First-Ever Pediatric Concussion Guidelines: Real-Life Cases

Debra Houry, MD, MPH


November 15, 2018

Editorial Collaboration

Medscape &

Recovery From mTBI

A CT scan in the ED was negative. The patient was discharged with education and referred to her primary care provider for follow-up the next day. At that visit, she reported amnesia for events 1 minute before and 30 seconds after the mTBI. She also reported feeling "slowed down," pressure in her head, and difficulty concentrating. An assessment revealed the following:

  • Problems with concentration (difficulty reciting four numbers backward);

  • Problems with balance (single leg and tandem balance); and

  • Difficulty with some verbal-auditory learning.

She was instructed to rest for 2-3 days and then begin light activities as tolerated. Following that, she could return to school but limit cognitive activities as needed, including postponing final exams scheduled for that week. The healthcare provider sent a letter to share with the patient's school.

After 8 weeks, all symptoms had resolved, and concentration, memory, and balance were back to baseline. She was instructed to gradually return to sports activities using a stepwise return-to-play progression.

Discussion with the patient and her family included many issues, including the athlete's age and the number, frequency, and severity of her mTBIs. The healthcare provider, the patient, and her family discussed delaying return to lacrosse for 6 months to a year and retirement from the sport as options.

Factors Influencing Recovery From mTBI

Recovery from pediatric mTBI is variable, and no single factor can predict symptom resolution or outcome. Symptoms experienced by most children resolve within 1-3 months after injury. Healthcare providers can more effectively counsel patients with mTBI when they have assessed risk factors for outcome and recovery. The risk for prolonged recovery has been associated with the following:

  • Severe symptom presentation right after the injury;

  • History of mTBI or intracranial injury;

  • Older adolescent;

  • Female sex;

  • Hispanic ethnicity;

  • Lower socioeconomic status;

  • Lower cognitive ability;

  • Neurologic or psychiatric disorder (such as depression);

  • Learning difficulties; and

  • Family and social stressors.

During your initial exam, ask about a history of previous mTBIs or other brain injuries, and when present, document the number, severity, and time of occurrence. Inquire about the mechanisms of previous mTBIs and the duration of symptoms. The effects of multiple mTBIs may be cumulative, especially when there is little time between injuries or when symptoms from the preceding injury have not completely resolved. An athlete's history of multiple mTBIs, with increasing number and severity of symptoms and longer recovery time needed, may prompt a discussion of discontinuing certain sports and recreational activities.

Tracking Recovery From mTBI

Tracking recovery over time is a key role for healthcare providers managing children with mTBI. There is no single assessment tool to track recovery. Instead, healthcare providers should use a combination of tools, which may include the following:

  • Validated, age-appropriate symptom scales;

  • Cognitive testing tools that measure reaction time; and

  • Cognitive testing tools that measure balance.

Assess the social supports already present in the child's life, including people who provide emotional support, problem-solving advice, constructive feedback, and positive affirmations. Emphasize social support as a key element of recovery when educating families and school professionals who will be interacting with the patient during recovery.

Preparticipation athletic examinations are a critical opportunity to identify athletes at increased risk for mTBI. The risk for delayed recovery or prolonged postconcussive symptoms is increased in the presence of certain premorbid conditions (eg, history of prior concussions or other medical problems).