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Guidelines in Focus: Concussion in Children and Adolescents
Byron D. Hughes MD, MPH, Nathaniel Kreykes, MD, Rosemary Nabaweesi, DrPH, Shannon Longshore, MD, Eric Sribnick, MD, John Petty, MD

Key Guideline Reference:

Zemek R, Duval S, Dematteo C. et al. Guidelines for Diagnosing and Managing Pediatric Concussion. Toronto, ON: Ontario Neurotrauma Foundation, June 2014.

Link to guideline: ONF Guidelines for Diagnosing and Managing Pediatric Concussion

Ontario Neurotrauma Foundation is a Canadian non-profit organization sponsored by the Ontario government. The organization is a leader in the field of neurotrauma.

The pediatric focused concussion guidelines were released in 2014 for children 5 to 18 years of age who had or may have sustained a concussion within the past month. Of note, the group found no validated clinical tools available for ages 0 to 5. Guidelines are further separated based on the role of the adult to the child (e.g. health care provider, caregivers, and schools/community sport organizations).

Guideline Highlights:

Recommendations are graded based on three levels of evidence: A, B, and C. A= Strongest evidence; B= Quality of patient-oriented evidence is limited; C= Usual practice, weak evidence.

The clinical guided recommendations are based on the timeline of the symptoms relative to the occurrence of a concussion:

1. In advance (before a concussion)
2. On Injury (if suspected)
3. On Presentation (assessment for red flags)
4. On Discharge (additional instructions and home care)
5. On interim assessment (determination of the necessary steps to return to normal activity)
6. On re-assessment (addressing persistent symptoms).

Key Definitions

Concussion: "Concussion is an injury to the brain caused by a blow to the head or to another part of the body that causes the head to spin or jolt. Even though concussions are common among children/adolescents, especially if they play contact sports such as hockey, these injuries tend to go unnoticed since there is often no bleeding, bruising or loss of consciousness, and symptoms can be very vague."

Persistent Symptoms: "Symptoms that last more than one month are called persistent symptoms."

For Healthcare Professionals: Level A evidence and tools to help accomplish it.

1. Assess any physical, cognitive, and neurological deficits.
   • Management of Acute Symptoms Algorithm.
   • Acute Concussion Evaluation (ACE).
   • ChildSCAT3 Sport Concussion Assessment Tool for Children aged 5-12 (symptom evaluation).
   • SCAT3 Sport Concussion Assessment Tool for Athletes aged 13+ (symptom evaluation).
   • Neurologic and Musculoskeletal Exam.
   
   
2. Determine the need for CT imaging.
   • PECARN Management Algorithm for Children After Head Trauma.
   • Algorithm for the management of the pediatric patient >/= 2 years with minor head trauma.
     *Importantly, most children and adolescents do not need imaging after sustaining a head injury.
   
   
3. Provide intensive educational program for the child/adolescent and the parents and/or caregivers.
   • Template Letter of Accommodation from Physician to School.
   • Returning to School-based Activities After Concussion Care Plan.

Examples of additional resources to help diagnose, treat, and manage concussions available within the guidelines are listed below:

1. Management of Acute Symptoms Algorithm
2. Neurologic and Musculoskeletal Exam
3. Assessment of Children and Adolescents with Headache
4. Template Letter of Accommodation from Physician to School
5. Diagnostic Criteria for Headaches
6. Approved Medications for Pediatric Indications

What's New?
Three recent publications contribute to our understanding of pediatric concussion assessment and management.

Article 1: Resch JE, Kutcher JS. The Acute Management of Sport Concussion in Pediatric Athletes. J Child Neurol. 2015; 30(12): 1686-1694.

Link to guideline: The Acute Management of Sport Concussion in Pediatric Athletes

The purpose of this review is to provide a clinical framework for the evaluation and management of sport concussion. In addition, this review provides considerations for health care professionals in regard to clinical measures and follow-up strategies during the acute phase following concussion in young concussed athletes. This review article highlights the pre-season clinical evaluation, outlines the assessment of acute brain injuries, and suggests appropriate follow-up strategies.

