Concussions fall under the category of traumatic brain injuries (TBI), and these can prove to be quite significant, leaving lingering effects – especially in cases involving children. Recognising concussions by their signs, understanding their symptoms, and managing them should be well understood by parents and those tasked with child care, as well as educators for children's safety. Here we take a deep dive into what causes concussions; we identify major signs and symptoms, meaning that once you read through you will have comprehensive guidance on managing this injury in children.

Introduction

A concussion is a type of mild TBI that comes about when the brain gets jolted within the skull due to a blow to the head or any part of the body, a fall, or any other forceful impact. Although termed "mild" since they do not often result in loss of life, they are still grave, more so among children as their brains are still developing.¹

As many children have very active lifestyles, they may be more susceptible to injuries while playing sports or during recreational activities. This makes them more susceptible to head injuries, especially concussions. According to the Centers for Disease Control and Prevention (CDC), approximately 283,000 children visited the emergency department each year from 2010 to 2016 for sports- and recreation-related TBIs, including concussions.

Causes of concussions in children

Common causes of concussions in children are:

Sports-related injuries

In children, sports and recreational activities are among the leading causes of concussions, with falls also ranking highly. Whilst contact sports, such as football or soccer, pose a larger risk, concussion can also occur in non-contact sports, such as gymnastics.²

Falls

Falls contribute significantly to concussions, especially in younger children who may be involved in playground accidents or those who fall from bikes or scooters. Falls are the primary reason for TBI in children under 14 years, and the most probable cause in infants admitted to the emergency room.³

Accidents

Head injuries are common in car accidents as well as other accidents despite safety measures (like helmets for cyclists) due to impact force.

Risk factors for concussions in children

Age

The most vulnerable to concussions are younger children, especially under the age of four. This is due to their developing motor skills which make them more prone to accidents.³,⁴

Gender

Research suggests that girls could be more predisposed to concussions than boys, especially when it comes to sports. Many reasons may contribute to this difference including biomechanical and hormonal variances.^4,5

Previous concussions

For those children who have had one concussion already, they are at a higher risk of getting another one, and should they get multiple concussions, the effects can be cumulative leading to longer recovery times and susceptibility to more injuries in the future. According to a 2017 poll of over thirteen thousand adolescents in the United States, nearly one-fifth had experienced a concussion at some point in their lives.⁶

Medical history

Some kids with specific medical conditions like ADHD or migraines could also be at higher risk for concussions and likely face extended periods of recovery.⁷

Signs and symptoms

Immediate symptoms

Children's signs and symptoms of concussions can differ greatly. Initial warning symptoms include:^1,4

• Headache: Headaches are among the most common symptoms of a concussion
• Nausea or vomiting: Immediately following an injury, nausea or vomiting may occur
• Dizziness: Having trouble staying balanced or feeling unstable
• Confusion: A state of disorientation or difficulty making sense of what is going on
• Loss of consciousness: While uncommon, children can experience a momentary loss of awareness

Delayed symptoms

It's possible for symptoms to gradually manifest and not necessarily show up right away. Among the delayed signs are:^1,4

• Trouble focusing: Having trouble concentrating on assignments or academic work
• Memory issues: Losing track of crucial facts, such as the recollection of the injury incident
• Sleep disturbances: Include sleeping more, less, or having difficulty going to sleep
• Emotional changes: Mood swings, melancholy, or increased anger
• Hypersensitivity to light and sound: Increased sensitivity to bright lights and strong sounds

Red flags

Even though the majority of concussions are mild, several signs could point to a more serious injury that needs to be treated right away:¹,⁴

• Deteriorating headache: A headache that becomes more intense over time
• Frequent vomiting: Several episodes of vomiting following an injury
• Severe drowsiness: Incapacity to wake up or difficulty remaining awake
• Seizures: It is important to treat any seizure as a medical emergency
• Unequal pupil size: A significant brain injury may be indicated by one pupil being larger than the other

Concussion symptoms in babies and toddlers

Young children and babies might be unable to tell you what is wrong. In addition to the aforementioned indicators, individuals ought to be on the lookout for a young child who is:⁴

• Reluctant or unable to feed
• Crying and sobbing and refusing to be consoled
• Losing enthusiasm for toys
• Losing new skills, such as learning to use the toilet

Diagnosis

Initial assessment

A healthcare practitioner will conduct an initial evaluation if a concussion seems likely. This includes asking about the injury event, symptoms, and medical history. They can also carry out a physical assessment, which is based on neurological functions. In cases with children aged between 5 and 12 years of age, a tool known as Child SCAT-5 is recommended, whereas SCAT-5 is recommended for children aged less than 5 years old or more than 12 years old for sports-related concussion assessment.^8,9

Imaging techniques

Imaging tests are generally not required to diagnose a concussion, although in some cases, healthcare providers may find indications of serious injury (e.g., continuous vomiting or severe headache) and resort to imaging such as computed tomography or magnetic resonance imaging to exclude other conditions such as skull fracture or intracranial bleeding.¹,⁹

