Insights on pediatric concussion diagnosis and management

Oct. 03, 2023

As school starts again for the fall, so do youth sports. With contact sports, such as football or soccer, concussion risk is elevated. Even beyond sports, concussion risk arises with any activity that transmits force to a child's head with back-and-forth motion, says Mary E. Lynch, M.D., a physiatrist at Mayo Clinic in Rochester, Minnesota.

Dr. Lynch explains what many in the lay public or even in medicine call "concussion" is properly called a traumatic brain injury (TBI). She feels language related to TBI is important.

"Using the term 'traumatic brain injury' is good to respect the injury and call it as such — not brush it off as 'just a concussion,'" says Dr. Lynch.

Age-related pediatric concussion risk

TBI risk varies by age, as different ages participate in distinct activities, says Dr. Lynch. All ages can sustain a concussion. In her TBI practice, she sees young children with TBIs from falling while climbing furniture, falling down the stairs or crashing while learning to bike ride. She sees older teens with TBIs from sports and crashing vehicles such as motocross bikes, ATVs and snowmobiles.

Parents should understand that these vehicles come with a high risk of TBI and other injuries, she indicates. Dr. Lynch views decision-making about all activities in which children participate as parents' personal decisions, considering the risks and benefits.

A diagnostic challenge

TBIs often can be easy to diagnose and other times difficult to recognize. Thus, Dr. Lynch suggests that trauma professionals thoroughly educate themselves about TBI symptoms. She particularly recommends the CDC Heads Up website for information.

A TBI involves injury to the head followed by symptoms within 24 hours. You cannot "see" the brain injury when you look at the child, only signs and symptoms. The minority of children have visible bruises or lacerations with this injury, complicating diagnosis.

Dr. Lynch says an important diagnostic step is asking the patient or family member to tell the injury story, including injury mechanism.

She believes the patient's symptoms will point the healthcare professional in a diagnostic direction. Key TBI diagnostic steps include:

  • Conduct a neurologic exam, including a mental status evaluation and an oculomotor dysfunction check.
  • Test balance and strength, inquiring if the patient has experienced sensation changes.
  • Observe and ask the patient or family about fatigue or feeling foggy or out-of-sorts.

As TBIs may not be immediately apparent, Dr. Lynch advises using a checklist. While looking at and speaking to the child and family, has the child:

  • Acted normally?
  • Complained of headache or vision changes?
  • Made sense?
  • Seemed off moodwise or irritable?
  • Vomited?
  • Been unable to eat or sleep?
  • Walked normally?

She believes parents know a child's baseline better than anyone and can speak to any diversion from the norm.

Though not always necessary, imaging can assist diagnosis. Imaging decisions are based on the patient's symptom severity, especially focal neurologic symptoms, weakness, asymmetric pupils or severe mechanism of injury. Children still can have significant symptoms even if their head CTs are normal.

TBI treatment

TBI treatment is symptom based, says Dr. Lynch. First, she recommends 48 hours of relative rest. This means during the first 48 hours post-injury, a patient could shower, clean a room, make a snack or walk around the house. A prescription to lie down continually is unnecessary.

This treatment strategy differs from the cocoon therapy healthcare professionals previously used, where the patient rests quietly and alone in the dark. She explains that data published in JAMA Pediatrics in 2019 indicate relative rest with light aerobic activity and participation in some daily activities has shortened patient recovery times and lessened the likelihood of prolonged symptoms.

As nausea and headache are common TBI symptoms, it can be helpful to use anti-nausea medication or use limited over-the-counter pain medications, such as acetaminophen and ibuprofen. She notes, however, if patients require numerous medications, they may need reevaluation for hidden injuries.

Other practices that contribute to TBI healing include:

  • Limit screen use.
  • Lower stimulation, such as not inviting friends to visit.
  • Avoid sports or anything that might re-injure.
  • After relative rest, stop any activity causing increase in symptoms.

If a patient's symptoms persist after concussion, Dr. Lynch says other contributing factors must be evaluated. Also, review any preexisting factors that may have been exacerbated by the injury, such as stress, sleep or mood issues, or problems at home.

Return to school and sports

Dr. Lynch recommends advising parents or guardians to encourage a child with a TBI to try some light school activities, such as reading, then test a partial return to school. Inform patients and their families they will need to fill out a return-to-school form with their primary care professionals. This form will address progressively returning to school and providing any accommodations, such as partial school day attendance. If patients tolerate a partial school return, they can move to a complete resumption of school attendance. Only after a successful return to full school activities should they return to full sports participation using a return-to-sports protocol.

Although some TBIs can be prevented by behavior, this is not absolute, according to Dr. Lynch.

"Unfortunately, TBIs are not completely preventable and are a fact of life," she says.

For more information

CDC Heads Up. Centers for Disease Control and Prevention.

Leddy JL, et al. Early subthreshold aerobic exercise for sport-related concussion: A randomized clinical trial. JAMA Pediatrics. 2019;173:319.

Refer a patient to Mayo Clinic.