Characteristics of concussion based on patient age and sex: a multicenter prospective observational study

Franz E. Babl Emergency Department, Royal Children’s Hospital, Melbourne;
Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne;

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Vanessa C. Rausa Clinical Sciences, Murdoch Children’s Research Institute, Melbourne;

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

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Amit Kochar Emergency Department, Women’s & Children’s Hospital, Adelaide, Australia;

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Mark D. Lyttle Faculty of Health & Life Sciences, University of the West of England, Bristol, United Kingdom;

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

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

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Sarah Dalton Emergency Department, The Children’s Hospital at Westmead, Sydney;

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John A. Cheek Emergency Department, Royal Children’s Hospital, Melbourne;
Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne;
Emergency Department, Monash Medical Centre, Melbourne, Australia;

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

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Jocelyn Neutze Emergency Department, Kidzfirst Middlemore Hospital, Auckland, New Zealand;

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Silvia Bressan Clinical Sciences, Murdoch Children’s Research Institute, Melbourne;
Department of Women’s and Children’s Health, University of Padova, Padova, Italy;

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

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

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

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Ed Oakley Emergency Department, Royal Children’s Hospital, Melbourne;
Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne;

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

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Louise M. Crowe Clinical Sciences, Murdoch Children’s Research Institute, Melbourne;
Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne;
School of Psychological Sciences, University of Melbourne, Melbourne;
Psychology Service, Royal Children’s Hospital, Melbourne;

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

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OBJECTIVE

Children with concussion frequently present to emergency departments (EDs). There is limited understanding of the differences in signs, symptoms, and epidemiology of concussion based on patient age. Here, the authors set out to assess the association between age and acute concussion presentations.

METHODS

The authors conducted a multicenter prospective observational study of head injuries at 10 EDs in Australia and New Zealand. They identified children aged 5 to < 18 years, presenting with a Glasgow Coma Scale score of 13–15, presenting < 24 hours postinjury, with no abnormalities on CT if performed, and one or more signs or symptoms of concussion. They extracted demographic, injury-related, and signs and symptoms information and stratified it by age group (5–8, 9–12, 13 to < 18 years).

RESULTS

Of 8857 children aged 5 to < 18 years, 4709 patients met the defined concussion criteria (5–8 years, n = 1546; 9–12 years, n = 1617; 13 to < 18 years, n = 1546). The mean age of the cohort was 10.9 years, and approximately 70% of the patients were male. Sport-related concussion accounted for 43.7% of concussions overall, increasing from 19.1% to 48.9% to 63.0% in the 5–8, 9–12, and 13 to < 18 years age groups. The most common acute symptoms postinjury were headache (64.6%), disorientation (36.2%), amnesia (30.0%), and vomiting (27.2%). Vomiting decreased with increasing age and was observed in 41.7% of the 5–8 years group, 24.7% of the 9–12 years group, and 15.4% of the 13 to < 18 years group, whereas reported loss of consciousness (LOC) increased with increasing age, occurring in 9.6% in the 5–8 years group, 21.0% in the 9–12 years group, 36.7% in the 13 to < 18 years group, and 22.4% in the entire study cohort. Headache, amnesia, and disorientation followed the latter trajectory. Symptom profiles were broadly similar between males and females.

CONCLUSIONS

Concussions presenting to EDs were more sports-related as age increased. Signs and symptoms differed markedly across age groups, with vomiting decreasing and headache, LOC, amnesia, and disorientation increasing with increasing age.

ABBREVIATIONS

ED = emergency department; GCS = Glasgow Coma Scale; LOC = loss of consciousness; SRC = sport-related concussion; TBI = traumatic brain injury.

OBJECTIVE

Children with concussion frequently present to emergency departments (EDs). There is limited understanding of the differences in signs, symptoms, and epidemiology of concussion based on patient age. Here, the authors set out to assess the association between age and acute concussion presentations.

METHODS

The authors conducted a multicenter prospective observational study of head injuries at 10 EDs in Australia and New Zealand. They identified children aged 5 to < 18 years, presenting with a Glasgow Coma Scale score of 13–15, presenting < 24 hours postinjury, with no abnormalities on CT if performed, and one or more signs or symptoms of concussion. They extracted demographic, injury-related, and signs and symptoms information and stratified it by age group (5–8, 9–12, 13 to < 18 years).

RESULTS

Of 8857 children aged 5 to < 18 years, 4709 patients met the defined concussion criteria (5–8 years, n = 1546; 9–12 years, n = 1617; 13 to < 18 years, n = 1546). The mean age of the cohort was 10.9 years, and approximately 70% of the patients were male. Sport-related concussion accounted for 43.7% of concussions overall, increasing from 19.1% to 48.9% to 63.0% in the 5–8, 9–12, and 13 to < 18 years age groups. The most common acute symptoms postinjury were headache (64.6%), disorientation (36.2%), amnesia (30.0%), and vomiting (27.2%). Vomiting decreased with increasing age and was observed in 41.7% of the 5–8 years group, 24.7% of the 9–12 years group, and 15.4% of the 13 to < 18 years group, whereas reported loss of consciousness (LOC) increased with increasing age, occurring in 9.6% in the 5–8 years group, 21.0% in the 9–12 years group, 36.7% in the 13 to < 18 years group, and 22.4% in the entire study cohort. Headache, amnesia, and disorientation followed the latter trajectory. Symptom profiles were broadly similar between males and females.

