Can we manage sport related concussion in children the same as in adults?

Abstract

At the present time, there are no evidence based guidelines using which sport related concussive injury in childhood and adolescence can be scientifically managed. There are significant differences between adults and children in this regard and a child who is symptomatic following head injury is likely to have sustained a far greater impact force as compared to an adult with the same post-concussive symptoms. The extent and duration of the cognitive effect on children with acute concussive injuries is variable and there may be persistent effects on scholastic performance and behaviour long after the clinical concussive symptoms and measurable neuropsychological impairment have resolved. Even subtle and transient impairments in attention and information processing skills can have a dramatic effect on the young person's capacity to cope with school demands, with these issues being particularly critical for those at later secondary school levels. Based on pilot data, cognitive maturation is greatest in those under 15 years of age and beyond this time plateaus to an adult level of performance. Although comparison to baseline cognitive performance remains a powerful method of assessing function following a concussion injury, its application in children under 15 years of age is problematic given the rapid cognitive maturation that is occurring in this period. With regular baseline testing, an "adult" management strategy could be adopted in this age group, whereas in its absence only an estimate of normal age related cognitive function can be made. Beyond 15 years of age, it would be reasonable to follow the adult concussion management consensus guidelines utilising a "return to baseline" approach. It is suggested that concussive symptoms take longer to resolve than in adults although this may be a surrogate marker of the biomechanical differences between child and adult concussion as outlined above. It is critical therefore that concussed children and adolescents not resume sport, school, or training until all the physical symptoms fully resolve. This is important also because of the risk of diffuse cerebral swelling that may occur in children after a single head injury no matter how trivial the impact may be. The adoption of a conservative adult management strategy with a thorough assessment of symptom resolution followed by "return to baseline" cognitive function remains the most appropriate management strategy in this age group. Further research is required to characterise the duration and nature of the subclinical cognitive impairment that may exist during this recovery period in children. Increased awareness of these issues by those involved in the management of a child with concussion may assist in avoiding problems caused by this putative impairment.