Pediatric sport and nonsport concussions presenting to emergency departments: injury circumstances, characteristics, and clinical management

Vanessa C. Rausa Clinical Sciences, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia;
Departments of Paediatrics and

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Meredith L. Borland Emergency Department, Perth Children’s Hospital, Perth, Western Australia, Australia;
School of Medicine, Divisions of Emergency Medicine and Paediatrics, University of Western Australia, Perth, Western Australia, Australia;

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Amit Kochar Emergency Department, Women’s & Children’s Hospital, Adelaide, South Australia, Australia;
Department of Acute Care Medicine, University of Adelaide, South Australia, Australia;

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Natalie Phillips Emergency Department, Queensland Children’s Hospital, Brisbane, Queensland, Australia;
Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia;

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Yuri Gilhotra Emergency Department, Queensland Children’s Hospital, Brisbane, Queensland, Australia;

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Sarah Dalton Emergency Department, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia;

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John A. Cheek Clinical Sciences, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia;
Departments of Paediatrics and
Emergency Department, The Royal Children’s Hospital, Melbourne, Victoria, Australia;
Emergency Department, Monash Medical Centre, Melbourne, Victoria, Australia;

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Jeremy Furyk Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia;
Emergency Department, University Hospital Geelong, Victoria, Australia;
School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia;

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Jocelyn Neutze Emergency Department, Kidz First Middlemore Hospital, Auckland, New Zealand;

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Gavin A. Davis Clinical Sciences, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia;
Department of Neurosurgery, Austin and Cabrini Hospitals, Melbourne, Victoria, Australia;

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Vicki Anderson Clinical Sciences, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia;
School of Psychological Sciences, University of Melbourne, Victoria, Australia;
Psychology Service, Royal Children’s Hospital, Melbourne, Victoria, Australia;

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Amanda Williams Clinical Sciences, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia;

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Stuart R. Dalziel Emergency Department, Starship Children’s Health, Auckland, New Zealand; and
Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, New Zealand

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Stephen J. C. Hearps Clinical Sciences, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia;

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Franz E. Babl Clinical Sciences, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia;
Departments of Paediatrics and
Emergency Department, The Royal Children’s Hospital, Melbourne, Victoria, Australia;
Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia;

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 MD , on behalf of Paediatric Research in Emergency Departments International Collaborative (PREDICT)
Free access

OBJECTIVE

The aim of this study was to compare injury circumstances, characteristics, and clinical management of emergency department (ED) presentations for sports-related concussion (SRC) and non-SRC.

METHODS

This multicenter prospective observational study identified patients 5–17 years old who presented to EDs within 24 hours of head injury, with one or more signs or symptoms of concussion. Participants had a Glasgow Coma Scale score of 13–15 and no abnormalities on CT (if performed). Data were stratified by age: young children (5–8 years), older children (9–12 years), and adolescents (13–17 years).

RESULTS

Of 4709 patients meeting the concussion criteria, non-SRC accounted for 56.3% of overall concussions, including 80.9% of younger child, 51.1% of older child, and 37.0% of adolescent concussions. The most common mechanism of non-SRC was falls for all ages. The most common activity accounting for SRC was bike riding for younger children, and rugby for older children and adolescents. Concussions occurring in sports areas, home, and educational settings accounted for 26.2%, 21.8%, and 19.0% of overall concussions. Concussions occurring in a sports area increased with age, while occurrences in home and educational settings decreased with age. The presence of amnesia significantly differed for SRC and non-SRC for all age groups, while vomiting and disorientation differed for older children and adolescents. Adolescents with non-SRC were admitted to a ward and underwent CT at higher proportions than those with SRC.

CONCLUSIONS

Non-SRC more commonly presented to EDs overall, with SRC more common with increasing age. These data provide important information to inform public health policies, guidelines, and prevention efforts.

ABBREVIATIONS

APHIRST = Australian Pediatric Head Injury Rules Study; CISG = Concussion in Sport Group; ED = emergency department; GCS = Glasgow Coma Scale; LOC = loss of consciousness; PREDICT = Paediatric Research in Emergency Departments International Collaborative; SRC = sports-related concussion; SSU = short-stay unit.

OBJECTIVE

The aim of this study was to compare injury circumstances, characteristics, and clinical management of emergency department (ED) presentations for sports-related concussion (SRC) and non-SRC.

METHODS

This multicenter prospective observational study identified patients 5–17 years old who presented to EDs within 24 hours of head injury, with one or more signs or symptoms of concussion. Participants had a Glasgow Coma Scale score of 13–15 and no abnormalities on CT (if performed). Data were stratified by age: young children (5–8 years), older children (9–12 years), and adolescents (13–17 years).

RESULTS

Of 4709 patients meeting the concussion criteria, non-SRC accounted for 56.3% of overall concussions, including 80.9% of younger child, 51.1% of older child, and 37.0% of adolescent concussions. The most common mechanism of non-SRC was falls for all ages. The most common activity accounting for SRC was bike riding for younger children, and rugby for older children and adolescents. Concussions occurring in sports areas, home, and educational settings accounted for 26.2%, 21.8%, and 19.0% of overall concussions. Concussions occurring in a sports area increased with age, while occurrences in home and educational settings decreased with age. The presence of amnesia significantly differed for SRC and non-SRC for all age groups, while vomiting and disorientation differed for older children and adolescents. Adolescents with non-SRC were admitted to a ward and underwent CT at higher proportions than those with SRC.

CONCLUSIONS

Non-SRC more commonly presented to EDs overall, with SRC more common with increasing age. These data provide important information to inform public health policies, guidelines, and prevention efforts.