CONCLUSIONS

Concussions presenting to EDs were more sports-related as age increased. Signs and symptoms differed markedly across age groups, with vomiting decreasing and headache, LOC, amnesia, and disorientation increasing with increasing age.

In Brief

The aim of this study was to describe the age-related signs, symptoms, and epidemiology of concussion presentations to the emergency department in children by using a large multicenter prospective observational data set. Signs and symptoms of concussion varied by age, with higher levels of vomiting in younger children and higher levels of loss of consciousness and amnesia in older children. Concussions were increasingly sports related as age increased. The study illuminates age-related signs and symptoms of concussion and the epidemiology of concussion based on patient age.

Traumatic brain injuries (TBIs) are common among children and youths.1 Mild TBI, of which concussion is a subset, accounts for up to 90% of emergency department (ED) presentations of pediatric head injury.2,3 Concussion is defined as a TBI induced by biomechanical forces, resulting in complex physical and neurological sequelae, and can be suspected when somatic, cognitive, and/or emotional symptoms; physical signs (e.g., loss of consciousness [LOC], amnesia); balance impairment; cognitive impairment; or sleep/wake disturbance are observed.4 The clinical signs and symptoms are considered to reflect functional rather than structural injury.4

The recognition of concussion in young people has increased in recent years,5 translating to a rise in ED presentations,6 with the most recent global estimate suggesting 4 million annual attendances.2,7 These estimates are considered to represent only 12% of all concussions in youths, with over 80% initially treated in primary care settings.5 These prevalence estimates render pediatric concussion an important public health issue, particularly given a poor understanding of concussion among parents,8,9 a lack of awareness of appropriate management guidelines,10,11 and consequences such as the increased family burden,12 costs associated with healthcare utilization,13 and risk of protracted recovery.14

There is a growing understanding of the epidemiology and acute clinical presentation of concussion among high school and collegiate populations.15,16 However, less is known about younger children or how the various pediatric age bands differ in this regard.7,17 Although specific to sport-related concussion (SRC), systematic reviews informing the 5th International Consensus Conference on Concussion in Sport found an absence of literature regarding how or whether the acute signs and symptoms of concussion in younger children differ from those in older children or adolescents.7,17 One review indicated that signs such as LOC, amnesia, balance problems, and disorientation were likely to have diagnostic and prognostic value, whereas more common symptoms such as headache, fatigue, and dizziness were considered to have less diagnostic certainty.7 Despite the paucity of research into younger children, emerging findings have suggested that the presentation of concussion may differ in various childhood developmental stages and that adolescents may display more symptoms of concussion with increasing age.17

While many epidemiological descriptions of pediatric concussion presentations exist, they are limited in terms of target population, setting, age bands, or data source and are often not prospective or multicenter.3,6,1822 Of the studies that include children and adolescents across the various developmental stages, and with the exception of mechanism of injury, there is limited analysis of the differences between pediatric age bands, particularly regarding clinical signs and symptoms.5,6,18,19,21,2325 Yet, a contemporary understanding of the epidemiology of pediatric concussion and the impact of age on concussion presentation is pivotal to inform acute care, educate ED medical staff, and guide appropriate recommendations, follow-up, and postacute multidisciplinary care.6 Our aim in this study was to describe age-related signs, symptoms, and epidemiology of ED concussion presentations across the age spectrum of children and adolescents by using a large, multicenter, prospective observational data set.26

Methods

Design

This planned study is part of APHIRST (Australasian Paediatric Head Injury Rules Study),26 a multicenter prospective observational study by the Paediatric Research in Emergency Departments International Collaborative (PREDICT).27 The primary aim of APHIRST was to determine the accuracy of three international pediatric head injury clinical decision rules for neuroimaging.26 The study was undertaken at nine pediatric EDs and one combined adult and pediatric ED across Australia and New Zealand. Institutional ethics approval was given at all participating sites.

Participants

Participants in the current study were a subsample of APHIRST, aged 5 years and older, who had sustained a head injury and had symptoms of concussion.28 APHIRST enrolled children whose age was < 18 years and who presented with head injuries of any severity during 2011–2014. Patients were excluded if they had sustained only a trivial facial injury, were referred to an external provider from ED triage (e.g., general practitioner), had neuroimaging prior to transfer to the study site, or did not wait to be examined. Concussion was defined by a Glasgow Coma Scale (GCS) score29 of 13–15 with no abnormalities on CT if performed and one or more of the following signs or symptoms, as measured as part of the decision rules under study: LOC, disorientation, amnesia, headache, vomiting, acting abnormally, irritability/agitation, abnormal drowsiness, repeated questioning, slow to respond, altered mental state, or focal neurology. Participants were excluded from the concussion subsample if they presented to the ED > 24 hours postinjury, the injury was secondary to a medical condition (e.g., epilepsy), or nonaccidental injury was suspected.

