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Information about current guideline
Concussion, relating to professional sport, has appeared in the headlines with increasing frequency over the last few years. The lessons learnt have trickled down to amateur and youth sport, and in June 2014, the Ontario Neurotrauma Foundation (ONF) published the “Guideline for diagnosing and managing paediatric concussion”1 with the aim to guide healthcare professionals in diagnosing concussion in children. The guideline is not limited to the initial assessment and management but includes a structure for ongoing reassessment, return to school and sport and an approach for managing common complications.
The ONF, funded by the Government of Ontario, is a “health organisation that focuses on the practical application of research to improve the lives of people with an acquired brain injury or spinal cord injury, and the prevention of neurotrauma injuries”.
The guideline targets a multidisciplinary approach in the education around the recognition and management of concussion, with recommendations not only for healthcare professionals but also parents and/or caregivers, schools and/or community sports organisations/centres.
The guideline covers the recommendations by timeline, including suggestions to perform baseline neurocognitive testing in children/adolescents who play high-risk sports to assist with return-to-play decisions should concussion be sustained, initial assessment and management when injury is sustained, discharge advice and reassessments for the child following a concussion.
While previous tools, such as the Child SCAT3, have addressed the assessment and initial management of concussion,2 this guideline is the most comprehensive review of evidence surrounding paediatric concussion. It builds on the 2011 ONF “Guidelines for Concussion/Mild Traumatic Brain injury and persistent symptoms second edition for adults (18+ years of age)”3 by incorporating a wide range of existing paediatric tools.
Key issues that this guideline addresses
Assessment of physical, cognitive and neurological deficits should be performed using a structured tool (eg, Child SCAT3).
Identification of ‘red flag’ features (box 1) warrants prolonged observation.
Physical and cognitive rest should be prescribed for an initial 24–48 h following a concussion.
A child should return to school only when symptom free.
Return to sport should be gradual and graded. If symptoms reoccur as activity is increased, the child should rest for 24 h and go back a step.
Sleep disturbance is common and advice on strategies to promote good sleep should be given proactively.
Driving, alcohol and recreational drugs should be avoided while recovering.
Children should be reviewed if symptoms persist for 7–10 days as well as prior to returning to any exercise and prior to returning to contact sport.
Children with multiple concussions, or symptoms persisting for over a month, should be referred to a specialist.
In children who remain symptomatic at 1 month, assess the child's mood and look for mental health symptoms. If symptoms are present, a referral to mental health services should be considered.
The main bulk of evidence to develop this guideline was obtained from studies based on sports-related injuries leading to paediatric concussion.
Red flag symptoms
Complaints of neck pain
Increasing confusion or irritability
Seizure or convulsion
Weakness or tingling/burning in arms or legs
Deteriorating conscious state
Severe or increasing headache
Unusual behaviour/change in behaviour
Rather than develop a rigid pathway, this guideline blends together a number of existing guidelines including >40 tools from a structured approach to initial assessment to advice for schools on managing a child returning following a concussion.
Underlying evidence base/methodology
A core group of experts, predominantly from Canada and the USA, compiled data from searching through existing publications and reviewing surveys examining the level of knowledge of concussion in sports coaches, first responders and healthcare professionals. Information was collated and the guideline established/revised internally until considered suitable.
The guideline was developed with a view to focus on clinical assessment and management rather than prevention of paediatric concussion.
What do I need to know?
The guideline does not apply to children under 5 years.
The guideline does not apply to children/adolescents who have moderate-to-severe closed head injuries, moderate-to-severe developmental delay, neurological disorders, penetrating brain injuries or brain damage from other causes, such as injuries at birth or in infancy.
Symptoms of concussion may only appear several hours after and evolve for 1–2 days after injury.
What can I continue to do as before?
Consider the need for CT in head injury in line with existing guidance (eg, National Institute for Health and Care Excellence CG1764).
What should I start doing?
Consider a diagnosis of concussion in all children sustaining a head injury.
Early recognition and diagnosis is vital to prevent the development of persistent symptoms (see box 2).
Consider that the patient may not be fully aware of, or able to articulate, their symptoms.
Consider admission or prolonged observation if ‘red flag’ symptoms (see box 1) are present in children who have had normal imaging, but symptoms persist.
Be aware that concussion can affect the patient’s sleep pattern, cause headaches, persistent fatigue and mental health problems.
Provide children and carers with a plan for a gradual, graded return to sport.
Consequences of delayed management of paediatric concussion
Persistent symptoms of concussion result in
Missing weeks, or even months, of school
Attention and memory deficits
Becoming clumsy and accident-prone
Becoming socially withdrawn to cope with headaches and mood changes
What should I do differently?
In addition to standard head injury advice at discharge, provide children and carers with written and verbal advice related to concussion and common complications, after assessment.
Link to full guideline: http://onf.org/documents/guidelines-for-pediatric-concussion
Link to SCAT3 (13+ years old): http://bjsm.bmj.com/content/47/5/259.full.pdf
Link to Child SCAT 3 (5–12 years old): http://bjsm.bmj.com/content/47/5/263.full.pdf
Link to National Institute for Health and Care Excellence Paediatric Head Injury management guideline (CG 176): https://www.nice.org.uk/guidance/cg176
Unresolved controversies/future research
No validated clinical tool for concussion for children aged 0–5. Diagnosing concussion in children under five is controversial because it relies heavily on the child's ability to recognise and/or communicate his/her symptoms. Most preschool children have not developed that capacity, and there are no validated tools for this age group.
Limited, but growing, body of evidence for these guidelines.
Insufficient evidence on which to base the timeframe of a safe return to school and to sport.
There is limited research on pharmacotherapy on the management of acute headaches. This guideline suggests using simple analgesia such as paracetamol and/or ibuprofen (once intracranial bleed has been excluded) and prescribing an initial 24–48 h of physical and cognitive rest, although the recovery rate can be variable and unpredictable.
Clinical bottom line
The field of paediatric concussion is still in its infancy compared with that of general traumatic brain injury (moderate and severe). Despite this, the Ontario Neurotrauma Foundation guideline provides an evidence-based approach to the management of paediatric concussion and aids access to a wide range of tools available to assist in this.
Twitter Follow James Ross at @jgr147
Contributors SH: conception and design. SH and JR: manuscript draft, revision and final approval.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.
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