Pediatric concussion is a growing public health concern, estimated to account for 4 million annual emergency department (ED) attendances globally.1,2 Total concussion rates are estimated to be significantly higher, given that ED presentations are believed to account for only 12% of all children and adolescents with concussion.2 Defined as a traumatic brain injury following an impulsive force transmitted to the brain, concussion triggers a neurotransmitter and metabolic cascade, with possible blood flow change, axonal injury, and inflammation affecting the brain.3 Concussion results in nonspecific and heterogenous symptoms4 that resolve within 4 weeks postinjury for most children and adolescents, although they persist beyond 4 weeks at a rate of approximately 30%.5

Policies, guidelines, education, and prevention efforts can have an important public health impact in reducing concussion rates at a primary prevention level, as well as avoiding recurrent concussion, supporting optimal recovery, and reducing the risk of protracted recovery at a secondary and tertiary prevention level.6 Timely recognition of injury, appropriate postinjury management and intervention, and adherence to return to school and play protocols are important to mitigate the risk of poor outcomes.3 Sports-related concussions (SRCs) are typically favored in media coverage, community messaging, consensus guidelines, and prevention efforts,3,7,8 with limited data to guide clinical management for more common nonsports etiologies in pediatric concussion. For example, guidelines informing recognition, evaluation, and rehabilitation of concussion, alongside protocols for returning to learning and sport, have been developed from an evidence base of SRC literature.3,9 Primary prevention strategies and modifiable risk factors have been evaluated for sports, including personal protective equipment, policy, rule, and law changes, and training strategies to reduce the risk of concussion,10 while frameworks to inform primary, secondary, and tertiary prevention efforts have also been developed for the sporting context.6 There is a risk that public health efforts will inadequately address all pediatric concussions if non-SRC and any characteristics unique to these injuries are not appropriately considered. Recent epidemiological data from the US revealed a decrease in the number of pediatric sport concussions presenting to EDs over the last decade, potentially reflecting the efficacy of growing primary prevention efforts.11 Non-SRC needs to be examined in equal measure to allow ongoing evaluation and improvement of any prevention efforts and outcomes.

For Australian and New Zealand children presenting to EDs with concussion, an understanding of where and how they are sustaining their injuries, across sports and nonsports activities, and how the characteristics of the presentations and clinical management differ, is pivotal for representative policy and prevention efforts at a community and healthcare level. Furthermore, understanding these trends in the context of specific age groups of young children (5–8 years), older children (9–12 years), and adolescents (13–17 years) can contribute unique information to guide how these public health efforts may need to differ by age. The most recent Concussion in Sport Group (CISG) consensus guidelines highlight the dearth of evidence for children younger than 12 years and the importance of addressing this gap.3 Prevention strategies, patient outcomes, and an understanding of modifying factors, including mechanisms of injury, are some of the recommended areas for future pediatric concussion research.12 The pediatric recommendations highlight that developing this literature may require changes to how SRC is defined and recognized in younger age groups12

The aim of this study was to compare injury circumstances—activity and location of injury, injury characteristics, and clinical management of pediatric ED presentations for SRC and non-SRC—using a large, multicenter, prospective observational dataset.13

Methods

Study Design

This was a substudy of the Australian Pediatric Head Injury Rules Study (APHIRST),13 a Paediatric Research in Emergency Departments International Collaborative (PREDICT)14 multicenter prospective observational study. Recruitment for APHIRST occurred at 9 pediatric EDs and 1 combined adult and pediatric ED across Australia and New Zealand.13 Institutional ethics approval was given at all participating sites.

Participants

Participants were a subsample of 5–17 year olds who presented with symptoms of concussion following a head injury. Children younger than 5 years were excluded due to difficulties that can be associated with accurate diagnosis of concussion in younger and preverbal children. Participants were characterized by mechanism of injury (SRC vs non-SRC) and age (young children aged 5–8 years, older children aged 9–12 years, and adolescents aged 13–17 years). During 2011–2014, APHIRST enrolled children presenting to EDs with head injuries of any severity. Children were excluded if they did not wait to be examined, were referred to an external provider from ED triage (e.g., general practitioner), sustained only a trivial facial injury, or underwent neuroimaging prior to transferring to a study site. Concussion was defined by a Glasgow Coma Scale (GCS) score15 of 13–15 with no abnormalities on CT if performed, and one or more of the following signs or symptoms: loss of consciousness (LOC), disorientation, amnesia, headache, vomiting, acting abnormally, irritability/agitation, abnormal drowsiness, repeated questioning, slowness to respond, altered mental state, or focal neurological deficit. The concussion subsample excluded ED presentations more than 24 hours postinjury, head injuries secondary to a medical condition (e.g., epilepsy), or where nonaccidental injury was suspected.

Procedures

Study and recruitment procedures have been previously outlined.13 Eligible patients were first identified at ED triage and enrolled by their treating clinician. Informed verbal consent was obtained from parents, guardians, or older adolescents. Collected data included demographic and epidemiological information, injury-related information, ED observation and hospital admission details, and details of imaging undertaken.

Data Analysis

Summary statistics describe the total sample, with means or medians used to describe continuous data and percentages used to describe categorical data. Interquartile ranges were presented alongside medians, and 95% CIs for percentages and means. Data were stratified by mechanism of injury, non-SRC versus SRC, for the total sample and separately for young child (5–8 years), older child (9–12 years) and adolescent (13–17 years) age groups. All categorical variables were compared between groups using chi-square tests. Wilcoxon rank-sum tests were used for continuous data. All analyses were conducted using Stata (version 15.0).