Procedures

Recruitment and study procedures have been detailed previously.26 Eligible patients were identified at ED triage, and patients were enrolled by their treating clinician. Parents, guardians, or older adolescents provided informed verbal consent. Consent included permission to contact families 14–90 days post–ED presentation for follow-up. Research assistants made telephone contact with families if no cranial CT was performed in the ED to screen for possible missed intracranial injuries. Collected data included demographic and epidemiological information, injury-related information, hospital timelines from triage to discharge, ED observation and hospital admission details, and 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, standard deviations alongside means, and 95% confidence intervals alongside percentages. Data were stratified by age groups (5–8, 9–12, and 13 to < 18 years) and child sex. Age group means were compared using ANOVA, and mean ranks were compared using Kruskal-Wallis tests. All categorical variables were compared between groups using chi-square tests. Effect sizes were presented for all tests: η2 for continuous measures and Cramer’s V for categorical measures. All analyses were conducted using Stata version 15.0 (StataCorp).

Results

Sample

Of the 20,137 participants recruited to APHIRST over an approximate 4-year period, 8857 were aged 5 to < 18 years. Of these, 968 patients were excluded because of an abnormal CT (n = 289), a GCS score < 13 (n = 58), a suspected nonaccidental injury (n = 42), an injury secondary to a medical condition (n = 71), admission to the intensive care unit (n = 21), or ED presentation > 24 hours postinjury (n = 487). Of the 7889 remaining participants, 3180 (40.3%) did not meet our criteria for concussion (i.e., did not present with signs or symptoms) and 4709 (59.7%) did (Fig. 1). Mechanism of injury was sport related for 43.7% (95% CI 42.3–45.2) of concussed participants compared with 25.8% (95% CI 24.3–27.4) of those who did not meet concussion criteria. Characteristics of concussion participants are shown in Table 1.

FIG. 1
FIG. 1

Patient flowchart. ICU = intensive care unit; NAI = nonaccidental injury.

TABLE 1.

Characteristics of 4709 concussed patients

FactorNo. of Pts%95% CI
Mean age in yrs 470910.9*10.8–11.0
Median age in yrs 470911.18.0–13.8
GCS score
 15441693.893.0–94.5
 142365.04.4–5.7
 13571.20.9–1.6
Female sex§140329.828.5–31.1
Mechanism of injury
 Pedestrian struck by moving vehicle751.61.3–2.0
 Bike rider struck by automobile90.20.1–0.4
 Motor vehicle related2294.94.3–5.5
 Object struck head, accidental51811.010.1–11.9
 Fall from bicycle (no helmet)1332.82.4–3.3
 Playing62013.212.2–14.2
 Other/unknown56712.011.1–13.0
 Fall255854.352.9–55.8
  ≤1 m140829.928.6–31.2
  >1 m64613.712.7–14.7
  >1.5 m3878.27.4–9.0
  >3 m451.00.7–1.3
  Unknown721.51.2–1.9
SRC206043.742.3–45.2
Symptom
 Vomiting128327.226.0–28.5
 Headache304064.663.2–65.9
 LOC 105622.421.2–23.6
 Amnesia141430.028.7–31.4
 Abnormal drowsiness2555.44.8–6.1
 Disorientation170336.234.8–37.6
 Acting abnormally107922.921.7–24.1
 Irritability/agitation1282.72.3–3.2
 Repeated questioning1533.22.8–3.8
 Slow to respond3046.55.8–7.2
 Altered mental state2435.24.5–5.8
 Seizure 1062.31.8–2.7
 Suspicion of depressed fracture00.00.0–0.1
 Signs of base of skull fracture170.40.2–0.6
 Scalp hematoma146931.229.9–32.5
 Positive neurology1803.83.3–4.4
Median LOS in days46933.32.1–5.3
Admitted1590 33.832.4–35.1
 Ward3557.56.8–8.3
 SSU124826.525.2–27.8
Observed 4+ hrs179638.136.7–39.5
Admitted/observed 4+ hrs213445.343.9–46.8
CT scan80917.216.1–18.3

LOS = length of stay; Pts = patients; SSU = short stay unit.

Mean value with standard deviation.

Median value.

Interquartile range.

Sex data missing for 2 cases.

Motor, sensory, coordination, or reflex abnormality.

Demographics

The mean age of concussed patients was 10.9 years (SD 10.8–11.0). Males accounted for approximately 70% of concussions. Characteristics by age groups (5–8, 9–12, 13 to < 18 years) are summarized in Table 2. There was a similar number of concussions across the three age groups. A higher proportion of females sustained a concussion in the 5–8 years group (35.6%, 95% CI 33.2–38.1) than those in the 9–12 years (28.3%, 95% CI 26.1–30.6) and 13 to < 18 years (25.5%, 95% CI 23.3–27.7) groups. Table 3 provides a breakdown of concussion characteristics by sex.

