Pediatric Concussion Care

Red Flag Symptoms of Concussion

• Red flag symptoms of concussion include:
• Severe or increasing headache
• Neck pain or tenderness
• Double vision or loss of vision
• Weakness or numbness/tingling in extremities
• Seizure or convulsions
• Loss of consciousness
• Increased confusion or deteriorating conscious state
• Repeated vomiting
• Increasingly restless, agitated or combative state
• Slurred speech
• Visible skill deformity

Although validated clinical decision-making rules are highly sensitive, these tools are meant to assist, but not replace, clinical judgment. CT scans should be used judiciously as the exposure of children/adolescents to the effects of ionizing radiation carries a small increased lifetime risk of cancer. If a structural brain injury is suspected in a patient with acute head trauma undergoing initial medical assessment in the office setting, urgent referral to an Emergency Department should be arranged. Diagnostic imaging of the spine should be considered when symptoms are suggestive of structural cervical spine injury. Imaging should be considered in patients with severe neck pain, tenderness or clinical evidence of radiculopathy or myelopathy. The choice of imaging modality (plain radiographs, CT or MRI of the cervical spine) should be guided by the suspected pathology. Patients with positive traumatic findings observed on diagnostic imaging of the brain or spine should be urgently referred to a neurosurgeon for consultation.

• Age (increased risk with increased age).
• Sex (female).
• Duration of recovery from a previous concussion.
• High pre-injury symptom burden.
• High symptom burden at initial presentation.
• Clinical evidence of vestibular or oculomotor dysfunction.
• Vestibular-Ocular Reflex (VOR) and tandem gait parameters.
• Orthostatic intolerance.
• Personal and family history of migraines.
• History of learning or behavioural difficulties.
• Personal and family history of mental health.
• Family socioeconomic status/education.

Advise/emphasize that returning to full-contact sport or high-risk activities before the child/adolescent has recovered increases the risk of delayed recovery and for sustaining another more severe concussion or more serious injury.

• Worsening symptoms (headache, confusion, irritability).
• Decreased level of consciousness.
• Prolonged clinical symptoms (persistent/prolonged vomiting, severe headache, etc.).
• Bleeding disorders.
• Multi-system injuries.
• Co-morbid symptoms.

Those with a confirmed diagnosis of concussion may be managed by a healthcare professional who within their formally designated scope of practice has the capacity to manage ongoing concussion-related symptoms.

• The outcome of the initial medical assessment.
• Indicate to the child/adolescent and their parents, teachers, and coaches if they have been medically cleared to participate in full-contact sports or high-risk activities.
• Living Guideline Post-Concussion Information Sheet
• Link: Canadian Guideline on Concussion in Sport Medical Assessment Letter (Parachute Canada).
• Link: Montreal Children’s Hospital discharge instructions.

• Living Guideline Post-Concussion Information Sheet.
• An overview of common concussion symptoms.
• Warning signs that should prompt emergency medical assessment.
• Suggestions regarding activity modifications and non-pharmacological strategies to manage symptoms.
• Information on how and when to make a gradual return-to-school and low-risk physical activities.
• Information on when a medical follow-up appointment is needed.

For teens who work, please consult the “Guidelines for Concussion/ Mild Traumatic Brain Injury and Persistent Symptoms 3rd Edition For Adults (18+ years of age)” for recommendations on how to work with the adolescent’s employer regarding non-academic accommodations so that the adolescent can gradually return to work while promoting recovery.

Return to full-contact sport or high-risk activity decisions can be complicated for children/adolescents with more complex medical histories. The following factors should be taken into consideration in the discussion and decisions made about return-to-sport or retirement:

• Concussion history.
• Co-morbidities (e.g., learning and communication deficits, ADHD, physical disabilities, psychiatric disorders).
• Absolute contraindications for return-to-sport and high-risk activities.
• Early recurrence or greater frequency of symptoms.
• Lower injury threshold.
• Increasing recovery time.
• Potential short- and long-term sequelae.

Some patients may benefit from neuropsychological assessment to determine resolution of cognitive problems. If a post-injury cognitive or neuropsychological assessment is deemed clinically necessary, it is recommended that this assessment be interpreted by a pediatric neuropsychologist.

• Migraine, tension, or cluster headaches.
• Cervicogenic headaches.
• Physiological or exercise-induced headaches.
• Headaches associated with prolonged visual stimulation.
• Occipital neuralgia.

• If headaches are occurring frequently.
• If headaches are disabling.
• If acute headache medications are contraindicated or poorly tolerated or are being used too frequently.

1. Those for whom access or travel for follow-up is limited or unavailable such as those who live in rural and remote communities.
2. Those who have undergone a previous in-person medical assessment by the treating physician or nurse practitioner
3. Those whose symptoms are stable, improving, or resolved
4. Those who do not report any subjective red flags (e.g., blurred or double vision, weakness or numbness, vertigo) and who have a satisfactory virtual physical examination with no objective red flags (e.g., diplopia on extraocular movement testing, positive pronator drift, pain on testing of cervical spine range of motion)
5. Those who do not require supplemental testing (diagnostic imaging, neuropsychological testing, graded aerobic exercise testing), and/or inter-disciplinary referrals to optimize patient care

• Ask about socioeconomic status (caregiver education, family income, occupation)
• Ask about social impacts and life stressors (school setting, friends, teammates)
• Ask the child/adolescent and parents and/or caregivers to complete the following, as appropriate

If CBT is unavailable to the patient or the patient is waiting for CBT treatment:

• Optimize and implement sleep hygiene
• Monitor the patient weekly for the first few weeks.
• Re-emphasize that patients with sleep disturbances should continue to engage in sub-symptom threshold cognitive and physical activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) as tolerated.
• Consider referring to an interdisciplinary concussion team.

• If sleep issues persist for more than 6 weeks post-acute injury, sleep hygiene can’t be optimized, and if poor sleep quality is impacting the ability to return-to-school or ability to recondition: Refer to a sleep specialist who has experience with concussion and polysomnography or to an interdisciplinary concussion team that has the expertise to understand sleep disturbances in the context of concussion-related symptoms.
• Consider ordering sleep tests to rule out possible sleep-related breathing disorders, nocturnal seizures, periodic limb movements, or narcolepsy. Examples of sleep tests include Sleep Study, Multiple Sleep Latency Test, and the Maintenance of Wakefulness Test.

• Ensure that medications do not result in dependency and that the patient has minimal adverse effects. The aim is to establish a more routine sleep pattern.
• Potential medication options include trazodone 12.5 mg or amitriptyline 5.0 – 10.0 mg.
• If sleep disturbances persist after pharmacological treatment refer to a pediatric sleep specialist ideally with experience with concussion and polysomnography.

For symptoms that interfere with daily functioning for more than 4 weeks following acute injury, further evaluation by experienced professionals to assess cognitive problems may be required. Depending on the nature of the cognitive symptoms, examples of professionals may include:

• Experienced educational professionals.
• Pediatric neuropsychologists.
• Occupational therapists.
• Speech language pathologists.

Other assessments may be required to determine the underlying cause(s) and any pre-existing contributing factors that can be managed:

• Use a risk score to assess any modifiers that may delay recovery.
• A mental health assessment and a closer look at the family may be recommended.
• Vision, vestibular, and hearing assessments may be recommended.
• Physical examination.
• As per usual pediatric clinical practice, broad clinical history taking is recommended to understand the youth’s developmental, medical, social, academic, and family histories. Particular consideration should be given to the interplay between these pre-existing factors and current cognitive profile/presentation/symptoms.