Results

Sample

From 2011 to 2014, 20,137 patients were recruited to APHIRST, of whom 8857 were 5–17 years old. Following 968 exclusions, 4709 (59.7%) of the remaining 7889 patients presented with signs and symptoms consistent with our definition of concussion, including 1546 young children (5–8 years), 1617 older children (9–12 years), and 1546 adolescents (13–17 years). SRC and non-SRC accounted for 2060 (43.7%) and 2649 (56.3%) presentations. Participant flow is provided in Fig. 1.

FIG. 1.
FIG. 1.

Patient flowchart.

Demographics

The mean age of the overall sample was 10.9 years and 70.2% were male. Patients with a non-SRC were on average younger than those with an SRC (mean 9.8 vs 12.3 years, p < 0.001), and more likely to be female (36.8% vs 20.8%, p < 0.001). Young children had the highest proportion of non-SRCs, with the proportions decreasing with increasing age (young children = 80.9%, older children = 51.1%, adolescents = 37.0%). Demographic, injury-related, and clinical management characteristics of patients by age and SRC versus non-SRC are shown in Supplementary Table 1. Comparisons between age groups for SRC and non-SRC are shown in Tables 1 and 2.

TABLE 1.

Characteristics of patients with SRC by age group

FactorTotalYoung Children, 5–8 yrsOlder Children, 9–12 yrsAdolescents, 13–17 yrsp Value
 No. (%)95% CINo. (%)95% CINo. (%)95% CINo. (%)95% CI
No. of patients2060295791974
Sex*
 Male1630 (79.2)77.4–80.9214 (72.5)67.1–77.6611 (77.2)74.2–80.1805 (82.8)80.3–85.1<0.001
 Female428 (20.8)19.1–22.681 (27.5)22.4–32.9180 (22.8)19.9–25.8167 (17.2)14.9–19.7
GCS score
 151914 (92.9)91.7–94.0277 (93.9)90.5–96.3736 (93.1)91.1–94.7901 (92.5)90.7–94.10.808
 14116 (5.6)4.7–6.713 (4.4)2.4–7.443 (5.4)4.0–7.360 (6.2)4.7–7.9
 1330 (1.5)1.0–2.15 (1.7)0.6–3.912 (1.5)0.8–2.613 (1.3)0.7–2.3
Vomiting410 (20.0)18.3–21.8110 (37.7)32.1–43.5169 (21.5)18.7–24.5131 (13.5)11.4–15.9<0.001
Headache1412 (69.8)67.7–71.8166 (57.4)51.5–63.2535 (69.1)65.7–72.4711 (74.0)71.1–76.7<0.001
LOC573 (29.5)27.5–31.636 (13.0)9.3–17.6185 (25.0)22.0–28.3352 (37.9)34.8–41.1<0.001
Amnesia788 (39.8)37.6–42.074 (26.6)21.5–32.2284 (37.3)33.8–40.8430 (45.7)42.5–49.0<0.001
Abnormal drowsiness102 (5.0)4.1–6.018 (6.2)3.7–9.643 (5.5)4.0–7.341 (4.3)3.1–5.70.309
Disorientation890 (46.0)43.7–48.292 (32.7)27.3–38.6341 (46.0)42.3–49.6457 (50.0)46.7–53.3<0.001
Acting abnormally453 (22.5)20.6–24.379 (27.2)22.2–32.8183 (23.6)20.6–26.7191 (20.1)17.6–22.80.024
Irritability/agitation55 (2.7)2.0–3.515 (5.1)2.9–8.322 (2.8)1.8–4.218 (1.9)1.1–2.90.010
Repeated questioning83 (4.1)3.3–5.06 (2.1)0.8–4.430 (3.8)2.6–5.447 (4.9)3.6–6.40.092
Slow to respond140 (6.9)5.8–8.021 (7.2)4.5–10.857 (7.2)5.5–9.362 (6.4)5.0–8.20.776
Altered mental state119 (5.8)4.9–6.915 (5.2)2.9–8.447 (6.0)4.4–7.957 (5.9)4.5–7.60.875
Seizure38 (1.9)1.3–2.66 (2.0)0.8–4.47 (0.9)0.4–1.825 (2.6)1.7–3.80.032
Focal neurological deficit90 (4.4)3.6–5.49 (3.1)1.4–5.836 (4.6)3.2–6.345 (4.7)3.5–6.30.480
Admitted
 SSU585 (79.2)76.1–82.081 (81.8)72.8–88.9223 (80.2)75.0–84.7281 (77.6)73.0–81.80.569
 Ward154 (20.9)18.0–24.018 (18.2)11.2–27.256 (20.1)15.6–25.480 (22.2)18.0–26.80.642
Observed 4+ hrs823 (40.0)37.8–42.1110 (37.3)31.8–43.1312 (39.4)36.0–43.0401 (41.2)38.1–44.30.458
CT scan322 (15.6)14.1–17.335 (11.9)8.4–16.1120 (15.2)12.7–17.9167 (17.2)14.8–19.70.082

The percentages stated are based on total available data for each variable. Boldface type indicates statistical significance.

Sex data missing for 2 cases

TABLE 2.

