Pediatric Concussion: A CHOP Collaborative Study

Pediatric concussion is of great interest to healthcare personnel, school personnel and parents due to concerns of increased incidence and associated short- and long-term negative consequences. In collaboration with the Centers for Disease Control and Prevention, our team at the Children’s Hospital of Philadelphia’s (CHOP) Center for Injury Research and Prevention conducted several studies that leveraged the broad concussion patient population throughout the CHOP network to ask the following questions:

• Who sustains these injuries?
• Where do the injuries occur?
• How can we optimize acute management?

Our first analysis estimated that one-third of all patients with concussion within the CHOP network were less than 12 years – disputing the myth that concussion is solely an adolescent athlete problem. By examining all points of health care entry for concussion patients, we highlighted the importance of the primary care clinician; 4 out of 5 kids were seen first within the CHOP network in primary care – suggesting that the burden of youth concussion may be underestimated by primarily counting emergency department visits. These findings emphasized the need for primary care clinicians to have up-to-date training on concussion diagnosis and management.

To address this need, we implemented a standard concussion management tool that capitalized on the CHOP network’s single, linked electronic health record to provide prompts and supports for primary care providers as they diagnose these injuries. We evaluated improvements in two key concussion management practices: (1) performance of a screening visio-vestibular exam and (2) provision of return-to-learn/return-to-play (RTL/RTP) guidance. The combination of in-person training and electronic clinical decision support effectively changed provider behavior: visio-vestibular exams and RTL/RTP were documented for 2% and 19% of visits before implementation of the tool, respectively, compared with 71% and 73% after implementation.

Lastly, to highlight the fact that youth concussions occur in life and not just in sports, we categorized the broad mechanisms of injury for children under age 18 years. Although overall 70% of concussions were from sports and recreation mechanisms, only 40% were from full contact/collision sports, and the proportion from sports and recreation was lower among younger children than adolescents.

In short, it is important for professionals who work with children to understand that concussion is an injury that occurs not just in adolescents, but even in young children, and in all sorts of activities, not just sports and recreation. Further, children with concussion benefit from active management in their gradual return to activities after the injury as they recover.

References

1. Arbogast K. B., Curry A. E., Pfeiffer M. R., et al. Point of Health Care Entry for Youth With Concussion Within a Large Pediatric Care Network. JAMA Pediatrics. 2016;170(7):e160294. doi:10.1001/jamapediatrics.2016.0294.
2. Arbogast, K. B., Curry, A. E., Metzger, K. B., et al. Improving Primary Care Provider Practices in Youth Concussion Management. Clinical Pediatrics, 56(9), 854-865. doi:10.1177/0009922817709555.
3. Haarbauer-Krupa et al., Variations in Mechanisms of Injury for Children with Concussion. Journal of Pediatrics. 2018. doi:10.1016/j.jpeds.2018.01.075.

This article was contributed by Kristy Arbogast, Ph.D.