Children With Brain Injuries Often Have Persistent Symptoms

Allison Shelley

March 08, 2012

March 8, 2012 — Young people with mild traumatic brain injury (TBI) are at heightened risk of developing postconcussive symptoms, including cognitive symptoms such as inattention and forgetfulness, report researchers.

"Not all mild traumatic brain injuries are alike," lead investigator Keith Owen Yeates, PhD, from Nationwide Children's Hospital in Columbus, Ohio, told Medscape Medical News. "It's important to assess risk factors for symptoms that persist."

The prospective, longitudinal study is published online March 5 in Archives of Pediatrics and Adolescent Medicine.

Mild TBIs are common in children and adolescents, and every year more than 500,000 young people under the age of 15 sustain head injuries that require hospital care.

In an accompanying editorial, Frederick P. Rivara, MD, from the University of Washington in Seattle, says the message emerging from this research is that the group of injuries classified as mild TBI, including sports-related concussions, should not necessarily be treated as minor injuries that quickly resolve.

"There is a need for leadership," he emphasized. "While the Centers for Disease Control and Prevention have developed their 'Heads-Up' campaign on improving knowledge about TBI, especially sports-related TBI, there have been no rigorous evaluations of its effectiveness."

More than half the states have now passed laws requiring children to be removed from play after sustaining a sports-related concussion and not to return until being evaluated by someone other than the coach, he noted. "Evaluations of this type of law are also lacking."

Prospective Study

In this new study, investigators looked at 186 children with mild TBI and compared them with 99 young people who had orthopedic injuries. They evaluated reliable change in postconcussive symptoms and related functional consequences in the first year after injury.

The young people, age 8 to 15 years, were seen in emergency departments at 2 children's hospitals. Parents rated symptoms retrospectively shortly after injury. They rated postconcussive symptoms at 2 weeks and 3 and 12 months after injury.

Investigators used a regression-based approach to determine whether each child displayed reliable increases in postconcussive symptoms.

The researchers assessed health-related quality of life at 3 and 12 months. They also collected information on children's educational programming.

The investigators found that children with mild TBI were significantly more likely than those with orthopedic injuries to show reliable increases in both somatic and cognitive symptoms.

"They tended to have persistent headaches," Dr. Yeates said. "They found it difficult to pay attention in school and often missed class. They did fewer chores at home and the symptoms also had an impact on their social participation, so the real-life consequences were significant."

Reliable increases in symptoms were associated with declines in health-related quality of life and an increased likelihood of educational intervention.

For children with mild TBI, reliable increases in symptoms were more common among those with loss of consciousness or abnormalities on neuroimaging.

"Unfortunately, imaging cannot detect all problems," Dr. Yeates said. There are currently no good biomarkers for recovery from TBI. "It's important we take all injuries seriously."

Many Questions

Parents across the United States, their athletic children, and their children's doctors, coaches, and athletic trainers want answers to many questions, Dr. Rivara pointed out in his editorial. "How do factors such as age and sex of the patient and genotype for genes such as APOE, TP53, COMT, and DRD2 moderate both the severity of the injury and the recovery from it?"

How good are the tools used both in the field and in the office, such as the Sport Concussion Assessment Tool, for assessing concussion, Dr. Rivara asked. How well do they relate to more detailed neuropsychological testing or to sophisticated imaging studies and the yet-to-be-found biological markers for TBI? Does the symptom-free waiting period matter? If so, how long should it be?

"Our research community and its funders, such as the National Institutes of Health, the Centers for Disease Control and Prevention, and private foundations," Dr. Rivara noted, "need to step forward and begin to supply the answers."

This study was funded by the National Institutes of Health. The researchers have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med.Published online March 5, 2012. Abstract

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