THE ROLE OF THE PRIMARY CARE CLINICIAN
Primary care clinicians are central to pediatric concussion management because they facilitate and oversee a child’s recovery. They may administer neuropsychologic testing, monitor symptom resolution, and supervise the concussed child’s gradual return to physical and academic activities through the individualized phases of RTP and return-to-school protocols.4,20,23
The NP or PA functions as the main point of contact within the heath care team, organizing the plan of care and coordinating with parents, teachers, and coaches throughout the recovery process. Close follow-up care, including detailed documentation, should take place at well-child examinations to help ensure that the child’s development continues to progress as expected.
Referrals
Although referrals to a specialist are not typically necessary, persistent symptoms—those lasting longer than 10 days and not usually specific to concussion—warrant immediate and appropriate referral.3,22 Approximately 30% of mTBI patients experience long-term, often significant aftereffects, underscoring that mTBI is not a single entity and that each patient is unique.24
Risk factors for protracted symptoms
Factors that may be associated with prolonged or persistent duration of symptoms include early posttraumatic headache, previous concussion, early amnesia, alteration in mental status, disorientation, fatigue/fogginess, developmental disorders (eg, learning disabilities, ADHD), and psychiatric disorders (eg, anxiety, depression).4,13 Studies have examined this association, and there is conflicting evidence as to whether prolonged symptoms are attributed to, or are a combination of, preconcussion modifying factors, concussive episode severity, and/or coexistent pathologies.3,4
Concussion complications
Postconcussion syndrome can occur in pediatric athletes after a single concussion.3,23 The syndrome is not clearly understood but is characterized by the persistence of multiple cognitive, physical, and/or emotional symptoms of a concussion for weeks or even months, making it difficult to both diagnose and manage.5,15
Second impact syndrome, only documented in pediatric athletes, occurs when a child sustains a concussion before fully recovering from a prior concussion. This can lead to cerebral vascular congestion, cerebral swelling, and in some cases, death.15 Immediate removal of a concussed child from play until completely asymptomatic is obviously essential to the prevention of this rare catastrophe.
Any child with persistent symptoms should be referred to a multidisciplinary team of providers experienced in concussion management. This team may include, but is not limited to, neurologists, developmental pediatricians, concussion specialists, and psychologic, cognitive, and/or physical therapists.3,5
CONCUSSION EDUCATION
Family
Family-centered education is another essential component of pediatric concussion management. Parents and guardians are extremely influential and important to a child’s overall recovery, especially a younger child’s. While older pre–high-school-age children are much more capable of self-reporting symptoms, the younger child may not yet be developmentally able to do so, making the parent or guardian’s assistance and input essential.14
Unfortunately, studies have shown that a significant number of parents lack a good understanding of what constitutes a concussion as well as of the appropriate steps to ensure their child’s safe return to sport and school.22,25 Many parents view concussion as meaning a less severe head injury than if mild TBI or minor TBI is used.26 It is imperative that clinicians ensure that parents understand the seriousness of their child’s concussive injury and how to judge when their child may safely return to school.
GAAME is an acronym for a simple concussion action plan for parents of young sports participants. The name is based on the first word of each step in the plan:
Get out, Assess, Ask, Medical attention, and Emergency situation.
The GAAME handout (see "Parent Guide") briefly explains the steps to take if a child experiences a blow to the head during a sports activity. It can be given to parents of all pre–high-schoolers, whether their children participate in organized sports or not.
GAAME utilizes a five-step approach that immediately pulls the child out of the game and highlights the important information a clinician will need when the child receives medical attention.3 Parents, guardians, and other involved parties serve as a child’s best advocate by being informed and alert to the early signs and symptoms of a concussion and by helping the child to identify his or her own symptoms.
School personnel
Teachers and other school officials must recognize both the necessity of cognitive rest during concussion recovery and their role in enabling a child’s gradual return to the cognitive demands of school. A child may require such adjustments as a shorter school day or week, a reduced workload, and extra time for tests to avoid exacerbation of concussion symptoms.5,22 In light of state concussion laws (see below), schools commonly ensure that personnel are well-informed about concussion and its aftereffects in the classroom.
Sports officials
Heightened awareness of the need for more effective concussion education and management in youth sports has led to enactment of laws on youth sports-related concussions in all 50 states and the District of Columbia.27 Most of these laws include
1. Inform and educate coaches, athletes, and their parents and guardians about concussion through training and/or a concussion information sheet.
2. An athlete who is believed to have a concussion is to be removed from play right away.
3. An athlete can only return to play or practice after at least 24 hours and with permission from a health care professional.
Clinicians should also be familiar with the laws in their states as they may affect clinical decisions (eg, timing of RTP protocol).
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