Objective To identify pre-existing characteristics associated with prolonged recovery from concussion in a sample of patients referred to a pediatric sports medicine clinic. Study design This was a retrospective, exploratory cohort study of 247 patients age 5-18 years old with concussion referred to a tertiary pediatric hospital-affiliated sports medicine clinic from July 1, 2010, through December 31, 2011. A random sample of all eligible patient visits (3740) was chosen for further review and abstraction. Statistical comparisons between subsets of patients were conducted using exact chi-square tests, logistic regression, quantile regression, and Kaplan Meier survival curves. Results The median time until returning to school part-time was 12 days (interquartile range (IQR) 6-21); until returning to school full-time without accommodations was 35 days (IQR 11-105); until becoming symptom-free was 64 days (IQR 18-119); and until being fully cleared to return to sports was 75 days (IQR 30-153). 73% of all patients were symptomatic for >4 weeks, 73% were prescribed some form of school accommodation, and 61% reported a decline in grades. Characteristics associated with a prolonged recovery included a history of depression or anxiety; an initial complaint of dizziness; abnormal convergence or symptom provocation following oculomotor examination on physical examination; and history of prior concussion. Conclusion Pediatric and adolescent patients with concussion may experience cognitive and emotional morbidity that can last for several months following injury. Clinicians should consider specific pre-existing characteristics and presenting symptoms that may be associated with a more complicated recovery for concussion patients.

Objective To characterize the prevalence and recovery of pediatric patients with concussion who manifest clinical vestibular deficits, and to describe the correlation of these deficits with neurocognitive function, based on computerized neurocognitive testing, in a sample of pediatric patients with concussion. Methods This was a retrospective cohort study of patients age 5–18 years old with concussion referred to a tertiary pediatric hospital-affiliated sports medicine clinic from 7/1/2010–12/31/2011. A random sample of all eligible patient visits was obtained, and all related visits for those patients were reviewed. Results 247 patients were chosen from 3740 eligible visits for detailed review and abstraction. 81% showed a vestibular abnormality on initial clinical exam. Those patients with vestibular signs on initial exam took a significantly longer time to return to school (median 59 days vs. 6 days, p=0.001) or to be fully cleared (median 106 days vs. 29 days, p=0.001). They additionally scored more poorly on initial computerized neurocognitive testing, and took longer for neurocognitive deficits to recover. Those patients with three or more prior concussions had a higher prevalence of vestibular deficits and took longer for those deficits to resolve. Conclusion Vestibular deficits in children and adolescents with a history of concussion are highly prevalent. These deficits appear to be associated with extended recovery times and poorer performance on neurocognitive testing. Further studies evaluating the effectiveness of vestibular therapy on improving such deficits are warranted.

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Objective: Up to one-third of children with concussion have persistent postconcussion symptoms lasting beyond 4 weeks. Females have been shown to have prolonged concussion recovery compared with males. This study examined characteristics in pediatric athletes with concussion to investigate the underlying factors that may contribute to this difference and their relation to recovery trajectories in females compared with males. Design: A retrospective cohort study of pediatric patients with sports-related concussion (SRC). Setting: A subspecialty pediatric concussion program. Subjects: One hundred ninety-two records were reviewed, 75 females and 117 males, ages 7 to 18 years old. Assessment of Risk Factors: Sex of patient, time to presentation to specialty care after injury, presence of vision, and vestibular deficits on initial clinical examination. Main Outcome Measures: The main outcome of interest was time to clinical recovery, defined by resolution of symptoms, recovery of physical examination deficits, including vision and vestibular examination, recovery of neurocognitive function, and return to school, exercise, and sport. Results: Pediatric females, on average, presented later to specialty care for evaluation after SRC than males. Females also took longer to recover on 5 markers of recovery: time to return to school without accommodations, time to return to noncontact exercise, time to return to full sport, time to recovery of neurocognitive function on computerized testing, and time to clinical recovery of vision and vestibular deficits on examination including smooth pursuits, saccades, gaze stability, near point of convergence, and balance. These sex-based differences in recovery disappeared when controlling for time to presentation to specialty care. Conclusions: In this cohort of pediatric patients, ages 7 to 18 years old with SRC, females took longer to recover than males. Our results indicate, however, that a modifiable extrinsic factor, time to presentation to specialty care, may contribute to this difference in recovery between the sexes.

A structured intervention, tailored to pain management shortcomings commonly found in the pediatric ED, can lead to improvements in the treatment and prevention of pain in childhood emergencies.