Cognitive testing

Healthcare practitioners might employ cognitive tests to appraise memory, concentration and problem-solving skills in children with concussions – an intervention meant to establish the concussion severity level and guide the plan of management.¹,^4,9

Management and treatment

Initial response

The first response when one has a concussion is critical, these steps are taken:⁴

• Rest: Physical rest is a necessity, as is cognitive rest. Consequently, children should refrain from completing tasks that require focus, this includes schoolwork or even video games. The American Academy of Neurology and the American Academy of Paediatrics advocate for rest in children following a concussion⁹
• Hydration and nutrition: Ensure the child is well hydrated and given a balanced diet that can promote healing
• Monitoring: Watch closely for signs of deterioration during the first 24-48 hours. Watch for any signs of worsening condition, such as repeated vomiting, severe headache, increased confusion, or seizures

Gradual return to activities

The child should begin returning to normal activities as symptoms improve, and this is best done progressively. Here's how it can be accomplished:^4,9,10

• Complete rest: Until the child is symptom-free even at rest
• Light physical activity: Any form of light activity that does not make the symptoms worse
• School activities: Back to school but with some adjustments e.g., shorter days or more breaks
• Moderate physical activity: Participation in non-contact sports like running or swimming
• Full contact sports: Do not indulge until a healthcare provider gives the go-ahead after recovery from the condition
• Pain management: Over-the-counter pain relief, such as paracetamol, may be used for headaches, but medications like ibuprofen and aspirin should be avoided unless directed by a doctor, as they can increase the risk of bleeding¹¹

School accommodations

It is hard for children to go back to school when they are getting better after sustaining a concussion. Some of the accommodations that may be helpful are:¹⁰

• Shortened school days: For fatigue prevention, make sure the school day is short
• Frequent breaks: Have breaks during the day for resting
• Extended time for assignments: Give more time than usual to complete assignments and tests
• Quiet environment: Try not to expose the child to loud noise and bright lights as this could be uncomfortable

Long-term management

In the majority of cases, children achieve complete recovery from a concussion within a few weeks but in some cases, they may develop persistent symptoms even after that period. Children who experience a concussion may still exhibit symptoms weeks later.

In a 2014 study, it was found that nearly one-fourth of children complained of headaches one month after the injury. Additionally, about 20% reported fatigue, and close to 20% stated they had cognitive difficulties post-injury.¹² Persistent symptoms are what is referred to as post-concussion syndrome.¹³ Some of the strategies in long-term management include:

• Regular checkups: Consistent follow-up visits with a healthcare provider to ensure continual monitoring and evaluation of progress
• Different therapies: For those symptoms that are not disappearing easily, they may be recommended physical therapy, occupational therapy or cognitive therapy
• School support services: In addition to treatment, additional support can be obtained from school counsellors or psychologists

Emergency management

There are cases where a head injury can lead to a hematoma and bleeding in the child's brain, though these are uncommon. But when such bleeding occurs, it has the capability of raising pressure on the brain, which can also be life-threatening. Make sure to take your child to the hospital as soon as possible if they show any signs or symptoms of a concussion.

Prevention

Sports safety

The tagline "When in doubt, sit them out" has become the mainstay for sports-related concussion management.¹³ If someone suspects that a child has obtained a concussion injury, they should avoid returning to play with no doubt about whether it happened or not. Preventing concussions in sports involves several key strategies:¹⁴

• Suitable gear: Children need to have suitable, properly fitting helmets and other protective gear
• Regulation adherence: Ensuring that sports safety rules and regulations are followed to minimise risks through education. Make sure your child follows rules and regulations during play
• Awareness education: Teaching children about safe play and the importance of recognising concussion symptoms

Home and playground safety

An environment that is safe at home and also on the playground can eliminate such falls and injuries:¹⁴

• Supervision: Watch the children when they are playing
• Safe play areas: Be sure to create a place where it is safe for them to play by keeping free of any potential hazards and ensuring that the equipment in the playground is always maintained
• Safety gates: Use safety gates at stairs to avoid fall accidents among younger children

Car safety

Implementing proper car safety measures can notably lower the risk of concussions due to car accidents:¹⁴

• Car seats: Car seats are a must, but not just any seat will do. Use age-appropriate car seats and booster seats, each specially designed to keep your child safe in the event of an accident
• Seat belts: Seat belts are non-negotiable for every passenger. Ensure that children are always properly buckled in, as this is their best protection if the worst should happen
• Safe driving: Safe driving should always be a top priority when behind the wheel, as many accidents can be avoided by responsible habits on the road

Summary

Concussions in children are a significant health issue that requires prompt recognition and proper management. By understanding the signs and symptoms and providing appropriate care, parents and educators can help ensure a full recovery and prevent long-term complications. Additionally, preventive measures can help reduce the risk of concussions, safeguarding children’s health and well-being.

Awareness and education are crucial components in managing concussions effectively. By fostering a proactive approach and a supportive environment, we can protect the health of our children and promote a safer, healthier lifestyle.