clinicaltrials.gov Identifier: NCT00621478.

IMPORTANCE Soccer, originally introduced as a safer sport for children and adolescents, has seen a rapid increase in popularity in the United States over the past 3 decades. Recently, concerns have been raised regarding the safety of soccer ball heading (when an athlete attempts to play the ball in the air with his or her head) given the rise in concussion rates, with some calling for a ban on heading among soccer players younger than 14 years. OBJECTIVES To evaluate trends over time in boys' and girls' soccer concussions, to identify injury mechanisms commonly leading to concussions, to delineate soccer-specific activities during which most concussions occur, to detail heading-related soccer concussion mechanisms, and to compare concussion symptom patterns by injury mechanism. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of longitudinal surveillance data collected from 2005-2006 through 2013-2014 in a large, nationally representative sample of US high schools. Participants were boys and girls who were high school soccer players. EXPOSURES Concussions sustained during high school-sanctioned soccer games and practices. MAIN OUTCOMES AND MEASURES Mechanism and sport-specific activity of concussion.RESULTS Overall, 627 concussions were sustained during 1 393 753 athlete exposures (AEs) among girls (4.50 concussions per 10 000 AEs), and 442 concussions were sustained during 1 592 238 AEs among boys (2.78 concussions per 10 000 AEs). For boys (68.8%) and girls (51.3%), contact with another player was the most common concussion mechanism. Heading was the most common soccer-specific activity, responsible for 30.6% of boys' concussions and 25.3% of girls' concussions. Contact with another player was the most common mechanism of injury in heading-related concussions among boys (78.1%) and girls (61.9%). There were few differences in concussion symptom patterns by injury mechanism. CONCLUSIONS AND RELEVANCEAlthough heading is the most common activity associated with concussions, the most frequent mechanism was athlete-athlete contact. Such information is needed to drive evidence-based, targeted prevention efforts to effectively reduce soccer-related concussions. Although banning heading from youth soccer would likely prevent some concussions, reducing athlete-athlete contact across all phases of play would likely be a more effective way to prevent concussions as well as other injuries.

TBI occurs frequently among homeless young people and is a marker of adverse outcomes such as mental health difficulties, suicidal behavior, substance use, and victimization.

BACKGROUND: Computed tomography (CT) is commonly used for children when there is concern for traumatic brain injury (TBI) and is a significant source of ionizing radiation. Our objective was to determine the feasibility and accuracy of fast MRI (motion-tolerant MRI sequences performed without sedation) in young children. METHODS: In this prospective cohort study, we attempted fast MRI in children ,6 years old who had head CT performed and were seen in the emergency department of a single, level 1 pediatric trauma center. Fast MRI sequences included 3T axial and sagittal T2 single-shot turbo spin echo, axial T1 turbo field echo, axial fluid-attenuated inversion recovery, axial gradient echo, and axial diffusion-weighted single-shot turbo spin echo planar imaging. Feasibility was assessed by completion rate and imaging time. Fast MRI accuracy was measured against CT findings of TBI, including skull fracture, intracranial hemorrhage, or parenchymal injury. RESULTS: Among 299 participants, fast MRI was available and attempted in 225 (75%) and completed in 223 (99%). Median imaging time was 59 seconds (interquartile range 52-78) for CT and 365 seconds (interquartile range 340-392) for fast MRI. TBI was identified by CT in 111 (50%) participants, including 81 skull fractures, 27 subdural hematomas, 24 subarachnoid hemorrhages, and 35 other injuries. Fast MRI identified TBI in 103 of these (sensitivity 92.8%; 95% confidence interval 86.3-96.8), missing 6 participants with isolated skull fractures and 2 with subarachnoid hemorrhage. CONCLUSIONS: Fast MRI is feasible and accurate relative to CT in clinically stable children with concern for TBI.

