Managing Concussions and Traumatic Brain Injuries in Children and Adolescents

Nearly 2 million concussions are sustained by children between the ages of 2 and 17 each year in the U.S. As many as 50% of these concussions are thought to go unreported, which means nearly half of all children who sustain a concussion aren’t treated in a healthcare setting. This statistic is quite alarming, considering a concussion, despite level of severity, is a type of traumatic brain injury (TBI) that affects how the brain functions. While there are no structural changes on brain imaging with concussion, there is disruption of nerve cells and important chemicals referred to as neurotransmitters which lead to a variety of symptoms

Types of Concussions and Traumatic Brain Injuries

“TBI is an umbrella term for a bump, blow, or jolt to the head or body that causes a change in brain function,” explains UT Health Austin pediatric nurse practitioner Kelly Gettig, APRN, MSN, CBIS, CIC, CPNP-PC/AC, who has more than 15 years of experience in pediatric trauma, specifically that of TBI, and is a certified brain injury specialist recognized by the Brain Injury Association of America. Gettig also serves as the Co-Director of the TBI and Concussion Clinic within UT Health Pediatric Neurosciences at Dell Children’s, a clinical partnership between UT Health Austin and Dell Children’s Medical Center.

“A concussion can lead to persistent symptoms if not assessed and treated by a healthcare professional who is trained in evidence-based concussion care,” continues Gettig. “Our goal at the TBI and Concussion Clinic is to determine the best treatment plan for recovery after concussion or TBI to help children and adolescents return to academic, athletic, home, and community settings as quickly and safely as possible.”

Sports Concussion

Sports concussions are those concussions sustained by athletes both on the field and off the field (e.g., motor vehicle accident, wheeled activities, falls). These patients are typically competitive athletes who require an athlete-centered approach to care when providing guidance for return to play and sports clearance following injury.

“Currently, we are working with LoneStar Soccer Club and Austin ISD to ensure that coaches and athletic trainers have a direct referral line to a licensed nurse with expertise in early concussion care,” shares Gettig. “We also work with these organizations to coordinate an in-clinic evaluation within 3-5 days of injury. Our athletic trainer provides in-clinic sports assessments and liaisons with athletic trainers in the school setting to ensure a safe and rapid return back to both physical activity and academics.”

Complex Concussion

Complex concussions involve symptoms of concussions that are not improving within the expected 2-4 weeks. Patients with certain risk factors, such as anxiety or depression, attention-deficit/hyperactivity disorder (ADHD), learning disabilities, chronic headaches, or repeat concussions, are at increased risk for prolonged recovery.

“We have expertise in treating children and adolescents who are not recovering as expected and are continuing to struggle for weeks or even months after injury,” says Gettig. “We provide evidence-based care and education to prevent persistent post-concussive symptoms.”

Traumatic Brain Injury

Traumatic brain injuries usually consist of more significant injuries that require a higher level of specialized care. TBIs are classified as mild, moderate, or severe and often involve changes on brain imaging such as skull fractures or bleeding around or inside the brain. These patients have typically been hospitalized or received inpatient rehabilitation following an injury.

“For complicated mild to moderate TBI, our initial patient evaluation is conducted with both a medical provider and neuropsychologist,” explains Gettig. “We look at recovery through all domains—physical, cognitive, and emotional symptoms—and individual neurocognitive testing is performed to monitor for subtle (or obvious) changes in thinking, which helps guide return to academics. We follow our patients until they are fully recovered.”

Common Concussion and TBI Symptoms

The most common symptoms of concussion and TBI are headache and dizziness. There also may or may not be a loss of consciousness or some memory loss surrounding the events of the injury as well as other physical, cognitive, emotional, and sleep-related symptoms. Symptoms can evolve over the first few hours to days after the sustained injury.

