The Management of Minor Closed Head Injury in Children

To the Editor. The members of the AAP's Committee on Quality Improvement are to be commended for their recommendations in the management of minor closed head injuries in children.1 Although it is important for pediatricians to be aware of the indications for radiologic investigation and/or neurosurgical intervention, appropriate counseling regarding an adequate amount of recovery time needs to be given to prevent further brain injury.2In the United States, 500 000 head injuries are reported per year and 10% of these occur during recreational sports.3 Although some patients with mild concussions experience loss of consciousness, many have headaches and abnormalities in motor function, vision, sensation, thought processing, memory, or behavior. These symptoms may take days or weeks to disappear.4 Pediatricians are frequently involved in the early assessment period in the sport setting, emergency department, or private clinics. Unfortunately, many will unknowingly permit return to recreational activities before full neurologic recovery has occurred. Should the child or adolescent incur a second head injury before symptoms resolve, there is increased risk for second-impact syndrome. This disorder occurs when a second, often minor, head injury occurs in an individual who has not recovered from a previous concussion. The second impact can lead to a rapid and progressive neurologic collapse accompanied by coma, respiratory failure, and eventual death. The pathophysiology is thought to be related to a disrupted autoregulation of cerebral blood flow leading to increased vascular congestion within the cranium. This results in high intracranial pressure followed by uncal and cerebellar herniation through the foramen magnum. Second-impact syndrome and the effects of cumulative head injury are particularly concerning when athletes minimize neurologic symptoms in hopes of gaining clearance to return to sports.Pediatricians must be sure the child is medically ready to resume full activities and exposure to further injury. Several guidelines have been published that discuss return-to-play criteria based on the number and severity of concussions.5–7 Although variations exist, all guidelines concur that no athlete should return to sport until all concussive symptoms have resolved at rest and with exertion.8Children with minor head trauma should be assessed for radiologic or neurosurgical intervention. In addition, children with head injuries not requiring radiologic or neurosurgical intervention must be carefully evaluated and closely monitored. Patients, parents, and coaches must understand the need to have full resolution of all neurologic symptoms before a safe return to contact or collision sports is possible. The lack of evidence for more severe injury should not be interpreted as evidence of no injury.In Reply. The letter from Dr LeBlanc provides useful and complementary information, regarding children engaged in sports at the time of injury, to the recommendations contained within the guideline for minor closed head injury in children. The case defined in our guideline fits most closely with grade 1 sports-related head injury within the references cited by LeBlanc; that is, minor head injury without neurologic findings on examination. However, our guideline also includes children suffering a “brief loss of consciousness (LOC) defined as less than one minute.” The inclusion of LOC places these cases into grade 2. In the sports-related guidelines referenced by LeBlanc, children whose symptoms resolve within minutes (grade 1) may return to play. For those suffering LOC (grade 2), return to play is not recommended until appropriate evaluation by a physician is completed and the symptoms of any concussion have completely resolved.It is worth noting that in the Genuardi and King articles cited by LeBlanc, appropriate discharge instructions were provided to youths hospitalized for minor head injury in only 30% of those instances where they were indicated. However, instructions were found to be appropriate in all cases where the extent of injury was defined as grade 1.One should also note that second-impact syndrome, mentioned by Dr. LeBlanc and defined as fatal brain swelling occurring after minor head injury in those who still have symptoms from a previous head injury, has only been described in adolescents and adults. This potential in adolescents and adults is important to bear in mind and certainly underscores the importance of allowing symptoms of injury to resolve before risking additional injury, though no reports in the literature describe second-impact syndrome in younger children.Though not explicitly discussed by the subcommittee on head injury in the formation of our guideline, the recommendation to not recommend return to sport until symptoms of concussion have cleared is consistent with the recommendations contained within the guideline on minor head injury in children and should be viewed as a complementary piece of information to our guideline.