TABLE 2.

Characteristics of 4709 concussion patients by age group

Factor5–8 Yrs9–12 Yrs13 to <18 Yrsp ValueEffect Size
No.%95% CINo.%95% CINo.%95% CI
Total no. of patients154632.8 161734.31546 32.8
GCS score
 13211.40.8–2.1191.20.7–1.8171.10.6–1.80.2070.03
 14654.23.3–5.3784.83.8–6.0936.04.9–7.3
 15146094.493.2–95.5152094.092.7–95.1143692.991.5–94.1
Female sex55135.633.2–38.145828.326.1–30.639425.523.3–27.7<0.0010.09
Mechanism of injury
 Pedestrian struck by moving vehicle291.91.3–2.7231.40.9–2.1231.50.9–2.20.5490.02
 Bike rider struck by automobile30.20.0–0.610.10.0–0.350.30.1–0.80.2420.02
 Motor vehicle related452.92.1–3.9895.54.4–6.7956.15.0–7.5<0.0010.06
 Object struck head, accidental966.25.1–7.517710.99.5–12.624515.814.1–17.8<0.0010.12
 Fall from bicycle (no helmet)412.71.9–3.6513.22.4–4.1412.71.9–3.60.6140.01
 Playing473.02.2–4.023614.612.9–16.433721.819.8–23.9<0.0010.23
 Other/unknown25416.414.6–18.418011.19.6–12.81338.67.3–10.1<0.0010.10
 Fall103166.764.3–69.086053.250.7–55.666743.140.7–45.7<0.0010.19
  ≤1 m59738.636.2–41.147929.627.4–31.933221.519.5–23.60.0550.05
  >1 m24415.814.0–17.722013.612.0–15.418211.810.2–13.5
  >1.5 m1419.17.7–10.71237.66.4–9.01238.06.7–9.4
  >3 m211.40.8–2.1150.90.5–1.590.60.3–1.1
  Unknown281.81.2–2.6231.40.9–2.1211.40.8–2.1
SRC29519.117.2–21.179148.946.5–51.497463.060.5–65.4<0.0010.37
Symptom
 Vomiting64541.739.2–44.240024.722.7–26.923815.413.6–17.3<0.0010.24
 Headache83854.251.7–56.7109367.665.3–69.9110971.769.4–74.0<0.0010.15
 LOC 1499.68.2–11.233921.019.0–23.056836.734.3–39.2<0.0010.27
 Amnesia29118.816.9–20.950231.028.8–33.462140.237.7–42.7<0.0010.18
 Abnormal drowsiness1097.15.8–8.4794.93.9–6.1674.33.4–5.50.0020.05
 Disorientation43728.326.0–30.659636.934.5–39.367043.340.8–45.9<0.0010.14
 Acting abnormally41026.524.3–28.836422.520.5–24.630519.717.8–21.8<0.0010.06
 Irritability/agitation563.62.7–4.7412.51.8–3.4312.01.4–2.80.0190.04
 Repeated questioning251.61.0–2.4593.62.8–4.7694.53.5–5.6<0.0010.07
 Slow to respond1016.55.4–7.91106.85.6–8.1936.04.9–7.30.6510.01
 Altered mental state714.63.6–5.8805.03.9–6.1926.04.8–7.20.2120.03
 Seizure 291.91.3–2.7241.51.0–2.2533.42.6–4.50.0010.06
 Suspicion of depressed fracture00.00.0–0.200.00.0–0.200.00.0–0.2
 Signs of base of skull fracture50.30.1–0.840.20.1–0.680.50.2–1.00.4310.02
 Scalp hematoma54835.433.1–37.951131.629.3–33.941026.524.3–28.8<0.0010.08
 Positive neurology*352.31.6–3.1674.13.2–5.2785.04.0–6.3<0.0010.06
Median LOS in days 15443.01.8–4.916123.42.1–5.415373.62.4–5.7<0.0010.01
Admitted480 31.028.7–33.4552 34.131.8–36.5558 36.133.7–38.50.0110.04
 Ward785.04.0–6.31298.06.7–9.41489.68.2–11.1<0.0010.10
 SSU40726.324.1–28.643026.624.5–28.841126.624.4–28.9<0.0010.11
Observed 4+ hrs52033.631.3–36.163239.136.7–41.564441.739.2–44.2<0.0010.07
Admitted/observed 4+ hrs63140.838.4–43.374546.143.6–48.575849.046.5–51.6<0.0010.07
CT scan22414.512.8–16.326316.314.5–18.232220.818.8–22.9<0.0010.07

Boldface type indicates statistical significance.

Motor, sensory, coordination, or reflex abnormality.

Median value.

Interquartile range.

TABLE 3.

