Concussion: Kids' Symptoms May Linger and Change Over Time

Norra MacReady

May 12, 2014

Children who suffer a concussion may experience symptoms for several weeks after the injury, and those symptoms may differ from the ones seen at presentation, new findings suggest.

"The typical patient will see physical effects such as headache immediately after the injury, emotional symptoms that develop later in the recovery period, and cognitive symptoms may be present throughout," lead author Matthew A. Eisenberg, MD, and colleagues write in an article published online May 12 in Pediatrics.

Concussion is one of the most common reasons children present for medical care in the United States, yet little is known about its symptom course and effect on the developing brain. "There is thus little evidence to help guide physicians, patients, and their families regarding incidence and duration of such typical complaints after a head injury as fatigue, poor concentration, and irritability," the authors write.

Therefore, Dr. Eisenberg, from the Division of Emergency Medicine, Boston Children's Hospital in Massachusetts, and colleagues performed a secondary analysis of patients seen in the emergency department of a tertiary care hospital within 72 hours of a concussion between September 1, 2011, and August 31, 2012. In an earlier analysis of these patients, the authors had identified factors associated with a prolonged recovery course.

The patients ranged in age from 11 to 22 years. The investigators excluded patients from the analysis if they arrived at the hospital with a Glasgow coma score less than 13, suggesting a moderate to severe brain injury; coexisting skull or long-bone fractures; injuries to abdominal or intrathoracic organs or to the spinal cord; cognitive or developmental disabilities that would prevent them from completing a questionnaire; or involvement with law enforcement or social services. The primary study outcome was the time it took for postconcussive symptoms to resolve.

Symptoms were assessed using the Rivermead Post-Concussion Symptoms Questionnaire (RPSQ), a validated 16-item symptom checklist on which patients rate symptoms from 0 (not experienced at all) to 4 (a severe problem). The researchers defined symptom duration as the time from when the patient first gave the symptom a score of 2 or more to the time it was rated at 0 or 1. Follow-up questionnaires also asked patients about their cognitive symptoms, school performance, and athletic activities, ranging from full rest to full participation. The patients completed questionnaires at presentation and at 1, 2, 4, 6, 8, and 12 weeks after their emergency department visit or until they gave all symptoms on the RPSQ a score of 0 or 1. Patients who failed to return 2 or more consecutive questionnaires were considered lost to follow-up.

Overall, 235 children participated in the study, with a mean age of 14.3 years, and 57.4% were boys.

Headache was the most common symptom on arrival at the emergency department, reported by 85.1% of the patients, followed by fatigue (64.2%), taking longer to think (57.8%), and poor concentration (52.4%).

After the initial assessment, 3.8% of the remaining children developed a headache, 15.4% developed fatigue, 11.1% were taking longer to think, and another 13.1% complained of poor concentration.

By day 7, headaches were still occurring in 69.2% of the patients, but by day 90 they had resolved in all but 5.2% of 207 children evaluated at that point. Fatigue persisted in 59.8% of children at day 7 and was reported by 3.4% of 207 children at day 90. More than half of the children (54.3%) reported slower thinking at day 7 and 4.3% at day 90. In addition, 56.8% reported poor concentration at day 7 and 3.4% at day 90.

Emotional symptoms also developed. Depression, frustration, irritability, and restlessness were initially seen in 22.9%, 27.7%, 25.5%, and 24.6% of children, respectively, but by day 7, those percentages had increased to 25.6%, 37.6%, 30.3%, and 31.6%, respectively. By 90 days, however, those symptoms had largely resolved, being reported by 1.4%, 1.4%, 1.9%, and 1.4% of patients, respectively.

Similarly, sleep disturbance occurred in 11.6% of patients initially, in 24.8% at day 7, and in only 1% of the patients at 90 days.

The median duration for all symptoms was 13 days (95% confidence interval [CI], 11 - 15 days), ranging from depression, which lasted a median of 9 days (95% CI, 7 - 11 days), to irritability, which lasted a median of 16 days (95% CI, 9 - 23 days), and sleep disturbance, which also lasted a median of 16 days (95% CI, 10 - 22 days).

The findings show that patients were still struggling with a significant burden of symptoms a week after their injuries, including headaches, fatigue, forgetfulness, poor concentration, and emotional problems. Patients also experienced sensitivity to light and sound, initially reported by 42.5% and 40.4% of patients, respectively, and, at day 7, by 44% and 43.2% of patients, respectively.

"Taken together, these findings show that although concussion symptoms often resolve quickly, they can be debilitating in the short term for many patients," the authors write. "[C]hildren who have a concussion should be warned about the possibility of developing fatigue and sleep issues, and these symptoms should be specifically assessed during follow-up evaluation." Parents and clinicians should also watch for emotional changes associated with these symptoms.

Study limitations include the lack of a control group, reliance only on the children's self-reported symptoms, and defining symptom duration as the date from when they were first reported to the date when they were reported as resolved, which may have led to under- or overreporting of symptoms. In addition, these patients were seen at a tertiary care center, so they might have been more severely injured than average.

"For families and school personnel, this knowledge may help them better prepare the home and school environment for expected obstacles to recovery and return to normal academic and athletic participation. For health care providers, it may help reduce unnecessary testing and referrals owing to concern that a patient’s course is atypical, better target post-concussive evaluations to expected symptoms, and better inform the anticipatory guidance given to patients and their families. "

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online May 12, 2014.

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