Mild Traumatic Brain Injury in Children
Mild Traumatic Brain Injury in Children
Sports injuries are the leading cause of TBI in children five to 18 years of age (CDC, 2011). Non-fatal emergency room visit data obtained through the CDC's National Electronic Injury Surveillance System – All Injury Program, United States 2001- 2009, provide insight into potential risk of TBI with various sports activities (CDC, 2011). Figure 3 illustrates the rates of sports-related concussions for high school students by activity and gender (Marar, Mcllvain, Fields, & Comstock, 2012).
(Enlarge Image)
Figure 3.
Sports-Related Concussions for High School Students
Sources: Adapted from Marar, Mcllvain, Fields, & Comstock, 2012.
High school sports are known risk factors for mTBI. Concussive injuries to males occur most frequently in contact football and soccer. Female youth experience mTBI most commonly from soccer and basketball injures (Giza et al., 2013). Other accidents that result in TBI in children five to 18 years of age involve bicycles, playground incidences, all-terrain vehicles, skateboards, and horseback riding (Cohen et al., 2009).
Sports injuries often occur in the school setting where lay providers are the first ones to evaluate the child. The National Association of State High School Associations (NFHS) offers training for high school coaches on the management and evaluation of concussions and other problems that can and do occur in the sports arena on a regular basis (see Figure 2). The training is robust and offers a sound grounding in principles to keep children safe.
One of the most common questions asked following mTBI is, "When can the child return to sports activities?" The answer depends upon several factors, including but not limited to the severity and mechanism of the injury and the number of previous concussions. Sarsfield, Moreley, Callahan, Grant, and Wojcik (2013) described emergency department discharge practices and found that caregivers often were not given appropriate instructions for when their children could resume activities. The "Cantu Evidence Based System and Return to Play Guidelines" is one of the more popular guides available (Russo Buzzini & Guskiewicz, 2007). Cantu (2001) developed a grading system that subdivides concussions into three categories: Grade 1 – No loss of consciousness and amnesia that lasts less than 30 minutes after the event; Grade 2 – loss of consciousness is less than five minutes and amnesia lasts 30 minutes to under 24 hours; Grade 3 – When loss of consciousness is for more than five minutes and amnesia lasts for more than 24 hours. Grade 1 concussions are considered to be mTBI; Grades 2 and Grade 3 are more severe and beyond the scope of this article.
Carrol et al. (2004) performed a meta-analysis of 428 studies looking at mTBI epidemiology, treatment, and prognosis. The researchers found consistent evidence that children who suffer mTBI recover rapidly and have few, if any, cognitive or behavioral problems. Most symptoms are completely resolved three to 12 months after injury. It is interesting to note, however, that poverty is associated with a poorer outcome (Geberding & Binder, 2003).
Exploration of research on the impact of mTBI on children and the evaluation of interventions to improve outcomes are growing. Ponsford and colleagues (2001) questioned whether providing children with information on mTBI would have an impact on their outcomes three months after injury. The researchers studied children six to 15 years of age who had a history of mTBI with loss of consciousness for less than 30 minutes. The children were randomized to intervention and non-intervention groups. In the intervention group, the 61 children were assessed at one week after injury and given an information booklet outlining what to expect after mTBI and suggested coping strategies, and as sessed again at the three-month post-injury mark. The 58 children in the non-intervention group were assessed three months after injury only and did not receive the booklet. These two mTBI groups were compared to two control groups of children with minor injuries and no head trauma. The intervention group of children with mTBI seen at one week reported more symptoms than controls, but demonstrated no impairment on neuropsychological measures. Although initial symptoms had resolved for most children three months following injury, 20% of the children reported significant ongoing problems. This group of children tended to have a history of previous head injury, learning or behavioral difficulties, other neurological or psychiatric disturbance, or family stressors. These findings are consistent with those of previous re searchers (Asarnow et al., 1987; Farmer, Singer, Mellitis, Hall, & Charney, 1987). Regarding the intervention, the children not seen at one week and not given the information booklet reported more symptoms overall and were more stressed three months after injury than the intervention group. Ponsford et al. (2001) concluded that providing an information booklet reduces anxiety and thereby lowers the incidence of ongoing problems.