Characteristics of 4707 concussion patients by sex

FactorMaleFemalep ValueEffect Size
No.%95% CINo.%95% CI
No. of patients3304 70.2140329.8
Mean age in yrs 330411.1*11.0–11.2140310.5*10.3–10.6<0.0010.20
Median age in yrs (IQR)330411.48.3–13.9140310.47.4–13.3<0.0010.01
GCS score
 13421.30.9–1.7151.10.6–1.80.6850.01
 141705.14.4–6.0664.73.7–5.9
 15309293.692.7–94.4132294.292.9–95.4
Mechanism of injury
 Pedestrian struck by moving vehicle371.10.8–1.5382.71.9–3.7<0.0010.06
 Bike rider struck by automobile70.20.1–0.420.10.0–0.50.619−0.01
 Motor vehicle related1424.33.6–5.0876.25.0–7.60.0060.04
 Object struck head, accidental40112.111.0–13.31178.36.9–9.9<0.001−0.06
 Fall from bicycle (no helmet)1033.12.6–3.8302.11.4–3.00.064−0.03
 Playing53216.114.9–17.4886.35.1–7.7<0.001−0.13
 Other/unknown39411.910.8–13.117312.310.7–14.20.6960.01
 Fall168851.149.4–52.886861.959.3–64.4<0.0010.10
  ≤1 m95528.927.4–30.545132.129.7–34.70.0560.06
  >1 m42112.711.6–13.922516.014.2–18.1
  >1.5 m2327.06.2–7.915511.09.5–12.8
  >3 m300.90.6–1.3151.10.6–1.8
  Unknown501.51.1–2.0221.61.0–2.4
SRC 163049.347.6–51.142830.528.1–33.0<0.001−0.17
Symptom
 Vomiting83325.223.7–26.744932.029.6–34.5<0.0010.07
 Headache212164.262.5–65.891865.462.9–67.90.4600.01
 LOC 79424.022.6–25.526118.616.6–20.7<0.001−0.06
 Amnesia108632.931.3–34.532723.321.1–25.6<0.001−0.10
 Abnormal drowsiness1955.95.1–6.8604.33.3–5.50.026−0.03
 Disorientation128538.937.2–40.641729.727.3–32.2<0.001−0.09
 Acting abnormally77423.422.0–24.930521.719.6–24.00.247−0.02
 Irritability/agitation932.82.3–3.4352.51.7–3.50.561−0.01
 Repeated questioning1133.42.8–4.1402.92.0–3.90.327−0.01
 Slow to respond2206.75.8–7.6846.04.8–7.40.416−0.01
 Altered mental state1785.44.6–6.2654.63.6–5.90.298−0.02
 Seizure 742.21.8–2.8322.31.6–3.20.9390.00
 Suspicion of depressed fracture00.00.0–0.100.00.0–0.3
 Signs of base of skull fracture110.30.2–0.660.40.2–0.90.6220.01
 Scalp hematoma101430.729.1–32.345332.329.8–34.80.2900.02
 Positive neurology§1173.52.9–4.2634.53.5–5.70.1310.02
Median LOS in days 32913.32.1–5.214003.32.1–5.90.2770.00
Admitted1124 34.032.4–35.7466 33.230.8–35.70.593−0.01
 Ward2317.06.1–7.91248.87.4–10.40.0100.06
 SSU90127.325.8–28.834724.722.5–27.10.007−0.07
Observed 4+ hrs125137.936.2–39.554538.836.3–41.50.5550.01
Admitted/observed 4+ hrs150245.543.8–47.263245.042.4–47.70.7940.00
CT scan57817.516.2–18.823116.514.6–18.50.392−0.01

Two cases were missing sex data. Boldface type indicates statistical significance.

Mean value with standard deviation.

Median value.

Interquartile range.

Motor, sensory, coordination, or reflex abnormality.

Mechanism of Injury

Falls were the predominant mechanism of injury (54.3%, 95% CI 52.9–55.8), most from a height ≤ 1 m (29.9%, 95% CI 28.6–31.2), followed by playing (13.2%, 95% CI 12.2–14.2). While the proportion of children sustaining concussion from falls decreased with increasing age (5–8 years = 66.7%, 9–12 years = 53.2%, 13 to < 18 years = 43.1%), the proportion that sustained concussion while playing increased with age (5–8 years = 3.0%, 9–12 years = 14.6%, 13 to < 18 years = 21.8%). The number of concussions resulting from an object striking the head also increased with age (5–8 years = 6.2%, 9–12 years = 11.0%, 13 to < 18 years = 15.8%), as did the number of motor vehicle accident–related concussions (5–8 years = 2.9%, 9–12 years = 5.5%, 13 to < 18 years = 6.1%). Examination of sex differences revealed that a higher proportion of males than females sustained a concussion while playing (16.1%, 95% CI 14.9–17.4 vs 6.3%, 95% CI 5.1–7.7) and after an object struck the head (12.1%, 95% CI 11.0–13.3 vs 8.3%, 95% CI 6.9–9.9).

