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Q&A: What’s New in Pediatric Concussion Care?
A CHLA sports medicine specialist shares the latest research and guidelines for managing concussions in kids.
On any given day, nearly 20% of patients seen by the Sports Medicine team at Children’s Hospital Los Angeles are children with concussions. That’s not surprising, given that nationwide, up to 1.9 million youth a year experience this mild traumatic brain injury.
At CHLA, Jonathan Santana, DO, sees many of these young patients. A primary care sports medicine specialist in the Jackie and Gene Autry Orthopedic Center, Dr. Santana has directed concussion oversight committees at multiple school districts and recently led CHLA’s participation in the multicenter Sport Concussion Outcomes in Pediatrics (SCOPE) study.
He shares the latest research findings, how concussion care has changed, and why early diagnosis and care are key.
How has concussion management changed in recent years?
It’s changed quite a bit. The old advice was to lie down in a dark, quiet room, and not return to school until symptoms had completely resolved. Today, it’s very much an active recovery.
The goal is to get kids back to school within two or three days—with accommodations such as modified workload and extra time to turn in assignments. Light aerobic activity, such as walking, is really important. The child’s symptoms might get a little worse during that activity, but that’s OK.
When can a child return to sports?
Every state has its own concussion laws, including a return-to-sport protocol. The key is that the child’s symptoms have resolved before they return. We don’t want the child to get another concussion before their current one has healed. That could put the child at risk for persistent symptoms and long-term effects.
But it’s not an all-or-nothing process. We ramp up activity gradually. We know that the sooner kids get back to their activities of daily living, the better chance they have of recovering within a month, which is always our goal.
What is the SCOPE study and what were the key findings?
CHLA was one of six hospitals around the country to participate in SCOPE. As a research group, we prospectively collected data on close to 250 youth athletes with concussions. We particularly looked at factors that might impact quality of life or predict how long symptoms will last.
One of our studies showed that the longer kids stay out of school after a concussion, the harder it is for them to recover. Another found that kids with symptoms lasting longer than 28 days were more likely to have anxiety and depression. We also showed that a validated clinical risk tool accurately predicted which patients would take longer to recover.
Where are the gaps in knowledge? What research is needed?
Although we understand more about the biochemical and metabolic changes that occur during a concussion, there’s still a lot we don’t know. In particular, we need more research in younger children.
If you look at all the studies on sports concussions, less than 5% covers kids who are 12 or younger. We need to better understand how younger children differ from older kids in terms of how they sustain their concussion, how they present, and how long they take to recover.
It is also harder to diagnose concussions in this group. Many younger kids get concussions outside of organized sports, where no adult witnesses the injury. And a 5-year-old can’t fully tell you what they’re feeling. Often, parents will notice behavioral changes in their child, such as being more irritable.
Jonathan Santana, DOIf you look at all the studies on sports concussions, less than 5% covers kids who are 12 or younger.
How is CHLA advancing care for children with concussions?
We try to see kids with suspected concussions within a few days. We also have partnerships with local high schools, where our athletic trainers are on staff and can quickly identify young athletes who may have sustained a concussion. That early care is important because we don’t want kids going back into a game or practice when they may have a concussion. Early care can also help promote faster recovery.
On the research front, one of our projects is looking at mechanisms of concussion and how those differ between kids in different age groups. My colleagues also recently published a paper showing that, under current return-to-sport guidelines, kids with concussions are not at higher risk of re-injury.
Kids will be kids. We can’t prevent every concussion out there. But the more we learn, the more we can reduce the risk of re-injury or prolonged symptoms. That’s the goal—to keep kids healthy and get them back to doing the things they love.