What are the treatment guidelines for a 6-year-old child with a concussion?

Management of Concussion in a 6-Year-Old Child

For a 6-year-old child with a concussion, use an age-appropriate validated symptom rating scale for diagnosis, provide strict rest for the first several days, then gradually resume activities that don't worsen symptoms, educate the family about warning signs and expected recovery, and coordinate a customized return-to-school plan with medical and school-based teams. 1

Diagnostic Approach

Initial Assessment

• Use an age-appropriate, validated symptom rating scale as a component of the diagnostic evaluation 1
• The Graded Symptom Checklist is useful in distinguishing children 6 years and older with mild traumatic brain injury (mTBI) from those without TBI within the first 2 days after injury 1
• Other validated symptom scales appropriate for this age include the Health and Behavior Inventory and the Post-Concussion Symptom Inventory 1

Imaging Considerations

• Do not use skull radiographs for diagnosis or screening for intracranial injury 1
• Head CT is the appropriate imaging choice only when clinically indicated based on risk factors for intracranial injury 1
• Do not use biomarkers outside of a research setting for diagnosis 1

Acute Management and Activity Restrictions

Initial Rest Period (First Several Days)

• Counsel the patient and family to observe more restrictive physical and cognitive activity during the first several days after injury 1
• This initial rest period is beneficial immediately after mTBI and may help accelerate recovery in those who are slow to recover 1
• The postinjury period represents a window of vulnerability for reinjury because the reinjury threshold is lower during recovery 1

Gradual Activity Resumption

• Following the first several days, counsel patients and families to resume a gradual schedule of activity that does not exacerbate symptoms, with close monitoring of symptom expression (number and severity) 1
• After successful resumption of gradual activity, offer an active rehabilitation program of progressive reintroduction of noncontact aerobic activity that does not exacerbate symptoms 1
• Counsel patients to return to full activity when they return to premorbid performance if they have remained symptom-free at rest and with increasing levels of physical exertion 1

Important caveat: Inactivity beyond the first 3 days may worsen self-reported symptoms in most children, so prolonged strict rest is not recommended 1

Family Education (Critical Component)

Required Educational Elements

Provide comprehensive education to the family that includes: 1

• Warning signs of more serious injury requiring immediate medical attention 1
• Description of the injury and expected course of symptoms and recovery 1
• Instructions on how to monitor postconcussive symptoms 1
• Prevention of further injury 1
• Management of cognitive and physical activity/rest 1
• Instructions regarding return to play/recreation and school 1
• Clear clinician follow-up instructions 1

Monitoring and Prognosis

Risk Assessment

• Closely monitor children determined to be at high risk for persistent symptoms based on their premorbid history, demographics, and/or injury characteristics 1
• Most children with mTBI experience symptom resolution within 1 to 3 months after injury 1
• For children whose symptoms do not resolve as expected with standard care (within 4-6 weeks), provide or refer for appropriate assessments and/or interventions 1

Psychosocial Support

• Assess the extent and types of social support (emotional, informational, instrumental, and appraisal) available to the child 1
• Emphasize social support as a key element in the education of caregivers and educators 1

Return to School Protocol

Gradual Academic Reintegration

• Medical and school-based teams should counsel the student and family regarding the process of gradually increasing the duration and intensity of academic activities as tolerated, with the goal of increasing participation without significantly exacerbating symptoms 1
• Return-to-school protocols should be customized based on the severity of postconcussion symptoms as determined jointly by medical and school-based teams 1

Educational Supports

• For any student with prolonged symptoms that interfere with academic performance, school-based teams should assess educational needs and determine the need for additional educational supports, including those described under federal statutes (e.g., Individuals With Disabilities Education Act §504) 1
• Postconcussion symptoms and academic progress should be monitored collaboratively by the student, family, health care professional(s), and school teams 1
• The provision of educational supports should be monitored and adjusted as needed 1

Common Pitfalls to Avoid

• Do not prescribe prolonged strict rest beyond the first several days, as this may worsen symptoms rather than improve them 1
• Do not allow return to play while the child is still symptomatic, as approximately 35% of patients who returned to activities at 2 weeks were still symptomatic, and many did not receive medical clearance 2
• Do not use computerized cognitive testing as the sole diagnostic tool in this age group; it may be used as a component but is more validated in high school athletes 1
• Do not routinely order neuroimaging unless there are clinical risk factors for intracranial injury 1