Concussion in Kids: Why Rest May Not Be Best

This transcript has been edited for clarity.

Christopher J. Chiu, MD: Welcome back to The Cribsiders on Medscape, where we do video recaps of our favorite Cribsiders episodes. On our pediatric medicine podcast, we interview leading experts in the fields to bring you clinical pearls, practice-changing knowledge, and answers to lingering questions about core topics in pediatric medicine. Justin, what are we talking about today?

Justin L. Berk, MD, MPH, MBA: Today, Chris, we are here to recap one of our latest episodes on concussion and mild traumatic brain injuries. Our expert was Dr Angela Lumba-Brown, a pediatric emergency medicine physician at Stanford University and concussion expert, and also one of the authors of the most recent guidelines on concussion management.

We discussed the diagnosis of concussion, treatment options, and return to play. The first thing we did was define concussion as a mild traumatic brain injury (mTBI). It's a head injury that results in some confusion or loss of consciousness, perhaps with some amnesia or other transient neurologic findings. As long as the Glasgow Coma Score is 13-15, it is considered a mild concussion. mTBI is a clinical diagnosis and does not require imaging.

Chu: We discuss some clinical tools that can be helpful to determine whether and when neuroimaging is indicated. One of these is the PECARN Pediatric Head Injury Algorithm that is based on age score, evidence of skull fracture, history of loss of consciousness, and mechanism of injury.

Berk: This is one that I've used a lot in the emergency department. Whenever you are seeing a toddler who has fallen out of bed, you can kind of plug in the details about the fall and how the child looked afterwards. It can be really helpful to determine whether this kid is at risk for a bad injury that needs imaging or it's fine to observe him or even just send them home.

Chu: One of my favorite takeaways from this episode was about return to play. We talked about restarting cognitive and physical therapies or activities within 2-3 days. This is a somewhat new recommendation based on evidence that activity can actually reduce symptom duration. Deep breathing exercises have also been shown to help reduce symptoms. This is huge because I remember back when I was a resident, we would have kids on cognitive and physical rest for weeks and even months. Is that how it was for you in training, Justin?

Berk: Yes, absolutely. These are new guidelines. Getting back and doing some light activity early on is really what's best rather than staying in a dark room for weeks.

Another thing I thought was interesting was the prolonged postconcussion syndrome that can occur in some patients. In fact, almost a third of patients will continue to have symptoms even months after their original head injury. For those patients, referral to a specialist or concussion clinic can be very helpful. They can provide vestibular physical therapy and other symptomatic treatments that can help move the recovery process along.

Chu: We also talked about the health disparities that exist in this concussion diagnosis and management. This is something to be aware of.

Berk: Across the board, kids from minority communities were less likely to get diagnosed and less likely to receive treatment for mTBI. It's important to try to maintain this health equity lens and make sure that we're treating everyone with the highest level of care.

Thank you for joining us for this video recap of The Cribsiders pediatric podcast, #19: Concussion – Knocking Out Diagnosis and Treatment. You can download the full episode on any podcast player, and check out our website.

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