Early Childhood Concussion Care

Early Childhood Concussion Care

Recommendations

A: Concussion recognition and directing to care considerations in younger children

Living Guideline Recommendation 1.4: “Concussion should be suspected and diagnosed as soon as possible to maintain health and improve outcomes. Concussion can be suspected in the community by healthcare professionals, parents, teachers, coaches, and peers. Those with a suspected concussion should be assessed by a physician or nurse practitioner to perform a thorough medical assessment to exclude more severe injuries, consider a full differential diagnosis, and confirm the diagnosis of concussion. It is important to note that some patients may experience a delayed onset of concussion symptoms. Delayed concussion symptoms also require medical assessment to exclude more severe injuries.”

Early Childhood Recommendation 1.4.1: Provide age-appropriate concussion recognition education and tools to people caring for or working with young children, including parents, caregivers, educators, teachers, childcare providers, and coaches, to support the early recognition of suspected concussion. Level of Evidence:

As with older children, the role of caregivers, teachers, educators, and coaches is essential in ensuring concussion recognition. Concussion in early childhood primarily happens within home, childcare, or school setting. The role of parents, caregivers, educators, and teachers is especially important in detecting a suspected concussion. Provide these key interest holders with concussion recognition tools that present age-appropriate concussion signs and symptoms.  

 Recommended concussion detection tools to share with parents, educators, teachers, coaches, and other individuals working with young children: 

 

B: Initial medical assessment, diagnosis, and management considerations in younger children

Early diagnosis of concussion in all ages is crucial to rule out more severe injuries to the brain, neck, and spine, prevent further injury, and improve recovery outcomes. It is important to note that children younger than 2 years old are at higher risk of skull fractures. The risk of skull fractures in children younger than 2 years old is estimated to be at 5% (Gravel et al., 2015).

  • Living Guideline Recommendation 2.1:  Perform a comprehensive medical assessment on all children with suspected concussion or with acute head or spine trauma. Include a clinical history, physical examination, and the evidence-based use of diagnostic tests or imaging, as needed.

The 2023 American Congress of Rehabilitation Medicine (ACRM; 2023) diagnostic criteria for concussion are intended for use across all age groups, including during early childhood. However, diagnosing concussions in very young children can be challenging due to their limited ability to communicate symptoms and unique pattern of signs and symptoms. Accordingly, diagnostic uncertainty tends to be higher in children aged 0-6 years than in older pediatric age groups, with a large proportion of children diagnosed using general labels such as “unspecified injury to the head, head trauma, or bruise” (Rose et al., 2023). Clinicians are encouraged to use a clear label when signs and symptoms are present, guided by definitions such as the one proposed by the American congress of Rehabilitation Medicine (ACRM; 2023). Clinicians are  encouraged to use age-appropriate assessment tools and closely monitor signs and symptoms of concussion in young children, which can differ compared to what is typically found in older individuals (Crowe et al., 2023; Barlow et al., 2010; Yumul et al., 2023; Suskauer et al., 2018; Podolak et al., 2020; Dupont et al, 2022; Dupont et al., 2023).

Special considerations for diagnosing concussion in younger children:

Early Childhood Recommendation 2.1.1: Use developmentally-appropriate assessment tools or measures and closely monitor any signs or symptoms of concussion in young children.

Early childhood post-concussive detection and assessment tools for clinicians:

  • REACTIONS – 8 Acute screener: Post-concussive symptoms brief screening tool – 8 statements/items
  • REACTIONS – 48 : Post-concussive symptoms inventory – 48 statements/items

Early Childhood Recommendation 2.1.2: The following considerations should be made to identify signs and symptoms of concussion in younger children:

2.1.2a: Due to limited verbal and cognitive abilities in young children, signs and symptoms may be easier to detect in young children using observable or behavioural manifestations (e.g., rubs head, eats less) rather than relying on self- or parent/caregiver perception of subjective sensation (e.g., headaches, nausea). Level of Evidence: B

2.1.2b:Compared to older children, young children tend to present less of the following symptoms:

    • Loss of consciousness
    • Vomiting
    • Headaches

Level of Evidence: B

2.1.2c: Compared to older children, the following symptoms of a concussion are more common in young children:

  • Irritability
  • Agitation
  • Changes in feeding and appetite
  • Stomach aches
  • Regression in toilet training
  • Increased dependence (i.e., clinginess) and comfort-seeking behaviours
  • Changes in sleep

Level of Evidence: B

2.1.2d: When assessing young children after a concussion, check for issues with eye movement and balance (oculomotor and vestibulo-ocular deficits).

Link: Vision, Vestibular and Oculomotor Function

Level of Evidence C

 

Early childhood recommendation 2.1.3: Diagnosis should follow evidence-based diagnostic criteria, ensuring a comprehensive evaluation of symptoms, mechanism of injury, and clinical examination findings.

The 2023 ACRM diagnostic criteria for concussion are intended for use across all age groups, including early childhood. Diagnosing concussions in very young children can be challenging due to their limited ability to communicate symptoms.

 


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