SRC accounted for 43.7% (95% CI 42.3–45.2) of concussions across all ages. The frequencies and rates of SRC and non-SRC are shown in Fig. 2. When examining age groups, non-SRC decreased with age, whereas SRC increased with age, with a peak at 14 years old. Within the 5- to 8-year subgroup, 19.1% (95% CI 17.2–21.1) had SRC, whereas 48.9% (95% CI 46.5–51.4) of the 9–12 years and 63.0% (95% CI 60.5–65.4) of the 13–18 years groups had SRCs. The proportion of SRCs was higher for males (49.3%, 95% CI 47.6–51.1) than females (30.5%, 95% CI 28.1–33.0).

FIG. 2
FIG. 2

Frequencies and rates of SRC and non-SRC by age.

Injury-Related Characteristics

More than 90% of concussed patients had a GCS score of 15 at ED presentation regardless of age group or sex. The most common acute symptoms were headache (64.6%, 95% CI 63.2–65.9), disorientation (36.2%, 95% CI 34.8–37.6), amnesia (30.0%, 95% CI 28.7–31.4), and vomiting (27.2%, 95% CI 26.0–28.5). Figure 3 shows the proportion of each age group that displayed each sign and symptom. When subgroups were considered, headache remained the most common symptom in all ages, whereas disorientation and amnesia remained the next most common symptoms for all but the youngest subgroup. Vomiting was more commonly observed among 5- to 8-year-olds (41.7%, 95% CI 39.2–44.2) and decreased with age (9–12 years = 24.7%, 95% CI 22.7–26.9; 13 to < 18 years = 15.4%, 95% CI 13.6–17.3). A small decrease in the proportion of youth presenting with abnormal drowsiness was also observed with increasing age (5–8 years = 7.1%, 95% CI 5.8–8.4; 9–12 years = 4.9%, 95% CI 3.9–6.1; 13 to < 18 years = 4.3%, 95% CI 3.4–5.5). LOC was reported among 22.4% (95% CI 21.2–23.6) of the total sample and was increasingly observed with age. Only 9.6% (95% CI 8.2–11.2) of children aged 5–8 years had LOC, whereas 21.0% (95% CI 19.0–23.0) and 36.7% (95% CI 34.3–39.2) of those in the 9–12 and the 13 to < 18 subgroups, respectively, had LOC. Amnesia followed a similar trajectory, present in 18.8% of 5- to 8-year-olds (95% CI 16.9–20.9), 31.0% (95% CI 28.8–33.4) of 9- to 12-year-olds, and 40.2% (95% CI 37.7–42.7) of 13- to 18-year-olds. Significant differences between age groups were also observed for headache and disorientation, both increasing in rate with increasing age. Symptom profiles were broadly similar between males and females. However, females were more likely than males to present with vomiting (32.0%, 95% CI 29.6–34.5 vs 25.2%, 95% CI 23.7–26.7), and a higher proportion of males presented with disorientation (38.9%, 95% CI 37.2–40.6 vs 29.7%, 95% CI 27.3–32.2), amnesia (32.9%, 95% CI 31.3–34.5 vs 23.3%, 95% CI 21.1–25.6), and LOC (24.0%, 95% CI 22.6–25.5 vs 18.6%, 95% CI 16.6–20.7).

FIG. 3
FIG. 3

Signs and symptoms by age group.

Clinical Management

Overall, 33.8% (95% CI 32.4–35.1) of the sample was admitted to the hospital, 26.5% (95% CI 25.2–27.8) to a short stay unit, and 7.5% (95% CI 6.8–8.3) to a ward. The proportion of admissions demonstrated a small increase with increasing age (5–8 years = 31.0%, 95% CI 28.7–33.4; 9–12 years = 34.1%, 95% CI 31.8–36.5; 13–18 years = 36.1%, 95% CI 33.7–38.5), although it was similar for males and females (34.0, 95% CI 32.4–35.7 vs 33.2, 95% CI 30.8–35.7, respectively). Among the entire sample, 38.1% were observed for over 4 hours. The proportion of children observed for over 4 hours increased with age (5–8 years = 33.6%, 95% CI 31.3–36.1; 9–12 years = 39.1%, 95% CI 36.7–41.5; 13–18 years = 41.7%, 95% CI 39.2–44.2) but did not differ between the sexes (males = 37.9%, 95% CI 36.2–39.5; females = 38.8%, 95% CI 36.3–41.5).

Approximately 17% (95% CI 16.1–18.3) of the total concussion sample underwent CT scanning compared with 1.8% (95% CI 1.3–2.3) of those who did not meet our concussion criteria. CT scan rates increased with age, with 14.5% (95% CI 12.8–16.3) of 5- to 8-year-olds, 16.3% (95% CI 14.5–18.2) of 9- to 12-year-olds, and 20.8% (95% CI 18.8–22.9) of 13- to 18-year-olds having CT. Rates of CT were similar for males and females. Consistent with study inclusion and exclusion criteria, all CT scans were normal.