Characteristics of patients with non-SRC by age group

FactorTotalYoung ChildrenOlder ChildrenAdolescentsp Value
No. (%)95% CINo. (%)95% CINo. (%)95% CINo. (%)95% CI
No. of patients26491251826572
Sex
 Male1674 (63.2)61.3–65.0781 (62.4)59.7–65.1548 (66.3)63.0–69.6345 (60.3)56.2–64.40.053
 Female975 (36.8)35.0–38.7470 (37.6)34.9–40.3278 (33.7)30.4–37.0227 (39.7)35.7–43.8
GCS scoreNONBREAKING_SPACE
 152502 (94.5)93.5–95.31183 (94.6)93.2–95.8784 (94.9)93.2–96.3535 (93.5)91.2–95.40.380
 14120 (4.5)3.8–5.452 (4.2)3.1–5.435 (4.2)3.0–5.833 (5.8)4.0–8.0
 1327 (1.0)0.7–1.516 (1.3)0.7–2.17 (0.9)0.3–1.74 (0.7)0.2–1.8
Vomiting873 (33.2)31.4–35.0535 (43.1)40.3–45.9231 (28.1)25.1–31.3107 (18.8)15.7–22.3<0.001
Headache1628 (63.1)61.2–64.9672 (55.5)52.6–58.3558 (69.1)65.7–72.2398 (70.8)66.9–74.6<0.001
LOC483 (19.7)18.2–21.3113 (9.9)8.2–11.8154 (20.0)17.2–22.9216 (40.2)36.0–44.4<0.001
Amnesia626 (25.6)23.9–27.4217 (19.2)17.0–21.6218 (28.3)25.2–31.6191 (35.1)31.0–39.2<0.001
Abnormal drowsiness153 (5.8)5.0–6.891 (7.4)6.0–9.036 (4.4)3.1–6.026 (4.6)3.0–6.60.007
Disorientation813 (32.7)30.9–34.6345 (29.1)26.5–31.8255 (33.0)29.7–36.5213 (40.3)36.1–44.6<0.001
Acting abnormally626 (24.2)22.6–25.9331 (26.9)24.5–29.5181 (22.4)19.6–25.4114 (20.8)17.5–24.50.007
Irritability/agitation73 (2.8)2.2–3.541 (3.3)2.4–4.519 (2.3)1.4–3.613 (2.3)1.2–3.90.299
Repeated questioning70 (2.7)2.1–3.419 (1.6)0.9–2.429 (3.6)2.4–5.122 (3.9)2.5–5.80.003
Slow to respond164 (6.3)5.4–7.380 (6.5)5.2–8.153 (6.5)4.9–8.431 (5.5)3.7–7.70.657
Altered mental state124 (4.7)4.0–5.656 (4.5)3.4–5.933 (4.1)2.8–5.635 (6.2)4.3–8.50.166
Seizure68 (2.6)2.0–3.323 (1.9)1.2–2.817 (2.1)1.2–3.328 (5.0)3.3–7.1<0.001
Focal neurological deficit90 (3.4)2.8–4.226 (2.1)1.4–3.131 (3.8)2.6–5.333 (5.8)4.0–8.1<0.001
AdmittedNONBREAKING_SPACE
 SSU663 (77.8)74.9–80.6326 (85.6)81.6–88.9207 (75.3)69.7–80.3130 (66.3)59.3–72.9<0.001
 Ward201 (23.6)20.8–26.660 (15.8)12.2–19.873 (26.6)21.4–32.268 (34.7)28.1–41.8<0.001
Observed 4+ hrs994 (37.5)35.7–39.4414 (33.1)30.5–35.8327 (39.6)36.2–43.0253 (44.2)40.1–48.4<0.001
CT scan424 (16.0)14.6–17.5178 (14.2)12.3–16.3124 (15.0)12.6–17.6122 (21.3)18.0–24.9<0.001

The percentages stated are based on total available data for each variable. Boldface type indicates statistical significance.

Injury-Related Signs and Symptoms

There were no statistically significant differences in the sign or symptom presentations of young children with non-SRC and SRC, except for the presence of amnesia (19.2% vs 26.6%, p = 0.006). Older children with non-SRC were more likely than those with SRC to present with vomiting (28.1% vs 21.5%, p = 0.002), although they were less likely to present with an LOC (20.0% vs 25.0%, p = 0.018), amnesia (28.3% vs 37.3%, p < 0.001), and disorientation (33.0% vs 46.0%, p < 0.001). This pattern was similar for adolescents, in which those with non-SRC were more likely than those with SRC to present with vomiting (18.8% vs 13.5%, p = 0.006), and less likely to present with amnesia (35.1% vs 45.7%, p < 0.001) and disorientation (40.3% vs 50.0%, p < 0.001). There were also statistically significant differences between the presence of seizure among adolescents with non-SRC compared to SRC (5.0% vs 2.6%, p = 0.015).

Clinical Management

There were no statistically significant differences between young and older children in the proportion of admissions, observations greater than 4 hours, or CT scan rates between non-SRC and SRC. Among adolescents, however, a higher proportion of those with SRC were admitted to short stay units (SSUs; 77.6% vs 66.3%, p = 0.004), while higher proportions of those with non-SRC were admitted to a ward (34.7% vs 22.2%, p = 0.001) and underwent CT (21.3% vs 17.2%, p = 0.042).

Activity at the Time of Injury

In the entire sample, concussions associated with rugby (16.0%) and bike riding (13.5%) represented the largest proportion of SRCs. Among young children, the highest proportion of SRCs occurred while bike riding (19.3%), using a scooter (16.3%), and playing soccer (11.2%). Among older children, the highest proportion of SRCs occurred while playing rugby (16.2%) and bike riding (13.0%). Among adolescents, the highest proportion of SRCs occurred playing rugby (19.7%) and Australian football (14.5%). Activities in which concussions were sustained by age group are shown in Table 3.

TABLE 3.

