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New Guidance on Management of Increasing Problem of Sports-Related Concussions in Children

Posted Sep 03 2010 12:00am
From Medscape Medical News
Pauline Anderson

September 2, 2010 — A new guidance document for the management of pediatric concussions recommends a more conservative approach to return to play policies for younger children with sports-related concussions.

Although there is little research on concussions in the pre–high school age group, there is evidence that high school athletes take longer to recover than college athletes, who take longer than professional athletes, said a lead author of the study, Mark Halstead, MD, assistant professor in the Departments of Pediatrics and Orthopedics at Washington University School of Medicine, St Louis, Missouri.

"We can only assume that if that trend continues, these younger children take even longer to recover, and my own personal experience is that this is the case," Dr. Halstead told Medscape Medical News.

The document, a clinical report from the American Academy of Pediatrics, is published in the September issue of Pediatrics.

A related paper in the same online issue shows that although participation in organized sports decreased by about 13% during a recent 10-year span, emergency department (ED) visits for concussions increased — by more than 50% in children 8 to 13 years old and by more than 200% in 14- to 19-year-olds — during the same period.

The study found that younger children accounted for about 35% of the 502,000 ED visits for concussions from 2001 to 2005. Overall, about half of these visits were sports related, but 58% were sports related among younger children.

Although it is important for children to play sports, these statistics underline the importance of ensuring they use proper prevention techniques while being physically active, lead study author Lisa L. Bakhos, MD, from the Department of Pediatric Emergency Medicine at Warren Alpert Medical School, Brown University, Rhode Island, told Medscape Medical News in an email.
"It's also important to make sure that if an injury does occur to seek medical attention and follow recommendations."

Conservative Approach Recommended

Young athletes whose brains are still developing pose a challenge because they may be more susceptible to the effects of a concussion, Dr. Halstead and colleagues write. Extensive research during the last 10 years has provided a better understanding of the course and potential long-term complications, resulting in an evolution in management, they note.
"Unfortunately, many parents, coaches, and young athletes still seem to believe that youth is a period of indestructibility."

This report, they write, "outlines the current state of knowledge on pediatric and adolescent sport-related concussions."

Other recommendations in the clinical report on concussion in children include the following
•Athletes with concussion should rest not only physically but also cognitively until symptoms have resolved both at rest and with exertion. This may require modification of school plans and perhaps time away from school, said Dr. Halstead, who has seen student averages drop from A to C during recovery from a concussion.
•Any child who sustains a concussion should be evaluated by a healthcare professional and receive medical clearance before returning to play. The misconception that a concussion may be "toughed out" and does not require a visit to the doctor still persists, according to the study authors.
•Even if young athletes become asymptomatic, they should not return to play on the same day of a concussion. Just 10 years ago, a young athlete with a "ding" or low-grade concussion would have been allowed to return to sports as soon as 15 minutes after symptoms had cleared, said the study authors.
•Neuropsychological testing can be helpful but does not in itself make a diagnosis or determine when return to play is appropriate.
•Retirement from contact sports may be necessary for athletes with a history of multiple concussions. "We know that athletes who have had 3 concussions are 9 times more likely to have more severe symptoms than someone who has never had a concussion, and often their symptoms are more prolonged," said Dr. Halstead.
Symptom-Based Approach

Some diagnostic tools for concussions are now outdated, including the once widely used 3-tier grading system, the study authors add. "That system focused heavily on loss of consciousness, which is not a very prominent feature of sport concussions; only 10% will lose consciousness," said Dr. Halstead.

Instead, an individualized symptom-based approach is more advisable. Signs and symptoms of concussion, many of which overlap, fall into 4 categories: physical, cognitive, emotional, and sleep. Headache is the most frequently reported symptom. Although loss of consciousness occurs infrequently, it is an important sign that may herald the need for further intervention.

Concussions represent about 8.9% of all high school athletic injuries. It is difficult to determine the equivalent rate among children in grade school and middle school athletes because data are lacking, said Dr. Halstead.