Guidelines on how to treat a concussion are variable depending on the source used to assess the initial injury and the child's underlying health and environmental factors. In general, it is recommended that the child athlete use a slow systematic approach to return to all activities. Athletic pursuits are often of most concern to the child who, with medical clearance, may begin with light aerobic activity (walking), followed by more sport-specific training (running) and ad vance to drills without contact (Kirkwood, Yeates, & Wilson, 2006). If the child's concussive symptoms return at any point in time or new symptoms arise, restrictions are reinstituted. If each phase is completed without recurrence of symptoms, the child may advance to full contact practice and then participate in the game (Kirkwood et al., 2006).
Parents are often most concerned about the child's return to school and academic performance. School personnel are an integral part of the child's life and should be told of the child's mTBI and symptoms to observe while the child is in the school setting. Working with the school to develop a transition plan is imperative. Fatigue and concentration issues can make it difficult for the child to return to a full day of school while making up missed work and participating in the new daily work expected in the classroom. Special accommodations, such as a 504 Edu cation Plan, special education classes, or homebound tutoring, may be needed to ensure the child has adequate rest to heal the brain and to set realistic expectations concerning academic progress (Kirkwood et al., 2006). Borg et al. (2004) looked at non-surgical interventions for children with mTBI and found that education on mTBI symptoms and recovery had a positive impact on decreasing parental anxiety.
Educating children and families about risks of TBI associated with sports and childhood activities, as well as what to expect after mTBI are important nursing interventions. How ever, the ultimate goal is prevention of mTBI to minimize long-term complications. Neuropsychological testing provides a road map for how the brain processes information and is very helpful to gage neurocognitive deficits following mTBI. Children with mTBI may experience temporary disruption of cognitive processing, making it extremely difficult to keep up or maintain normal levels of schoolwork. Alternate schedules for school may be necessary for the child to maintain grade-appropriate work. Many schools systems are starting to make baseline neuropsychological testing a requirement for each athlete prior to any sports participation. A baseline examination is critical to be able to understand the degree of change that occurs after injury. In jured children should resume sports activities only after they return to baseline. When the brain is overstimulated after a concussion, symptoms such as headaches and confusion may get worse or attention may be more difficult to maintain over a set period of time.
Sports-related Brain Injuries
Sports injuries are the leading cause of TBI in children five to 18 years of age (CDC, 2011). Non-fatal emergency room visit data obtained through the CDC's National Electronic Injury Surveillance System – All Injury Program, United States 2001- 2009, provide insight into potential risk of TBI with various sports activities (CDC, 2011). Figure 3 illustrates the rates of sports-related concussions for high school students by activity and gender (Marar, Mcllvain, Fields, & Comstock, 2012).
(Enlarge Image)
Figure 3.
Sports-Related Concussions for High School Students
Sources: Adapted from Marar, Mcllvain, Fields, & Comstock, 2012.
High school sports are known risk factors for mTBI. Concussive injuries to males occur most frequently in contact football and soccer. Female youth experience mTBI most commonly from soccer and basketball injures (Giza et al., 2013). Other accidents that result in TBI in children five to 18 years of age involve bicycles, playground incidences, all-terrain vehicles, skateboards, and horseback riding (Cohen et al., 2009).
Sports injuries often occur in the school setting where lay providers are the first ones to evaluate the child. The National Association of State High School Associations (NFHS) offers training for high school coaches on the management and evaluation of concussions and other problems that can and do occur in the sports arena on a regular basis (see Figure 2). The training is robust and offers a sound grounding in principles to keep children safe.
One of the most common questions asked following mTBI is, "When can the child return to sports activities?" The answer depends upon several factors, including but not limited to the severity and mechanism of the injury and the number of previous concussions. Sarsfield, Moreley, Callahan, Grant, and Wojcik (2013) described emergency department discharge practices and found that caregivers often were not given appropriate instructions for when their children could resume activities. The "Cantu Evidence Based System and Return to Play Guidelines" is one of the more popular guides available (Russo Buzzini & Guskiewicz, 2007). Cantu (2001) developed a grading system that subdivides concussions into three categories: Grade 1 – No loss of consciousness and amnesia that lasts less than 30 minutes after the event; Grade 2 – loss of consciousness is less than five minutes and amnesia lasts 30 minutes to under 24 hours; Grade 3 – When loss of consciousness is for more than five minutes and amnesia lasts for more than 24 hours. Grade 1 concussions are considered to be mTBI; Grades 2 and Grade 3 are more severe and beyond the scope of this article.
