these mild TBIs are not treated in a hospital or emergency department. Concussions can occur in any sport but have higher frequencies in the collision/contact sports such as:

• Football
• Ice hockey
• Soccer
• Rugby
• Horseback riding
• Lacrosse
• Basketball
• Wrestling

The Children’s National SCORE Program partners with coaches across the D.C./Maryland/Virginia region – and beyond – to support them in recognizing and responding to concussions in their players. If you are interested in learning about concussion education or further consultation please contact us.

The biggest problem in treating concussions is the lack of recognition and identification. This problem has been labeled the "silent epidemic" People are often not familiar with the signs and symptoms of a concussion. Contrary to popular belief, the child does not have to lose consciousness to sustain a concussion. In fact, nine out of ten children do not lose consciousness.

To help recognize a concussion you should watch for the following two things in the child or adolescent:

• A forceful blow to the head or body that results in rapid movement of the head
• Any change in their behavior, thinking or physical functioning (See the signs and symptoms of concussion listed in the table below.) 

Recognizing a Possible Concussion in a Child

Signs Observed by Others:

• Appears dazed or stunned
• Forgets plays or current activities
• Is confused about what they are doing
• Is unsure of recent events (game, score or opponent)
•  Moves clumsily
• Answers questions slowly
• Loses consciousness
• Shows behavior or personality changes- irritability, more emotional
• Can’t recall events before or after the hit or blow
• Vomits

Symptoms Reported by the Child/Adolescent:

• Headache
• Nausea 
• Balance problems or dizziness
• Double or fuzzy vision
• Sensitivity to light or noise
• Feeling sluggish or slowed down
• Feeling foggy or groggy
• Concentration or memory problems
• Confusion
• Fatigue

Appropriate evaluation and treatment is the key to a safe outcome. The symptoms of a concussion can cause problems when the child returns to school, home or community activities. The concussion evaluation assesses possible cognitive, behavioral or physical symptoms to assist in planning during recovery.

During an evaluation, a child will be given tests of attention, memory and speed. Test results are used to determine any needed interventions, as well as plan for return to school, sports and other physical activities. Often children with concussions experience prolonged symptoms, which interfere with their daily activities and sports. Clinicians will evaluate your child and help put a plan together that provides the necessary support for school, work and return to play decisions.

Just like all injuries or illnesses, every concussion must be managed and treated individually. The evaluation of the child or adolescent is important in determining the treatment for that person.

• REST and minimizing over-exertion (physical, mental) is the key to recovery
• Guidelines for managing concussions have been developed within the sports context due to the need for safe return to play in order to minimize the risk for re-injury. These guidelines are also relevant to the return of the child or teenager to any activity involving increased physical or mental exertion.
• The 2001 International Concussion in Sport (CIS) Group recommended the following new guidelines for returning athletes to play:
  • Emphasis on careful on-field evaluation
  • Restriction of play for symptomatic athletes: No athlete with any symptoms is to return to play.
  • Neuropsychological testing as the “cornerstone” to management
  • Once the athlete no longer has symptoms and their cognitive function has returned to normal, a graduated approach should be used in returning them to play, guided by careful individualized assessment and monitoring of post-concussive symptoms and neurocognitive functioning at each successive stage of activity, with the following progression:
    • Rest
    • Aerobic exercise
    • Sport-specific training
    • Non-contact drills
    • Full-contact training

• The developing brain appears to be more vulnerable to trauma
• High school athletes may take longer to recover from concussion than college athletes
• Amnesia (loss of memory at the time of injury), not loss of consciousness, appears to be the main indicator of concussion severity and predictor of post-injury deficits.
• Even seemingly mild concussions can have significant effects. Many athletes often continue to demonstrate significant problems one week post-injury despite the absence of overt signs or symptoms.
• Effects of multiple concussions can be cumulative. Prior concussions, especially if full recovery has not been achieved, may lower the threshold for the next concussion injury and increase symptom severity in subsequent
• Continued headaches indicate incomplete recovery. Athletes experiencing headaches one week post-injury are more likely to experience more overall symptoms and perform more poorly on neurocognitive measures than those who do not report headaches.
• Premature physical and/or mental exertion, before the brain has fully recovered, can both prolong recovery and worsen outcome of a concussion.