Girls are reported to have a higher rate of concussion than boys in similar sports, but the reasons for this are unknown, according to the study authors. For boys, football carries the highest risk of concussion, whereas for girls, the rate of concussion is highest in soccer and basketball.

Organized Team Sports

For the study by Bakhhos and colleagues, the researchers used a retrospective review of the National Electronic Injury Surveillance System (NEISS) from January 1, 1997, to December 31, 2007, and the NEISS All Injury Program (NEISS-AIP) from January 1, 2001, to December 31, 2005.

The NEISS is a data collection system conducted by the US Consumer Product Safety Commission of a national probability sample of 100 hospitals with a minimum of 6 beds and a 24-hour ED. The NEISS-AIP includes 66 of 100 NEISS hospitals and collects data on the basis of type of injury.

Researchers divided children into pre–high school (8-13 years) and high school (14-19 years) and causes of concussions into all causes, all sports-related causes, those related to individual and leisure sports, and those linked to organized team sports.

To calculate injury rates they used population projections from the US Census Bureau and averaged population data during the 5-year study period. Sports participation data came from the National Sporting Goods Association, which conducts annual mail-based surveys of 30,000 US households.

The study found that 1 in 1000 children aged 8 to 13 years and 3 in 1000 aged 14 to 19 years visited a hospital for a concussion sustained during 1 of the top 5 organized team sports. Most concussions among younger kids were sustained during football (22.6% of all sports-related concussions), followed by basketball (9.2%), soccer (7.7%), ice hockey (3.8%), and baseball (3.5%). In older children, football accounted for 53% of all team sports–related concussions, whereas soccer accounted for 18%, basketball for 16%, hockey for 8%, and baseball for 5%.

As for rates of concussion, ice hockey came out on top for both age groups (10 and 29 per 10,000 in the younger and older ages, respectively) followed by football (8 and 27 per 10,000, respectively) and then soccer, basketball, and baseball.

"Although football had the greatest number of concussions, the highest rate was actually in ice hockey," noted Dr. Bakhos. "For both, we need to be sure that helmets fit properly and we are not encouraging children to be overly and unnecessarily aggressive."

Dr. Bakhos said hockey players should be a special target for information on concussion prevention and management because this sport "is one of the most contact sports there is in the country."

As for soccer, measures such as padding goal posts and making sure field conditions are safe could help reduce concussions, which are not usually caused by "head butting" the ball but by collisions between players, said Dr. Bakhos.

Increasing Awareness

Even though participation in organized sports decreased by 13% from 1997 to 2007, visits to the ED for team sports –related concussions increased significantly among all children, but the reasons for this are unknown. "It could be secondary to increasing awareness and reporting or it could be due to the increased competitiveness of sport or the fact that children are generally larger than they used to be," said Dr. Bakhos.

Although some people point to the increasing variety of sports being made available to young athletes, Dr. Bakhos pointed out that the highest concussion rates seem to be in sports that have been around for some time.

The increasing intensity of competition could also play a role by putting the drive to win ahead of safety concerns, said Dr. Bakhos. "Parents, coaches, and players just need to put things into perspective and realize that health is the number one priority."

As for leisure and individual sporting activities, biking resulted in the most hospital visits for concussions in all age groups (18,252 in younger and 11,031 in older children). Playground activities and skiing were the next most common causes of concussion in this category among younger children, whereas for the older age group, snow skiing and combative sports were the next most common.

Less overall head injury force is needed to produce clinical symptoms in children than in adults, according to background information included in the study. There is some suggestion that concussion among younger children, who are still developing their essential skills, may produce more severe long-term developmental and cognitive problems.

Dr. Halstead and his coauthors filed conflict of Interest statements with the American Academy of Pediatrics (AAP) and any conflicts have been resolved. The AAP has neither solicited nor accepted any commercial Involvement in the development of the content of the article. Dr. Bakhos and her coauthors have indicated they have no financial relationships relevant to their article.

Pediatrics. 2010;126:e449-e556, 596-615.
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