Activities in which concussions were sustained by age group

ActivityTotalYoung ChildrenOlder ChildrenAdolescentsp Value
No. (%)95% CINo. (%)95% CINo. (%)95% CINo. (%)95% CI
Sports-related activities
 High-speed sports
  Bike riding279 (13.5)12.1–15.157 (19.3)15.0–24.3103 (13.0)10.8–15.6119 (12.2)10.2–14.40.007
  Scooter109 (5.3)4.4–6.448 (16.3)12.3–21.046 (5.8)4.3–7.715 (1.5)0.9–2.5<0.001
  Skateboarding98 (4.8)3.9–5.812 (4.1)2.1–7.030 (3.8)2.6–5.456 (5.8)4.4–7.40.132
  Horseriding80 (3.9)3.1–4.88 (2.7)1.2–5.339 (4.9)3.5–6.733 (3.4)2.3–4.70.132
  Ice skating39 (1.9)1.4–2.612 (4.1)2.1–7.014 (1.8)1.0–3.013 (1.3)0.7–2.30.010
  Snow sports10 (0.5)0.2–0.91 (0.3)0.0–1.94 (0.5)0.1–1.35 (0.5)0.2–1.20.926
  Roller-skating5 (0.2)0.1–0.62 (0.7)0.1–2.42 (0.3)0.0–0.91 (0.1)0.0–0.60.212
  Rollerblading3 (0.2)0.0–0.41 (0.3)0.0–1.91 (0.1)0.0–0.71 (0.1)0.0–0.60.637
  Skating (unspecified)1 (0.1)0.0–0.30 (0.0)0.0–1.21 (0.1)0.0–0.70 (0.0)0.0–0.40.448
 Water sports
  Swimming34 (1.7)1.2–2.316 (5.4)3.1–8.716 (2.0)1.2–3.32 (0.2)0.0–0.7<0.001
  Diving31 (1.5)1.0–2.18 (2.7)1.2–5.316 (2.0)1.2–3.37 (0.7)0.3–1.50.015
  Water sports24 (1.2)0.8–1.710 (3.4)1.6–6.27 (0.9)0.4–1.87 (0.7)0.3–1.50.001
  Boating11 (0.5)0.3–1.00 (0.0)0.0–1.25 (0.6)0.2–1.56 (0.6)0.2–1.30.396
  Surfing, bodyboarding9 (0.4)0.2–0.80 (0.0)0.0–1.23 (0.4)0.1–1.16 (0.6)0.2–1.30.355
 Club/bat sports
  Hockey46 (2.2)1.6–3.011 (3.7)1.9–6.620 (2.5)1.6–3.915 (1.5)0.9–2.50.065
  Cricket41 (2.0)1.4–2.75 (1.7)0.6–3.98 (1.0)0.4–2.028 (2.9)1.9–4.10.019
  Baseball/softball14 (0.7)0.4–1.14 (1.4)0.4–3.47 (0.9)0.4–1.83 (0.3)0.1–0.90.106
  Golf6 (0.3)0.1–0.63 (1.0)0.2–2.91 (0.1)0.0–0.72 (0.2)0.0–0.70.042
  Lacrosse3 (0.2)0.0–0.40 (0.0)0.0–1.20 (0.0)0.0–0.53 (0.3)0.1–0.90.187
 Racket sports
  Racket sports17 (0.8)0.5–1.37 (2.4)1.0–4.85 (0.6)0.2–1.55 (0.5)0.2–1.20.006
 Contact sports
  Football—rugby330 (16.0)14.5–17.710 (3.4)1.6–6.2128 (16.2)13.7–18.9192 (19.7)17.3–22.4<0.001
  Australian football231 (11.2)9.9–12.79 (3.1)1.4–5.781 (10.2)8.2–12.6141 (14.5)12.3–16.8<0.001
  Football—unspecified229 (11.1)9.8–12.610 (3.4)1.6–6.282 (10.4)8.3–12.7137 (14.1)11.9–16.4<0.001
  Martial arts10 (0.5)0.2–0.93 (1.0)0.2–2.93 (0.4)0.1–1.14 (0.4)0.1–1.10.364
  Boxing4 (0.2)0.1–0.51 (0.3)0.0–1.91 (0.1)0.0–0.72 (0.2)0.0–0.70.774
 Ball sports & athletics
  Soccer176 (8.5)7.4–9.833 (11.2)7.8–15.468 (8.6)6.7–10.875 (7.7)6.1–9.60.171
  Basketball108 (5.2)4.3–6.39 (3.1)1.4–5.753 (6.7)5.1–8.746 (4.7)3.5–6.30.034
  Netball39 (1.9)1.4–2.62 (0.7)0.1–2.416 (2.0)1.2–3.321 (2.2)1.3–3.30.249
  Athletics9 (0.4)0.2–0.80 (0.0)0.0–1.24 (0.5)0.1–1.35 (0.5)0.2–1.20.470
  Dodgeball8 (0.4)0.2–0.81 (0.3)0.0–1.96 (0.8)0.3–1.61 (0.1)0.0–0.60.087
  High jump7 (0.3)0.1–0.71 (0.3)0.0–1.92 (0.3)0.0–0.94 (0.4)0.1–1.10.852
  Volleyball6 (0.3)0.1–0.61 (0.3)0.0–1.91 (0.1)0.0–0.74 (0.4)0.1–1.10.538
  Touch football4 (0.2)0.1–0.50 (0.0)0.0–1.21 (0.1)0.0–0.73 (0.3)0.1–0.90.493
  Handball2 (0.1)0.0–0.40 (0.0)0.0–1.22 (0.3)0.0–0.90 (0.0)0.0–0.40.201
 Dance-related sports
  Gymnastics25 (1.2)0.8–1.88 (2.7)1.2–5.310 (1.3)0.6–2.37 (0.7)0.3–1.50.023
  Dancing7 (0.3)0.1–0.72 (0.7)0.1–2.43 (0.4)0.1–1.12 (0.2)0.0–0.70.460
  Cheerleading5 (0.2)0.1–0.60 (0.0)0.0–1.22 (0.3)0.0–0.95 (0.5)0.2–1.20.640
Non–sports-related activities
 Fall1731 (66.4)64.5–68.2896 (72.7)70.2–75.2521 (64.0)60.6–67.3314 (55.8)51.6–59.9<0.001
 Playing (other)561 (21.2)19.6–22.8301 (24.1)21.7–26.5194 (23.5)20.6–26.566 (11.5)9.0–14.4<0.001
 Playing (playground equipment)238 (9.0)7.9–10.1160 (12.8)11.0–14.864 (7.8)6.0–9.814 (2.5)1.3–4.1<0.001
 Motor vehicle related235 (8.9)7.9–10.164 (5.1)4.0–6.583 (10.1)8.1–12.388 (15.5)12.6–18.7<0.001
 Struck by high-impact object, accidental142 (5.4)4.6–6.349 (4.0)2.9–5.248 (5.9)4.3–7.745 (8.0)5.9–10.50.002
 Other/unknown/missing394 (14.9)13.5–16.3174 (13.9)12.0–16.0109 (13.2)11.0–15.7111 (19.4)16.2–22.90.002

