Research In Action

Research In Action

The Natural History of Concussion in Infants and Children Under Age 5
The Natural History of Concussion in Infants and Children Under Age 5
June 18, 2020

Clinicians have been challenged to diagnose and manage very young children with concussion mainly because accepted pediatric concussion diagnostic tools are validated for older children and adolescents (e.g., Post-Concussion Symptom Scale - PCSS). Older children are better equipped than very young children to self-report symptoms and follow instructions in objective diagnostic tools looking at systems commonly affected by concussion (e.g., balance and visual).

“Motor vehicle crashes were the third most common mechanism (8.2%) and represented mostly passengers.”

With a goal to help clinicians better understand the presentation and clinical characteristics of concussion in this young population, I recently published “Characteristics of Diagnosed Concussions in Children 0-4 Years of Age Presenting to a Large Pediatric Healthcare Network” in the journal Pediatric Emergency Care with colleagues from CHOP’s Minds Matter research team and the Centers for Disease Control and Prevention (CDC).

In this study, we retrospectively looked at 329 electronic records of 0 to 4-year-old patients who were diagnosed and received care for their concussion at CHOP over a 2-year period. The median age of this cohort was 3.1 years.

The vast majority (86.6%) sought care in an emergency department or urgent care. Most children presented to the CHOP system on the same day of injury (56.2%) or within the first week post-injury (an additional 37.7%). The clinical course of care for most children included 1 to 3 clinical visits (88.7%), while the remainder had 4 to 33 provider visits. Of the 137 patients who had imaging performed, 88.3% had normal radiological findings.

The common mechanisms of injury and symptoms are listed below, and I encourage you to read the full article for greater detail.

Common Mechanisms of Injury

  • Falls were the most common mechanism of injury (64.4%):
    • Children <2 years of age were more likely to have sustained a concussion from a fall than children ages 2 to 4 (78.3% vs 59.1%).
    • The most common type of fall for all patients was from furniture (33.0%), followed by the child slipping or tripping and subsequently hitting the ground (19.8%), and falling down stairs (17.5%).
  • One-fifth were struck by an object (20.1%).
  • Motor vehicle crashes were the third most common mechanism (8.2%) and represented mostly passengers.
  • None of these patients received a diagnosis of child abuse on the same day as their concussion visit.







Symptom Profile

  • Most patients or their parent/caregiver reported 1 to 3 distinct PCSS symptoms during their clinical course of care (63.1%). Only 7.9% reported 6 or more distinct PCSS symptoms.
  • Almost two-thirds (64.4%) reported at least one somatic symptom, while almost half (49.2%) reported sleep symptoms. Of the somatic symptoms, the most common was vomiting (75.0%), followed by headache (59.0%) and nausea (10.4%).
  • Approximately one in five reported emotional symptoms (21.9%) and a similar proportion had visio-vestibular symptoms (20.4%).
  • Children ages 2 to 4 years old or their parent/caregiver reported somatic and visio-vestibular symptoms more frequently than children younger than age 2.

Important Considerations

  • Fewer symptoms reported in children less than 2 years of age may suggest a lower symptom burden, under-reporting or under-recognition of symptoms by parents/caregivers. More research is needed to understand this.
  • Parents/caregivers often reported symptoms not commonly captured on standard concussion symptom scales, with “personality change” as the most common in our study. 
  • Behavioral changes reported included increased crying; increased neediness or attachment to parent/caregiver; increased meltdowns; increased regressive behaviors; decreased interaction; and increased frustration. The two most common additionally reported symptomswere personality changes (34.0%) and increased/decreased appetite (12.8%).
  • Additional symptoms reported that are not part of typical concussion scales included increased/ decreased appetite, increased/decreased urination, urination accidents, and constipation/diarrhea.

It’s important to highlight that these findings are relatively unique to this age group and emphasize the need to develop adequate tools to systematically assess common signs and symptoms experienced by this young age group. It's also important to remember that those younger than age 2 are at risk for skull fractures and more serious brain injuries. Their most commonly-experienced symptoms of concussion (e.g., vomiting) could be suggestive of a more serious traumatic brain injury, prompting parents to seek immediate evaluation in an ED.

We are using the data from this study to facilitate improvements in diagnosis and management of concussions at CHOP and hope for other pediatricians to consider this data for guidance in their own clinical practices.

Click here to read the study abstract.

Click here to read about similar papers describing the natural history of pediatric concussion.