1. CONCUSSION IN CHILDREN Not just little adults
Dr Leesa Huguenin, Clinical director, MP Sports Physicians

2. INCIDENCE OF CONCUSSION
Adolescent Rugby League
7% over 7 seasons
(2 or more 1%, three or more 0.2%)
Under 20 Elite Rugby Union UK 48.1 % at least one concussion, 27.1% sought medical attention for concussion over career
South Africa 14.1 % of 3000 players at least one concussion
New Zealand amateur RL, average 4.1 concussive incidents in U15 and 3.8 in U17 team
Averaged out, 0.3 – 11.4 % chance concussion per season RU, 7.7 – 22.7 RL.

3. SEQUELAE OF CONCUSSION IN CHILDREN
Youth athletes may have a more prolonged recovery and are more susceptible to a concussion accompanied by a catastrophic injury (American Medical Society for Sports Medicine Position statement 2013)
Children are yet to develop compensatory strategies in the brain to cope with temporary reduction in function. Therefore similar injury may result in much larger deficits, although these are likely to recover completely. (Keightly BJSM 2012)
Young adult males with repeat concussion have poorer cognitive function at least 3 months since last concussion.
Higher risk of second impact syndrome

4. PREVENTION OF CONCUSSION
HELMETS
MOUTH GUARDS
RULE CHANGES
? NECK STRENGTHENING
PARENTAL AND SIDE LINE EDUCATION

5. EDUCATION REQUIRED
COACHING/ FIRST AID STAFF Possible significant sequelae if concussion ignored
Coaches and first aiders CANNOT diagnose
Remove player and seek medical assessment
ATHLETES Dispel myths generated by TV coverage
Cannot return to play until medically cleared
SOCIAL MEDIA PRESENCE Many leagues are now placing information on websites. Through social media to increase awareness of the facts
MEDICAL PERSONELL The days of just pushing through are long gone
Symptoms = NO PLAY
SEM physicians can help with specifics of return to play

6. ASSESSMENT OF CONCUSSION IN CHILDREN
IN THIS CASE, THEY ARE JUST LIKE LITTLE ADULTS (SORT OF)
Sideline assessment SCAT 3 for children
Involves modified questions and tests
Rooms assessment Excluding any other predisposing factors
SCAT 3 can be used for monitoring progress
Must involve parental input (behaviour/ mood)
Scans Rarely required
Possibility of functional MRI scanning in future
being able to detect metabolic abnormalitites
to clarify diagnosis

8. POTENTIAL TECHNOLOGIES FOR ACCURATE ASSESSMENT
Functional Neuroimaging MRI – assesses for changes in BOLD (Blood Oxygen Level Dependent) signal changes
Lots of studies
Still trying to clarify specifics
Issue is that all concussion may not be the same beast
Quantitative EEG some changes have been identified reproducibly, but not specific to concussion
Recovery mimics concussion recovery timeframes
? Future promise
Doppler US

9. BUT………………………….. Current weaknesses with testing children
1. impact on developmental stage on performance
2. lack of baseline data in most cases
3. impact of attention deficit/ mood disorders on performance
4. if baselines are available, significant brain development can occur
between test times

10. AND………………………
“While standardised sideline tests are a useful frame work for examination, the sensitivity, specificity, validity and reliability of these tests among different age groups, cultural groups and settings is largely undefined” Am Med Soc position statement 2013

11. MANAGEMENT OF CONCUSSION IN CHILDREN
THERE IS NO SAME DAY RETURN TO SPORT FOR A CONCUSSED ATHLETE
NO NEED FOR IMAGING UNLESS SUSPECT INTRA CEREBRAL BLEED
MOST CONCUSSIONS CAN BE MANAGED ADEQUATELY WITHOUT NEUROPSYCHOLOGICAL TESTING
ANALGESICS
REST THE BRAIN (COMPUTERS/ TV/ BOOKS/ SCHOOL)
MODIFIED ACTIVITIES – STAY SYMPTOM FREE
MONITOR RECOVERY – FOLLOW UP AT ELAST WEEKLY UNTIL AFTER RTP
GRADED RETURN TO ACTIVITY

12. ANALGESICS NON SEDATING NO NSAIDS/ ASPIRIN PARACETAMOL
+/- ANTI EMETICS?

13. REST SCHOOL – MAY NEED DAYS OFF/ REDUCED HOURS/ SPECIAL CONSIDERATION
TV – LESS STIMULATING THAN SLEEP BUT………
VIDEO GAMES
READING
ACTIVITY – DO NOT INDUCE SYMPTOMS
SPORT – RTP AFTER GRADED INCREASE IN ACTIVITY ONLY AND UNDER MEDICAL GUIDANCE

14. MONITOR RECOVERY Weekly at least Firstly monitor symptoms
Then consider neuropsych testing if indicated
Then gradually increase activity
Must be symptom free at each step, as for adults,
but anticipate slower recovery

15. ROADBLOCKS TO RETURN Children describe fear of being hit again
Concern when NP tests remain abnormal when all symptoms are resolved
Baseline NP tests are not commonly done in juniors and there is still contention as to whether they can be compared to tests done many weeks or months later
Baseline tests may change as part of normal maturation and developmental process and can be dependent on current mood, fatigue and other factors
Huge difficulty when recovery patterns have not been adequately studied in atheltes under 15 yo
Cosideration should be made to with hold from sport until academic functions have normalised

16. BIGGEST HURDLES TO CURRENT CONCUSSION MANAGEMENT
DISSEMINATION OF ACCURATE KNOWLEDGE
Shifting embedded beliefs – helmets/ mouthguards
Education regarding symptoms
Education regarding risks of playing on
Education regarding appropriate follow up
Education regarding requirement for medical input in diagnosis and RTP decisions

17. THANK YOU !