Discussion

Using prospectively collected data, this study provides insight into the epidemiological profile of pediatric concussion across the age spectrum presenting to multiple EDs. It illuminates the differences in concussion presentations between younger and older age groups, which are often neglected in existing epidemiological studies. Overall, acute signs and symptoms postinjury, such as headache, disorientation, amnesia, vomiting, and LOC, were broadly similar to those in the published literature.7 Furthermore, our data showed markedly different patterns within the age bands reported, with high levels of vomiting in young children, which decreased with increasing age, and lower levels of LOC and amnesia in young children, which increased with age.

The number of overall mild head injury presentations, characterized by both concussed and nonconcussed patients, is consistent with those in prior studies showing that around 90% of head injury presentations are mild.2,22,30 Within the present study group, approximately 40% did not meet our defined concussion criteria. This may be a consequence of the limited symptom list adopted to define concussion in our study, which is not sensitive to the full spectrum of symptoms that may be reported in other studies.14

Males accounted for 70% of total concussions, consistent with rates in previous ED-based studies.3,19,22,23,31 Recent studies have identified sex differences in SRC incidence, with females more likely to sustain a concussion than males participating in the equivalent sport.3234 In our data, females were less likely to present with SRC. However, as this is not a population-based study, we do not report the incidence of SRC by sex, and the denominator of sports participation by sex is unknown. The reason for this difference in our data compared with previous studies is unknown, although it may reflect different referral patterns or self-presenting behaviors for concussed males and females, with concussed females less likely to present to EDs. Further, there may be more regulated codes for concussion and head injury management in male organized sport codes.

Female sex has also been associated with an increased concussion symptom load.14,35 However, in our large data set, the profiles of signs and symptoms were broadly similar between males and females, with vomiting the only symptom observed among females at a significantly higher rate than in males. A significantly higher proportion of males demonstrated LOC, amnesia, and disorientation. Evidence of an increased acute concussion symptom load among females is largely derived from studies utilizing parent- or child-rated symptom reports.3638 This is in comparison to our clinician-rated data, which may explain some of the discrepancy between these findings. Differences may also be related to other methodological differences. For example, studies that have reported sex differences often rely on total symptom scores, symptom domain aggregates, or the total number of reported symptoms,3638 none of which examine rates of individual symptom reports and differences in symptom profiles. Our study provides unique information on individual symptom expression by sex.

Falls were the predominant mechanism implicated in concussion, consistent with findings from previous studies examining mild3,19 and all severities of pediatric TBI.30 The proportion sustaining a fall-related concussion decreased with age, whereas a clear increase in a sport-related mechanism of injury was observed with increasing age. This pattern is not unique to this study.3,24 Other studies within Australia and New Zealand, as well as internationally, have demonstrated an increased rate of hospital presentations for sport-related head injury with increasing age.2,22,23,31 SRC accounted for more than 40% of total concussions and over 60% of concussions for those 13 to < 18 years old. SRCs more than doubled from the 5–8 years group to the 9–12 years group, which could be reflective of the age at which children commence team and contact sports.39 A peak in SRCs at 14 years of age followed by a small decrease may be reflective of adolescent presentations to EDs other than those involved in our study (e.g., nonpediatric-specific EDs), particularly given that 15- to 17-year-olds are shown to have the highest participation rates in organized sports and physical recreation.40

Nearly half the sample were either admitted or observed for ≥ 4 hours, and 17% of concussed patients had CT imaging. Acute CT utilization has been associated with the clinical presentation of signs or symptoms indicative of more severe injury including LOC, posttraumatic amnesia, vomiting, headache, or arousal-stimulation symptoms.41 While the imaging rate for our group is higher than the 10% CT rate in the overall APHIRST cohort,28 it is lower than CT rates internationally (e.g., North America: 23%,24 40.4%,6 and 69%23 of concussion ED presentations imaged). Importantly, validated clinical decision rules28 help to address the uncertainty around whether youths should undergo cranial CT scanning and speak to concerns around the negative effects and resource implications of unnecessary radiation exposure.

This study has some limitations. First, to avoid the challenges associated with appropriate concussion diagnosis in younger and preverbal children, this study was limited to school-age children and therefore does not reflect the profile of emergency presentations for children younger than the age of 5. Second, the study’s concussion definition included a symptom list that did not capture the full spectrum of possible postconcussion symptoms. Consequently, some concussions may have been misdiagnosed and categorized in the nonconcussed group. Concussions considered “sports-related” or occurring in the context of “playing” may have been interpreted differently by clinicians, and the terms could have been used interchangeably, as definitions of these terms were not provided. Finally, the rates of ED visits for mild head injury underestimate true incidence rates given the various points of healthcare entry for this population,5 with many youths not seeking medical care at all. Further, the epidemiology of concussed youth presenting to the ED may differ from that of patients who do not present to the ED (e.g., parents told to consider vomiting as a possible sign of more serious injury). Therefore, the patterns observed in this study are not generalizable beyond tertiary care pediatric EDs. Nevertheless, it is well accepted that the overall burden of concussion injuries is much greater than what is depicted in our data.

