BOSTON – Children who present to a primary care practice following a head or facial injury must be carefully evaluated for signs and symptoms of concussion, and those with concussion should be advised to give their brains a break, recommended a pediatric injury specialist at the annual meeting of the Pediatric Academic Societies.
Cognitive rest involves limiting "cognitive activity to a level that does not elicit symptoms." For children, this means forgoing computers, video games, texting/social media, reading for school and/or homework, and avoiding noisy or busy environments.
Dr. Kristy B. Arbogast
"The primary focus of pediatric concussion management should be return to cognitive activities and then return to the playing field," Dr. Kristy B. Arbogast said.
A review of records from a large pediatric primary care network showed that 25% of patients with concussion symptoms did not have concussion mentioned in the medical assessment or diagnosis, and nearly half of children in a random sample presented for reevaluation of concussion or persistent concussion symptoms, said Dr. Arbogast, an emergency physician and director of the Pediatric Injury Prevention Program at Children’s Hospital of Philadelphia.
"So-called ‘mild’ traumatic brain injuries are often far from mild. They lead to poor neurological outcomes that can adversely affect a child’s quality of life," she said.
Children with concussion make an estimated 144,000 emergency department visits annually in the United States. As children’s participation in year-round sports has increased, their risk of mild traumatic brain injury (TBI) has also increased, Dr. Arbogast noted.
Concussions among professional athletes receive considerable attention in the popular press, where the stories center on physical recovery and returning to the game. But for school kids, who are at significant risk for learning disabilities, memory problems, and emotional or behavioral changes after a TBI, the focus should be on physical and cognitive rest, she said.
Dr. Arbogast and her colleagues reviewed the concussion management and return-to-school practices of pediatric primary care providers by reviewing records from their hospital’s primary care network.
They looked for data on children aged 5-18 years with any presentation of mild TBI based on ICD-9 codes for skull fracture, concussion, intracranial injury, head injury (unspecified), or facial fracture. The children received initial or continuing care during the study period of July 2010 through June 2011.
The researchers included children who presented with one or more injury characteristics such as amnesia, loss of consciousness, cognitive symptoms (decline in school performance, report of being "in a fog"), emotional symptoms, and physical symptoms or exam findings including eye-tracking problems, headache, nausea/vomiting, poor balance, sleep disturbances, slow reaction times, or visual disturbance. Children with moderate or severe head trauma were excluded from the study.
The investigators randomly selected a sample of 193 patients who met all of the criteria. In all, 51% had a sports-related injury, 8% had previously had a concussion, and 6% had sustained a loss of consciousness.
There was no mention of concussion in the medical assessment or diagnosis of 25% of the sample. Of 94 children who presented for reevaluation of concussion, 33% reported a decline in school performance, 13% said they felt like they were "in a fog," 12% reported vision problems, 12% reported fatigue, and 11% had concentration problems (some reported more than one symptom).
When the authors looked at the written instructions primary care providers gave to the patients, they found that while 54% received return-to-play instructions, only 34% received return-to-school instructions, suggesting that in many cases the practitioners may have failed to recognize the importance of cognitive rest, Dr. Arbogast said. The remaining 12% of patients did not have written instructions documented.
She recommended that clinicians caring for children with suspected concussion ask about all symptoms individually in a systematic fashion, and prescribe a return-to-school protocol with a stepwise approach. The protocol includes a return to the previous step if an action elicits the return of symptoms, sending a standardized letter to notify the child’s school of the plan, and training the child’s parent or guardian to oversee the child’s progression from one step to the next.
The study was funded by the Children’s Hospital of Philadelphia and the University of Pennsylvania, also in Philadelphia. Dr. Arbogast and coinvestigators reported having no conflicts of interest to disclose.