Boldface type indicates statistical significance.

Sport-related activities accounting for concussion where statistically significant differences were observed between young child, older child, and adolescent age groups included bike riding (19.3% vs 13.0% vs 12.2%, p = 0.007), using a scooter (16.3% vs 5.8% vs 1.5%, p < 0.001), ice skating (4.1% vs 1.8% vs 1.3%, p = 0.010), swimming (5.4% vs 2.0% vs 0.2%, p < 0.001), diving (2.7% vs 2.0% vs 0.7%, p = 0.015), playing water sports (3.4% vs 0.9% vs 0.7%, p = 0.001), golf (1.0% vs 0.1% vs 0.2%, p = 0.042), racket sports (2.4% vs 0.6% vs 0.5%, p = 0.006), and gymnastics (2.7% vs 1.3% vs 0.7%, p = 0.023), with younger children accounting for the highest proportion of each activity. Higher proportions of older children sustained a concussion playing basketball than the younger child and adolescent age groups (6.7% vs 3.1% vs 4.7%, p = 0.034). Higher proportions of adolescents sustained a concussion while participating in contact sports compared with younger and older children, including rugby (19.7% vs 3.4% vs 16.2%, p < 0.001) and Australian football (14.5% vs 3.1% vs 10.2%, p < 0.001). Adolescents were also observed to have a higher proportion of SRC playing cricket (2.9% vs 1.7% vs 1.0%, p = 0.019).

For non–sports-related mechanisms, falls were responsible for the highest proportion of concussions in each age group. Falls were most common in younger children, as compared to older children and adolescents, with the proportion decreasing with increasing age (72.7% vs 64.0% vs 55.8%, p < 0.001). Younger children also sustained concussions in higher proportions than older children and adolescents while playing on playground equipment (12.8% vs 7.8% vs 2.5%, p < 0.001) and engaging in other playing (24.1% vs 23.5% vs 11.5%, p < 0.001). Higher proportions of adolescents, compared to older and younger children, sustained a concussion in a motor vehicle accident (15.5% vs 10.1% vs 5.1%, p < 0.001) and from being struck by a high-impact object (8.0% vs 5.9% vs 4.0%, p = 0.002).

Location of Injury

Across the entire sample, 26.2% of concussions were sustained in an indoor or outdoor sports area, and 21.8% and 19.0% of concussions were sustained at home or in an educational setting, respectively. The proportion of concussions sustained in an indoor or outdoor sports area increased with increasing age (young children 8.0%, older children 27.7%, adolescents 42.8%, p < 0.001), while there was a decrease with increasing age for concussions at home (young children 34.1%, older children 19.0%, adolescents 12.6%, p < 0.001) and in educational settings (young children 23.4%, older children 20.7%, adolescents 12.7%, p < 0.001). Location of injury by age group is shown in Table 4.

TABLE 4.

Location of concussion injury

LocationTotalYoung ChildrenOlder ChildrenAdolescentsp Value
No. (%)95% CINo. (%)95% CINo. (%)95% CINo. (%)95% CI
Sports area (indoor and outdoor)1234 (26.2)25.0–27.5124 (8.0)6.7–9.5448 (27.7)25.5–30.0662 (42.8)40.3–45.3<0.001
Home1028 (21.8)20.7–23.0527 (34.1)31.7–36.5307 (19.0)17.1–21.0194 (12.6)10.9–14.3<0.001
Educational setting893 (19.0)17.9–20.1361 (23.4)21.3–25.5335 (20.7)18.8–22.8197 (12.7)11.1–14.5<0.001
Outdoor environments (e.g., beach, river, park)194 (4.1)3.6–4.748 (3.1)2.3–4.168 (4.2)3.3–5.378 (5.1)4.0–6.30.025
Other/unknown427 (9.1)8.3–9.9157 (10.2)8.7–11.8141 (8.7)7.4–10.2129 (8.3)7.0–9.80.179
Thoroughfares (e.g., road, footpath)418 (8.9)8.1–9.7109 (7.1)5.8–8.4151 (9.3)8.0–10.9158 (10.2)8.8–11.80.006
Playground/recreational area291 (6.2)5.5–6.9138 (8.9)7.6–10.590 (5.6)4.5–6.863 (4.1)3.2–5.2<0.001
Swimming pool100 (2.1)1.7–2.639 (2.5)1.8–3.445 (2.8)2.0–3.716 (1.0)0.6–1.70.001
Commercial establishments (e.g., shop, restaurant)69 (1.5)1.1–1.924 (1.6)1.0–2.314 (0.9)0.5–1.531 (2.0)1.4–2.80.027
Missing55 (1.2)0.9–1.519 (1.2)0.7–1.918 (1.1)0.7–1.818 (1.2)0.7–1.80.955

Boldface type indicates statistical significance.