The authors recommend focusing your pre-season medical history on identifying premorbid conditions such as attention-deficit/hyperactivity disorder (ADHD) or learning disabilities such as dyslexia. A multidimensional approach consisting of neurocognitive, balance, and symptom measures are recommended to help frame the overall neurological evaluation of the potentially concussed athlete. Several assessment tools are provided in the article. Finally, a useful flow sheet guiding the clinician on the acute assessment of sports concussions is provided.

Article 2: Blume HK. Headaches after Concussion in Pediatrics: a Review. Curr Pain Headache Rep. 2015; 19: 42.

Link to guideline: Headaches after Concussion in Pediatrics: a Review

This review evaluates the extremely common and often vexing problem of headache following concussion in children. Post-traumatic headache (PTHA) is less well studied in children compared to adults. It has been best characterized in children who are seen in the ED and in young athletes. Between 10-45% of children with PTHA continue to have symptoms at 3 months, and 2% have symptoms at one year. Risk factors include a greater number of symptoms at presentation, adolescent age (increased risk compared to both pre-adolescent and college age), female sex, and prior headache history. PTHA may occur in isolation, or with other symptoms of the postconcussive syndrome: sleep disturbances, mood disturbances, dizziness, cognitive disturbances, nausea, etc. A structured evaluation, such as the CDC "Heads Up" questionnaire, can be very helpful. Imaging for subacute or chronic PTHA has very little usefulness, and should be considered for severe, significant, or focal changes. Management of PTHA is multifaceted. Education about PTHA for patients and families actually improves outcome, and it is essential to provide education to help them through this. Appropriate cognitive and physical rest should be emphasized. "Subthreshold" exercise rather than strict bed rest should be recommended. Nonpharmacologic therapies and avoidance of triggers are important. Regarding pharmacologic adjuncts, acetaminophen and NSAIDs, particularly naproxen, may help. Opioids should be avoided. Triptans may be considered in the setting or migraine symptoms. Finally, a strategy of “return to learn” at school should be initiated, to allow for integration back into school with appropriate allowances for symptom management.

Article 3: Fehr SD, Nelson LD, Scharer KR, et al.Risk Factors for Prolonged Symptoms of Mild Traumatic Brain Injury: A Pediatric Sports Concussion Clinic Cohort. Clin J Sport Med. 2017; 00:1–7.

Link to guideline: Traumatic Brain Injury: A Pediatric Sports Concussion Clinic Cohort

Concussion is a common injury in our youth. Little is known about characteristics and predictors of recovery in the pediatric age group. This article is a retrospective chart review evaluating predictors of prolonged symptom duration in patients with the diagnosis of concussion and were ages 10 to 18 years old. Symptom severity was defined as the total Post-Concussion Symptoms Scale (PCSS) score. Predictors of prolonged to reach recovery were higher symptom severity at the initial visit, loss of consciousness, and female sex.

What's Next?

Link to guideline: Head Trauma pathways on PTS site

Head trauma management care pathways provided by some of our institutional members are on the PTS website. These pathways provide information on assessing and managing head injuries ranging from mild to severe traumatic brain injury (TBI). Example #2 has a section relevant for all of our members, including those treating children in the pre-hospital setting (i.e. EMS). The timeline and organizational structure could certainly be adopted, and modified as necessary, by other institutions. Example #1 provides a great flowchart for managing pediatric patients beyond a concussion i.e. severe TBI. They've also included tiered pediatric intensive care unit (PICU) management guidelines to aid healthcare professionals treat those with severe head injuries. Example #3 expands on example #1 by adding a nice flowchart on cervical spine (c-spine) clearance covering the role of imaging and the preferred timing of neurosurgery consultation. How does your institution manage head injuries?