Conclusions

Concussion is a significant public health issue and a common injury in youth. Our data demonstrated that a higher proportion of males relative to females present to the ED. Although falls were the overall predominant mechanism of injury, as age increased, the frequency of SRC increased and fall-related injuries decreased. Signs and symptoms differed markedly across age groups, with vomiting decreasing and headache, LOC, amnesia, and disorientation increasing with advancing age. Males and females were broadly similar in their individual symptom presentations, with females only demonstrating significantly higher rates of vomiting.

Acknowledgments

We thank the participating families and emergency department staff and research staff at participating sites.

The study was funded by grants from the National Health and Medical Research Council (project grant GNT1046727, Centre of Research Excellence for Paediatric Emergency Medicine GNT1058560), Canberra, Australia; the Murdoch Children’s Research Institute, Melbourne, Australia; the Emergency Medicine Foundation (EMPJ-11162), Brisbane, Australia; Perpetual Philanthropic Services (2012/1140), Australia; Auckland Medical Research Foundation (No. 3112011) and the A + Trust (Auckland District Health Board), Auckland, New Zealand; WA Health Targeted Research Funds 2013, Perth, Australia; the Townsville Hospital and Health Service Private Practice Research and Education Trust Fund, Townsville, Australia; and supported by the Victorian Government’s Infrastructure Support Program, Melbourne, Australia. Dr. Babl’s time was partly funded by an NHMRC Practitioner Fellowship, Canberra, Australia, and a Melbourne Campus Clinician-Scientist Fellowship, Melbourne, Australia. Dr. Dalziel’s time was partly funded by Cure Kids New Zealand.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Babl. Analysis and interpretation of data: Babl, Rausa. Drafting the article: Babl, Rausa, Lyttle. Critically revising the article: all authors. Reviewed submitted version of manuscript: Babl, Rausa, Borland, Kochar, Phillips, Gilhotra, Dalton, Cheek, Furyk, Neutze, Bressan, Davis, Anderson, Williams, Oakley, Dalziel, Crowe, Hearps. Study supervision: Babl.

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  • Collapse
  • Expand

Image from Reynolds et al (pp 703–709).

  • 1

    Corrigan JD, Selassie AW, Orman JA. The epidemiology of traumatic brain injury. J Head Trauma Rehabil. 2010;25(2):7280.

  • 2

    Crowe L, Babl F, Anderson V, Catroppa C. The epidemiology of paediatric head injuries: data from a referral centre in Victoria, Australia. J Paediatr Child Health. 2009;45(6):346350.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Russo RN, Rice J, Chern PM, Raftos J. Minimal and mild paediatric brain injury: a 3-year cohort of consecutive presentations. Dev Neurorehabil. 2012;15(1):1318.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    McCrory P, Meeuwisse W, Dvořák J, Aubry M, Bailes J, Broglio S, et al. Consensus statement on concussion in sport–the 5th international conference on concussion in sport held in.Berlin, October 2016Br J Sports Med. 2017;51(11):838847.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Arbogast KB, Curry AE, Pfeiffer MR, Zonfrillo MR, Haarbauer-Krupa J, Breiding MJ, et al. Point of health care entry for youth with concussion within a large pediatric care network. JAMA Pediatr. 2016;170(7):e160294.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Zonfrillo MR, Kim KH, Arbogast KB. Emergency department visits and head computed tomography utilization for concussion patients from 2006 to 2011. Acad Emerg Med. 2015;22(7):872877.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Davis GA, Anderson V, Babl FE, Gioia GA, Giza CC, Meehan W, et al. What is the difference in concussion management in children as compared with adults? A systematic review. Br J Sports Med. 2017;51(12):949957.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Stevens PK, Penprase B, Kepros JP, Dunneback J. Parental recognition of postconcussive symptoms in children. J Trauma Nurs. 2010;17(4):178184.

  • 9

    Mannings C, Kalynych C, Joseph MM, Smotherman C, Kraemer DF. Knowledge assessment of sports-related concussion among parents of children aged 5 years to 15 years enrolled in recreational tackle football. J Trauma Acute Care Surg. 2014;77(3)(suppl 1):S18S22.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Haran HP, Bressan S, Oakley E, Davis GA, Anderson V, Babl FE. On-field management and return-to-play in sports-related concussion in children: Are children managed appropriately?. J Sci Med Sport. 2016;19(3):194199.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Weerdenburg K, Schneeweiss S, Koo E, Boutis K. Concussion and its management: What do parents know?. Paediatr Child Health. 2016;21(3):e22e26.

  • 12

    Ganesalingam K, Yeates KO, Ginn MS, Taylor HG, Dietrich A, Nuss K, et al. Family burden and parental distress following mild traumatic brain injury in children and its relationship to post-concussive symptoms. J Pediatr Psychol. 2008;33(6):621629.

    • Crossref
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