WHAT'S KNOWN ON THIS SUBJECT: Children are often evaluated in the emergency department after a concussion. Although prolonged symptoms are associated with higher initial symptom severity when measured 2 to 3 weeks after injury, a similar association with acute symptom severity has not been demonstrated. WHAT THIS STUDY ADDS:Higher acute symptom severity is not associated with development of persistent post-concussion symptoms 1 month after injury, but persistent post-concussive symptoms affect a significant number of children after concussion. Outpatient follow-up is essential to identify children who develop persistent symptoms. abstract BACKGROUND AND OBJECTIVES: Up to 30% of children who have concussion initially evaluated in the emergency department (ED) display delayed symptom resolution (DSR). Greater initial symptom severity may be an easily quantifiable predictor of DSR. We hypothesized that greater symptom severity immediately after injury increases the risk for DSR. METHODS:We conducted a prospective longitudinal cohort study of children 8 to 18 years old presenting to the ED with concussion. Acute symptom severity was assessed using a graded symptom inventory. Presence of DSR was assessed 1 month later. Graded symptom inventory scores were tested for association with DSR by sensitivity analysis. We conducted a similar analysis for post-concussion syndrome (PCS) as defined by the International Statistical Classification of Diseases and Related Health Problems, 10th revision. Potential symptoms characteristic of DSR were explored by using hierarchical cluster analysis. RESULTS:We enrolled 234 subjects; 179 (76%) completed follow-up. Thirtyeight subjects (21%) experienced DSR. Initial symptom severity was not significantly associated with DSR 1 month after concussion. A total of 22 subjects (12%) had PCS. Scores .10 (possible range, 0-28) were associated with an increased risk for PCS (RR, 3.1; 95% confidence interval 1.2-8.0). Three of 6 of the most characteristic symptoms of DSR were also most characteristic of early symptom resolution. However, cognitive symptoms were more characteristic of subjects reporting DSR.CONCLUSIONS: Greater symptom severity measured at ED presentation does not predict DSR but is associated with PCS. Risk stratification therefore depends on how the persistent symptoms are defined. Cognitive symptoms may warrant particular attention in future study. Follow-up is recommended for all patients after ED evaluation of concussion to monitor for DSR. Dr Grubenhoff conceptualized and designed the study, designed the database, oversaw data collection and analysis, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Deakyne performed the primary statistical analysis, assisted with study design and database design, managed study personnel in recruitment and data acquisition, and co-authored, reviewed, and revised the manuscript; Ms Brou assisted with the cluster analysis and drafting and reviewed and revised the manuscript; Dr Bajaj assisted with study design and ...

The graded symptom checklist reliably identified mTBI symptoms for all children aged 6 years and older. SAC scores tended to be lower for case-patients compared with controls but did not reach significance. Patients with altered mental status at the time of injury manifest an increased number and severity of symptoms. Additional research into strategies to identify cognitive deficits related to mTBI and classify mTBI severity in children is needed.

Objective To describe differences in outpatient follow-up and academic accommodations received by children with and without persistent post-concussion symptoms (PPCS) after emergency department (ED) evaluation. We hypothesised that children with PPCS would have more outpatient visits and receive academic accommodations more often than children without PPCS and that follow-up would be positively associated with receiving accommodations. Methods Children aged 8–18 years with acute (≤6 hours) concussion at time of presentation to a paediatric ED were enrolled in an observational study. Outcomes were assessed though telephone survey 30 days after injury. Results Of 234 enrolled participants, 179 (76%) completed follow-up. PPCS occurred in 21%. Only 45% of subjects had follow-up visits after ED discharge. Follow-up visit rates were similar for those with and without PPCS (58% vs. 41% respectively; p=0.07). Children with PPCS missed twice as many school days as those without (3 vs 1.5; p<0.001) but did not differ in receiving academic accommodations (36% vs 53%; p=0.082). Outpatient follow-up was associated with receiving academic accommodations (RR 2.2; 95% CI 1.4–3.5). Conclusions Outpatient follow-up is not routine for concussed children. Despite missing more school days, children with PPCS do not receive academic accommodations more often. Outpatient follow-up may facilitate academic accommodations.

Objective To characterize t h e psychological factors associated with persistent symptoms following pediatric concussion. Study design Longitudinal cohort study of 179 concussed children 8–18 years old evaluated in a pediatric emergency department. Participants were followed for one month for delayed symptom resolution defined as ≥3 symptoms that were new/worse than pre-injury symptoms measured using graded symptom inventory. Pre-injury psychological traits were measured by parental report on subscales of the Personality Inventory for Children-2 (maladjustment, cognitive abilities, somatization). Child report of post-injury anxiety and injury perception were measured using State-Trait Anxiety Inventory for Children (STAIC) and Children’s Illness Perception Questionnaire. Psychological instrument scores were compared between those with and without DSR using a Kruskal-Wallis test. Associations between psychological traits and DSR were investigated using logistic regression. Results DSR occurred in 21% of participants. Score distributions were significantly worse on the STAIC [38 (IQR 33–40) vs 35 (IQR 31–39); p=0.04] and somatization subscale [1 (IQR 0–3) vs 1 (IQR 0–1); p=0.01] among children with DSR compared with children with early symptom resolution (ESR). Somatization was associated with DSR [adjusted odds ratio (OR) 1.35, 95% CI: 1.08– 1.69]. The proportion of children with abnormal somatization scores was significantly higher in the DSR group (34.2%) than the ESR group (12.8%; p<0.01). Other psychological measures were not different between groups. Conclusion Somatization is associated with delayed symptom resolution in this cohort of concussed children. Post-concussive symptoms lasting at least one month may warrant referral to a neuropsychologist familiar with post-concussion care.