A Pediatric Neurosurgeon's Perspective

The guidelines above summarize our current level of understanding regarding concussions and recommendations for care of concussion patients. While strong evidence is lacking for most of the guidelines, much progress has been made in recognizing the importance of concussion and mild traumatic brain injury. The Ontario Neurotrauma Foundation (ONF) guidelines provide suggestions for care before injury, injury management, and post-injury care.

The definition for concussion provided by the ONF guidelines is adequate, but a useful addition to that definition would be that concussion involves a "biomechanically induced alteration of brain function."¹ Following a concussion, there are generally no changes noted on conventional imaging; nonetheless, concussion has been shown to predictably cause identifiable pathological changes in both animal models² and clinical studies⁶. Patients and parents may better understand the seriousness of a concussion if they recognize that temporary brain alterations can occur with these injuries.

As noted in the ONF guidelines and the recommended reading, there are a number of diagnostic tests that can be used, and no gold standard test has been identified. The education of trainers, coaches, and parents is essential, especially in regards to (1) signs/symptoms of concussion, (2) removing a child from play if concussion is suspected, and (3) early medical attention for clinical assessment and to obtain recommendations on management and return to play.

Of the recommendations in the ONF guidelines, the PECARN decision tool on whether to obtain a head CT is perhaps the recommendation with the highest level of evidence. This tool was developed from a study analyzing more than 40,000 pediatric patients.⁴

Clinical management of concussion, use of cognitive rest, and return to play guidelines are other areas where more research is needed. While the guidelines give broad, reasonable recommendations, there is still significant practice variation for topics such as cognitive rest.⁵

Finally, with the increased awareness of sports-related concussions, there is an increased concern regarding the effects of multiple concussions. Clinicians may want to inform patients and parents of current research suggesting a correlation between multiple concussions and long-term effects.^6,7

Eric Sribnick, MD, PhD
Nationwide Children's Hospital
The Ohio State University
Columbus, OH

¹Giza CC, Kutcher JS, Ashwal S, Barth J, Getchius TS, Gioia GA, Gronseth GS, Guskiewicz K, Mandel S, Manley G, McKeag DB, Thurman DJ, Zafonte R. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013 Jun 11;80(24):2250-7.

²Winston CN, Noël A, Neustadtl A, Parsadanian M, Barton DJ, Chellappa D, Wilkins TE, Alikhani AD, Zapple DN, Villapol S, Planel E, Burns MP. Dendritic Spine Loss and Chronic White Matter Inflammation in a Mouse Model of Highly Repetitive Head Trauma. Am J Pathol. 2016 Mar;186(3):552-67.

³Niogi SN, Mukherjee P, Ghajar J, Johnson C, Kolster RA, Sarkar R, Lee H, Meeker M, Zimmerman RD, Manley GT, McCandliss BD. Extent of microstructural white matter injury in postconcussive syndrome correlates with impaired cognitive reaction time: a 3T diffusion tensor imaging study of mild traumatic brain injury. AJNR Am J Neuroradiol. 2008 May;29(5):967-73.

⁴Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70.

⁵Johnson RS, Provenzano MK, Shumaker LM, McLeod TCV, Bacon CEW. The Effect of Cognitive Rest as Part of Postconcussion Management for Adolescent Athletes: A Critically Appraised Topic. J Sport Rehabil. 2017 Sep;26(5):437-446.

⁶Guskiewicz KM1, Marshall SW, Bailes J, McCrea M, Harding HP Jr, Matthews A, Mihalik JR, Cantu RC. Recurrent concussion and risk of depression in retired professional football players. Med Sci Sports Exerc. 2007 Jun;39(6):903-9.

⁷Didehbani N, Munro Cullum C, Mansinghani S, Conover H, Hart J Jr. Depressive symptoms and concussions in aging retired NFL players. Arch Clin Neuropsychol. 2013 Aug;28(5):418-24.

PTS would love to hear from you. If you want to submit your concussion management pathway, email it to guidelines@pediatrictraumasociety.org.

Keep an eye on the PTS website for new ideas and ways to make the care of injured kids better.