Vision, Balance Issues Common Following Concussions in Pediatric Patients

Christina Master, MD

Data from a new retrospective cohort study could prove useful in improving the diagnosis and management of concussions in pediatric patients.

The result of a collaborative effort by investigators from the Children's Hospital of Philadelphia (CHOP) and US Centers for Disease Control and Prevention (CDC), results of the study provide a comprehensive overview of the clinical presentation of concussions in patients aged 5-11 years in old.

"Since one-third of pediatric and adolescent concussion injuries occur in elementary school-age children, we set out to provide a comprehensive description of children ages 5-11 years who were diagnosed with concussion to pinpoint opportunities to improve the quality of diagnosis and care for this age group," said lead investigator Christina Master, MD, a sports medicine pediatrician at CHOP and a senior fellow at the Center for Injury Research and Prevention, in a statement.

With relatively little information available for clinicians to guide delivery of care for young children, Master and a team of colleagues sought to characterize the clinical presentation and course of care using data from children within the CHOP pediatric health care network. Using the network-wide EHR, investigators had access to data from 31 pediatric and adolescent primary care centers, 14 specialty care centers, a 535-bed inpatient hospital, 2 emergency departments, and 2 urgent care centers with more than 1 million visits per year.

Examining EHR data from July 1, 2014-June 30, 2015, investigates identified a total of 1626 patients between the ages of 5-11 years old with a concussion visit. For the purpose of the study, analysis was performed on a simple random sample of 20% of patients, which yielded a cohort of 306 patients.

The investigators’ analyses were designed to assess concussion symptoms across 5 specific categories—somatic symptoms, visio-vestibular symptoms, sleep symptoms, emotional symptoms, and cognitive symptoms. Of note, distributions of race/ethnicity, sex, age, insurance payor, and location of first visit were similar between the randomly selected sample and the entire study cohort.

Overall, 95.9% of patients reported at least 1 somatic symptom, 54.1% reported issues with sleep, and 66.1% reported visio-vestibular symptoms.

Analyses revealed 74.3% of patients had a standardized visio-vestibular assessment performed, including 92.9% of patients who sought subsequent specialty care. Conversely, just 42.9% of patients initially seen in the emergency department or in an urgent care setting underwent such an assessment.

Among patients who underwent a visio-vestibular assessment, 62.7% presented with deficits. Investigators highlighted visio-vestibular deficits were more common in children 9-11 years old than in children 5-8 years old (67.9% vs 53.2%; P=.03). The most commonly observed deficits were in gaze stability (41.7%), tandem gait (40%), and saccades (38.8%).

In regard to treatment, only 11.6% of patients were referred for rehabilitation therapies and just 43.8% were provided with a letter recommending school accommodations. Investigators noted 56.2% had documentation of clearance for return to play/activities at the end of their clinical course.

"Our older youth really benefit from early intervention in the form of school accommodations, return to school and physical activity plans, and vestibular or vision therapy. We believe intervening early can also improve outcomes for younger children diagnosed with visio-vestibular deficits,” Master added in the aforementioned statement.

This study, “Characteristics of Concussion in Elementary School-Aged Children: Implications for Clinical Management,” was published in The Journal of Pediatrics.