Pediatric Concussion Consensus Limited by
Weak Evidence

Damian McNamara

November 11, 2019

Concerning risk for concussion, there is no clear evidence in the literature that a specific age or developmental stage in children is safer or more appropriate for starting contact sports, a consensus panel of 11 experts revealed. Also, although history of concussion is a major risk for subsequent issues, there is no firm number of events that dictates when or if a child should stop playing contact sports altogether.

Recommending that children stop playing contact sports "is a complex decision that must take into account time between concussions, severity of symptoms, and child and parent desires," lead author of the consensus statement, Frederick P. Rivara, MD, MPH, told Medscape Medical News.

"There is no evidence that concussions limited to young ages increase the risk of CTE [chronic traumatic encephalopathy]," said Rivara, the Seattle Children's Hospital Guild Association Endowed Chair in Pediatric Research and vice chair and professor, Department of Pediatrics, University of Washington in Seattle.

The consensus statement was published online today in JAMA Pediatrics. US Lacrosse, USA Football, the American College of Sports Medicine, and USA Rugby funded the project.

The multidisciplinary expert panel used a consensus process called a modified Delphi approach to generate seven primary questions and, ultimately, 26 related recommendations. They based their suggestions on a review of evidence in the literature.

"Unfortunately, for many of the questions addressed in this consensus statement, limitations existed in the quantity and quality of the evidence to develop specific recommendations for youth sports stakeholders," the researchers note.

Despite the limitations, the current consensus statement aims to build on a previous report from the Institute of Medicine that addressed sports-related concussions in youth. "However, this was released more than 5 years ago, and it did not provide specific recommendations to guide youth athletes and their families, medical professionals, and athletic personnel and organizations," Rivara and colleagues write.

In addition, the CDC released its own recommendations in 2018 on diagnosis, management, and prognosis of mild traumatic brain injuries in children and adolescents, as previously reported by Medscape Medical News. However, the agency did not include any recommendations for prevention, the researchers note.  

The panel consisted of experts in pediatrics, pediatric neurology, pediatric neurosurgery, pediatric neuropsychology, physical medicine and rehabilitation, sports and exercise medicine, athletic training, physical activity, and sports injury epidemiology and prevention.

Body Checks, "Heading" and Other Specific Recommendations

Despite the overall paucity of published data, the experts reached some conclusions and recommendations. An increased risk associated with history of sports-related concussions is a prime example.

"Parents, youth sport participants, coaches, and other stakeholders should be educated that a history of concussion(s) (compared to no prior concussions) is associated with an increased risk of subsequent concussions," they write.

"Experiencing multiple concussions in youth is one risk factor among many that may be associated with more long-lasting symptoms and longer recovery."

The panel reports that not allowing boys younger than 13 years to body check other players during ice hockey can reduce risk of sports-related concussion. However, they add, this practice could increase certain injuries once older youth are permitted to body check opponents.

Curtailing physical contact during practice is one potential strategy to reduce concussions. The panel found this approach in American tackle football reduces head impacts, but the evidence is unclear whether it lowers the overall rate of sports-related concussions. 

A similar lack of evidence emerged regarding "heading" the ball (hitting it with top of head) during youth soccer. Again, it was unclear if reducing this action also reduces the risk of sports-related concussions.

Furthermore, the panel notes "the association between repetitive head impact exposure and changes on neuroimaging in youth is inconsistent and the clinical implications of these changes are unknown."

Protective Measures Effective?

Determining how helmets/headgear and mouth guards fit in the prevention of sports-related concussions was another aim.

Based on studies in the literature, the experts recommend youth wear helmets in all sports with a high risk of head contact. Examples include American tackle football, ice hockey, boys' lacrosse, downhill skiing, snowboarding, skateboarding, and bicycling.

In contrast, they found "little evidence to recommend the use of current headgear to prevent concussion in rugby…or to prevent concussion in soccer."

Similarly, they found little evidence that mouth guards lower sports-related concussion risks in youth athletes.

While addressing the potential concussion hazards of youth sports, Rivara and colleagues also emphasized the many potential benefits of participation.

"Youth sports, and the physical and psychosocial benefits gained from participation in youth sports, are critical to the development of healthy children and lifelong physically active individuals," they write. "The concerns regarding concussions that are associated with participation in contact or collision sports need to be balanced with the numerous benefits of an active lifestyle."

Future Goals

Although the evidence regarding youth athlete concussions is "rapidly accruing," the authors note, "many questions remain."

When asked about future research priorities for youth sports-related concussion, Rivara replied, "This is a big question. For this age group, it is to fill in the holes we found in our evidence search." Rivara reports receiving gifts from USA Football, US Lacrosse, USA Rugby, and the American College of Sports Medicine. 

The lack of relevant quality and quantity data in the literature noted by the panel aligns with the experience of Mark Halstead, MD, director of the Sports Concussion Program at Washington University in St. Louis, Missouri. When asked by Medscape Medical News to comment on the consensus statement, he said, "Unfortunately for many of the questions they were investigating, we still do not have much research or good quality research to help guide us for making recommendations for families about many things about concussions."

"This is especially true for kids in middle school or younger," he added.

He lamented the lack of evidence in most instances regarding age and the safety of youth athletics. "Obviously, we would love to have more specific information to give to parents regarding an age that is most appropriate to start contact or collision sports.

"Right now, we only have research that suggests a higher rate of concussions and injuries by age for ice hockey," which is why the panel made a specific recommendation in this sport, said Halstead, who is also medical director of the Washington University Young Athlete Center.

The recommendation to limit body checking in ice hockey to patients 13 and older in the current statement is a lower age than was recommended in a statement by the American Academy of Pediatrics, Halstead said. The AAP recommend that no checking be allowed below the age of 15 years.  

JAMA Pediatr. Published online November 11, 2019. Full text

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