Discussion

Pediatric concussion ED presentations have increased in recent years. Potential factors for a disproportional emphasis on SRC, compared to non-SRC causes, include media exposure, clinical guidelines, and prevention efforts.3,7 Clinical and community policy and public health efforts can benefit from a detailed understanding of injury circumstances, particularly in the pediatric domain, in which SRC is not the major cause of injury for all age groups. This secondary analysis of data from a multicenter, prospective, observational study aimed to compare non-SRC and SRC, examining clinical characteristics, clinical management, and how and where concussions were sustained among young children (5–8 years), older children (9–12 years), and adolescents (13–17 years) presenting to EDs in Australia and New Zealand.

Approximately 56% of our sample presented to EDs for non-SRC. Prior studies have reported varying proportions of pediatric SRC and non-SRC that were attributable to study setting (e.g., ED, outpatient clinic) or definition of sport. For example, ED settings report SRCs at comparable proportions of approximately 30%–50%,16,17 with the proportion increasing where the setting included primary care and outpatient clinic presentations,18,19 or where recreational activities (e.g., playing, playground) were grouped with sport-specific activities.18,20 In our data, non-SRCs were responsible for the highest proportion of ED concussion presentations and were particularly prevalent among younger children. More than 80% of young children sustained a non-SRC, a rate more than double the number of non-SRCs among adolescents. There was less of a divergence among older children, with just over half presenting with a non-SRC.

Unsurprisingly, falls were the most common mechanism for non-SRC across all age groups. This finding is consistent with several prior studies demonstrating falls as a primary mechanism of injury.21,22 Fitting with expected age-related activities, younger children with non-SRC encompassed the highest proportion of presentations to the ED following a fall or playing compared with older age groups, while adolescents with a non-SRC had the highest proportion of presentations following a motor vehicle–related accident compared with the younger age groups.

Consistent with several previous studies, the likelihood of sports-related head injury presentations increased with older age.16,18,23 This likely reflects higher organized sports and physical recreation participation rates among adolescents,24,25 although to some degree it may reflect higher healthcare utilization as a consequence of increased attention and awareness of concussions in sports relative to concussions in nonsport contexts. High-speed sports (e.g., bike riding, scooters) were the most common cause of SRC among younger children, while contact sports (e.g., rugby, Australian football) were the most common cause of SRC among older children and adolescents. Again, this finding is consistent with increased contact sports participation in adolescents.25 The highest proportion of SRC among older children and adolescents was sustained while playing rugby. For adolescents, this was followed by Australian football. There were several noncontact sports in which younger children sustained concussions at higher proportions than older age groups, including bike riding, using a scooter, and swimming.

Understanding where children and young people are sustaining concussions is as important to prevention and policy efforts as a characterization of the activities contributing to these injuries. While approximately one-quarter of all concussions were sustained in an indoor or outdoor sports area, approximately 1 in 5 occurred at home and 1 in 5 in an educational setting. For young children, injuries at home accounted for one-third of ED concussion presentations. This finding underscores the importance of ensuring parents have adequate knowledge, through tailored education, to support their confidence and ability to identify a suspected concussion and manage recovery consistent with best practice evidence.26 The frequency of concussions in education settings also highlights the importance of schools having clear and evidence-based concussion policies. The CISG guidelines call attention to return to learning as a vital part of the concussion recovery process and encourages healthcare professionals to collaborate with stakeholders on guidelines to support the management of concussion in schools and facilitate appropriate academic support where required.3

Comparison of injury-related characteristics revealed that following an SRC, there was a higher proportion of transient posttraumatic amnesia for all age groups, a higher proportion of LOC for older children, and a higher proportion of disorientation for both older children and adolescents than for non-SRCs. Following a non-SRC, only vomiting was present in higher proportions for older children and adolescents than in the SRC group. There is limited research examining differences in clinical outcome or clinical signs and symptoms by injury mechanism in ED settings. Studies in outpatient settings have yielded inconsistent results, with some reporting differences in symptom burden or clinical characteristics for SRC and non-SRC mechanisms,19,27 and others identifying higher symptom burden for 12- to 19-year-olds with non-SRC.28 In our sample, SRC resulted in a higher burden of various symptoms as compared to non-SRC. Despite these findings, there was no translation to differences in clinical management for younger and older children, where similar rates of observation, admission, and CT imaging were observed for non-SRC and SRC. Interestingly, despite the differences in signs and symptoms for adolescents being like those of older children, higher rates of admission to an SSU were observed for adolescents with SRC, while higher rates of ward admissions and undergoing a CT were observed for adolescents with non-SRC.