Carrol et al. (2004) performed a meta-analysis of 428 studies looking at mTBI epidemiology, treatment, and prognosis. The researchers found consistent evidence that children who suffer mTBI recover rapidly and have few, if any, cognitive or behavioral problems. Most symptoms are completely resolved three to 12 months after injury. It is interesting to note, however, that poverty is associated with a poorer outcome (Geberding & Binder, 2003).
Exploration of research on the impact of mTBI on children and the evaluation of interventions to improve outcomes are growing. Ponsford and colleagues (2001) questioned whether providing children with information on mTBI would have an impact on their outcomes three months after injury. The researchers studied children six to 15 years of age who had a history of mTBI with loss of consciousness for less than 30 minutes. The children were randomized to intervention and non-intervention groups. In the intervention group, the 61 children were assessed at one week after injury and given an information booklet outlining what to expect after mTBI and suggested coping strategies, and as sessed again at the three-month post-injury mark. The 58 children in the non-intervention group were assessed three months after injury only and did not receive the booklet. These two mTBI groups were compared to two control groups of children with minor injuries and no head trauma. The intervention group of children with mTBI seen at one week reported more symptoms than controls, but demonstrated no impairment on neuropsychological measures. Although initial symptoms had resolved for most children three months following injury, 20% of the children reported significant ongoing problems. This group of children tended to have a history of previous head injury, learning or behavioral difficulties, other neurological or psychiatric disturbance, or family stressors. These findings are consistent with those of previous re searchers (Asarnow et al., 1987; Farmer, Singer, Mellitis, Hall, & Charney, 1987). Regarding the intervention, the children not seen at one week and not given the information booklet reported more symptoms overall and were more stressed three months after injury than the intervention group. Ponsford et al. (2001) concluded that providing an information booklet reduces anxiety and thereby lowers the incidence of ongoing problems.
Treatment
Guidelines on how to treat a concussion are variable depending on the source used to assess the initial injury and the child's underlying health and environmental factors. In general, it is recommended that the child athlete use a slow systematic approach to return to all activities. Athletic pursuits are often of most concern to the child who, with medical clearance, may begin with light aerobic activity (walking), followed by more sport-specific training (running) and ad vance to drills without contact (Kirkwood, Yeates, & Wilson, 2006). If the child's concussive symptoms return at any point in time or new symptoms arise, restrictions are reinstituted. If each phase is completed without recurrence of symptoms, the child may advance to full contact practice and then participate in the game (Kirkwood et al., 2006).
Parents are often most concerned about the child's return to school and academic performance. School personnel are an integral part of the child's life and should be told of the child's mTBI and symptoms to observe while the child is in the school setting. Working with the school to develop a transition plan is imperative. Fatigue and concentration issues can make it difficult for the child to return to a full day of school while making up missed work and participating in the new daily work expected in the classroom. Special accommodations, such as a 504 Edu cation Plan, special education classes, or homebound tutoring, may be needed to ensure the child has adequate rest to heal the brain and to set realistic expectations concerning academic progress (Kirkwood et al., 2006). Borg et al. (2004) looked at non-surgical interventions for children with mTBI and found that education on mTBI symptoms and recovery had a positive impact on decreasing parental anxiety.
Actions
Educating children and families about risks of TBI associated with sports and childhood activities, as well as what to expect after mTBI are important nursing interventions. How ever, the ultimate goal is prevention of mTBI to minimize long-term complications. Neuropsychological testing provides a road map for how the brain processes information and is very helpful to gage neurocognitive deficits following mTBI. Children with mTBI may experience temporary disruption of cognitive processing, making it extremely difficult to keep up or maintain normal levels of schoolwork. Alternate schedules for school may be necessary for the child to maintain grade-appropriate work. Many schools systems are starting to make baseline neuropsychological testing a requirement for each athlete prior to any sports participation. A baseline examination is critical to be able to understand the degree of change that occurs after injury. In jured children should resume sports activities only after they return to baseline. When the brain is overstimulated after a concussion, symptoms such as headaches and confusion may get worse or attention may be more difficult to maintain over a set period of time.
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