Physical Symptoms

• Headache
• Nausea/vomiting
• Dizziness
• Balance problems
• Feeling tired, having no energy
• Fuzzy or blurry vision
• Sensitivity to noise or light

Cognitive Symptoms

• Feeling mentally “foggy” or slowed down
• Difficulty concentrating
• Difficulty remembering new information
• Difficulty thinking clearly

Emotional Symptoms

• Feeling more emotional than normal
• Irritability
• Nervousness or anxiety
• Sadness

Sleep-Related Symptoms

• Sleeping less than usual
• Sleeping more than usual
• Trouble falling asleep

“Signs of a more serious head injury may include persistent vomiting; changes in behavior or mental status, such as slurred speech; or persistent sleepiness or lethargy,” reveals Gettig. “If your child is experiencing these symptoms within the first 72 hours following injury, you should seek immediate medical attention.”

Recovery Period

“Mental and physical rest is recommended for 1-3 days following injury,” explains Gettig. “It is okay to participate in brief periods of cognitive activity, such as reading, schoolwork, or screen time, if symptoms are mild and the activity does not worsen symptoms. It is also okay to participate in low-level physical activity, such as walking; however, no moderate or heavy physical activity; sports; or high-risk activity, such as wheeled activities; should be performed until clearance is given by a medical provider.”

Care Tips Immediately After Injury:

• Limit physical activity
• Avoid activities that put the child at risk for another injury to the brain (e.g., wheeled activities, trampolines)
• Limit cognitive activity (e.g., screen time, schoolwork)
• Participate in relaxing activities (e.g., reading, drawing, playing with toys)
• Take naps during the day as needed.
• Get a good night’s sleep

“Patients generally recover fully from concussion within 2-4 weeks,” shares Gettig. “Following 24-48 hours of rest, gradual return to non-strenuous activities and school is advised. As a rule of thumb, if an activity does not worsen your child’s symptoms, then the activity should be okay to participate in. If your child’s symptoms worsen, cut back on the activity until it is tolerated.”

Care Tips 24-48 Hours Post-Injury:

• Get maximum nighttime sleep by avoiding screen time in the hour before bed and keeping a fixed bedtime and wake-up schedule
• Avoid long naps or naps late in the day
• Participate in light aerobic exercise (e.g., taking short walks)
• Return to cognitive activities as tolerated
• Return to school as tolerated

New Treatment Methods

Current concussion and TBI literature support active rehabilitation involving gradual return to academics and non-contact physical activity within the first few days following injury. Aerobic exercise in the early recovery period is shown to decrease symptoms and speed recovery for children and adolescents with concussion or TBI.

“For the past 2 decades, concussion and TBI management has been focused on rest,” says Gettig. “Scientific evidence now strongly supports that active rehabilitation decreases symptoms and speeds recovery. Active rehabilitation includes gradual return to cognitive activity, such as screen time and schoolwork, following 1-2 days of rest and return to physical activity, including cardio/aerobic exercise, in the first week following injury.”

Aerobic exercise is an effective treatment for the nervous system changes that cause many symptoms of concussion and TBI. For patients with sport-related concussion, gradual return to physical activity begins with graded treadmill testing in clinic with an athletic trainer. The patient’s heart rate is recorded when symptoms are elicited or increased, and this is used to prescribe individualized exercise therapy to sub-symptom threshold (aerobic exercise that is light enough to not cause symptoms to worsen). Athletes are then prescribed an individualized exercise plan, which may include walking, jogging, or the use of a treadmill or stationary bike at home or school. Athletes typically return to the clinic weekly for symptom management and progress monitoring until cleared for return to contact play.

“In typical concussion management, athletes are often deconditioned at the time of clearance, which leads to an increased risk for re-injury,” explains Getting. “With our evidence-based protocol, athletes return to contact practice and games in good physical condition.”

The TBI and Concussion Clinic care team takes a multidisciplinary approach to patient care, meaning your child will benefit from the expertise of multiple specialists across a variety of disciplines. Specialized physicians with extensive experience in treating concussion and TBI work alongside a team of pediatric experts, including nurse practitioners, neuropsychologists, athletic trainers, and more, to develop an individualized treatment plan for patients. Patient, family, and community education around concussion and TBI recovery can also be provided.

View and print our downloadable TBI/Concussion and Sports Concussion flyers.

<br>For advice on early concussion care or to schedule an appointment with the TBI and Concussion Clinic, please call 1-512-628-1850.