Limitations of the Study

This study has several limitations. First, the profile of concussion presentations is limited to a school-age pediatric population, and given the restricted criteria of symptoms used to define concussion, a subset of the full spectrum of postconcussion symptoms. Consequently, some clinically diagnosed concussions may have been missed in our sample. Second, the breakdown of non-SRC and SRC activities was susceptible to varied interpretations because clinicians were not provided with clear definitions (e.g., how "playing" was defined). Furthermore, "unspecified" options for certain activities (e.g., football) were also available, thus preventing a true count of specific variations of football. Third, a more granular understanding of activities and the efficacy of prevention strategies was lacking; for example, the proportion of bike riders wearing helmets, or the proportion of footballers immediately removed from play following a head impact. We did not include patients who had not reported at the ED visit of having our predefined symptoms of concussion. These patients may represent a cohort who may have developed symptoms of concussion in the days following their injury if they had been contacted. The lack of follow-up for the entire sample also meant links between acute presentation and delayed recovery or symptom progression over time could not be examined. Generalization of the trends and characteristics depicted in this study beyond the tertiary ED must be made with caution. A large proportion of children and adolescents either do not seek medical care, or are assessed and treated in outpatient healthcare settings,2 and this sample exclusively included those presenting within 24 hours of injury, which may represent those with more serious symptoms postinjury. Finally, while this paper uses an older dataset (2011–2014), the findings address gaps in the literature. The 2023 CISG Consensus Statement and systematic reviews emphasize the paucity of evidence that exists for patients aged 5–12 years, and most particularly for children younger than 8 years.3,12 Directions for future research stemming from the CISG include understanding modifying factors in these younger age groups, including mechanisms of injury, which is illustrated by our data.12 Furthermore, relationships between mechanism of injury, age, and clinical characteristics are unlikely to have changed significantly over the medium term.

Conclusions

Data from this multicenter prospective observational study reveal approximately 56% of children and adolescents in our sample presented to EDs for non-SRC. More than 80% of young children (aged 5–8 years) sustained a non-SRC, a rate more than double the number of non-SRCs among adolescents. The most common mechanism of non-SRC was falls across all age groups. High-speed sports (such as bike riding and scooters) were the most common cause of SRC among younger children, while contact sports (e.g., rugby and Australian football) were the most common cause of SRCs among older children and adolescents. Approximately 1 in 4 concussions were sustained in an indoor or outdoor sports area, while concussions sustained at home or educational settings both occurred at rates of 1 in 5. While SRCs resulted in a higher burden of some symptoms compared with non-SRCs, this did not translate to differences in clinical management for younger and older children. Higher proportions of adolescents with SRC were admitted to an SSU, while higher proportions of adolescents with non-SRC were admitted to wards and underwent CT.

Given the overall high rates of pediatric concussion, evidence-based guidelines and appropriate management and preventative strategies are pivotal, irrespective of injury mechanism. Equal attention to SRC and non-SRC is important for reducing the burden of overall concussion injuries. Appeals for increased attention to non-SRC have been made previously, in recognition of a gap in public health efforts.18,26,29 Our data support the need to address this gap. While our data demonstrate clear patterns of increasing SRC with older age, they also revealed that non-SRC injuries predominate in the study of a large ED cohort, particularly among younger children, where approximately 4 of 5 concussions are non–sport related. Importantly, our data address a gap highlighted by the recent CISG Consensus Statement, examining the age groups < 12 years old. Understanding differences in injury mechanism, activity, and location of injury by age group, as well as symptom presentations and clinical management in the ED, provides important factors to consider in the development and ongoing refinement of clinical management and various public health measures.

Acknowledgments

We would like to thank the participating families and ED and research staff at participating sites. This study was funded by the following organizations: Perpetual Philanthropic Services (all authors, fund ID no. 2012/1149); the A+ Trust (all authors); WA Health Targeted Research Funds; Townsville Hospital and Health Service Private Practice Research and Education Trust Fund; Victorian Government’s Infrastructure Support Program; National Health and Medical Research Council (NHMRC) Practitioner Fellowship (Babl); Cure Kids New Zealand (Dalziel); Australian Government Research Training Program (Rausa); Auckland Medical Research Foundation (AMRF; all authors, grant no. 3112011); the Department of Health, NHMRC (all authors, grant no. GNT1046727); the Emergency Medicine Foundation (EMF; all authors, grant no. EMPJ-11162); and Murdoch Children’s Research Institute (MCRI; all authors).

Disclosures

Dr. Davis reported being a member of the Scientific Committee of the 6th International Conference on Concussion in Sport; an honorary member of the AFL Concussion Scientific Committee; a section editor for Sport and Rehabilitation in the journal Neurosurgery; and attending meetings organized by sporting organizations, including the National Football League, National Rugby League, International Ice Hockey Federation, International Olympic Committee, and Fédération Internationale de Football Association; however, he has not received any payment, research funding, or other monies from these groups other than for travel costs.

Author Contributions

Conception and design: Borland, Kochar, Cheek, Neutze, Williams, Dalziel, Babl. Acquisition of data: Borland, Kochar, Phillips, Gilhotra, Dalton, Cheek, Furyk, Neutze, Williams, Dalziel, Babl. Analysis and interpretation of data: Rausa, Borland, Kochar, Dalton, Cheek, Furyk, Dalziel, Hearps, Babl. Drafting the article: Rausa, Borland, Kochar, Furyk, Neutze, Davis, Hearps, Babl. Critically revising the article: Rausa, Borland, Kochar, Phillips, Cheek, Furyk, Neutze, Davis, Anderson, Dalziel, Hearps, Babl. Reviewed submitted version of manuscript: Rausa, Borland, Kochar, Phillips, Gilhotra, Cheek, Furyk, Davis, Anderson, Dalziel, Hearps. Approved the final version of the manuscript on behalf of all authors: Rausa. Statistical analysis: Rausa, Hearps. Study supervision: Babl.

Supplemental Information

Online-Only Content

Supplemental material is available online.

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Supplementary Materials

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Illustration from Dugan et al. (E13). © Kristen L. Williams, published with permission.

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