Concussion: Why Nurses Need to Understand This Hidden Injury

Ann Worley


Pediatr Nurs. 2019;45(5):235-243. 

In This Article

Unique Dangers to the Pediatric Population

Although most concussion studies have focused on adults, there are anatomical and developmental characteristics that seem to predispose children and adolescents to complications from concussions. The following are physiological reasons for this phenomenon and may serve to increase the threshold of concussion injuries to children:

  • Immature body musculature and ability to support the body's weight (Cantu, 2013; Gillooly, 2016; McBride, 2012; Norton, Feltz, Brocker, & Granitto, 2013).

  • Relative size of an under-developed neck to the size of the head, resulting in a bobble-head doll effect during an impact (Cantu, 2013; McBride, 2012; Norton et al., 2013).

  • Size and thickness of cranial bones. Children's skulls do not reach full strength and thickness until early adolescence (Graham, Rivara, Ford, & Spicer, 2014).

  • Incomplete development of myelin sheath in the central and peripheral nervous system, causing an increased risk of tearing of the nerve fibers (Cantu, 2013; Norton et al., 2013).

  • Greater brain water content and developing vasculature (Gillooly, 2016; Manzanero et al., 2017).

Not only do children and adolescents exhibit physical immaturity, but their rapid brain growth in the areas of concentration, establishing memory patterns, reasoning, problem-solving, and other cognitive skills may further increase their vulnerability to suffer injury. Furthermore, many children have not attained the developmental levels to understand their injury or even acquired the verbal skills to describe symptoms they are experiencing, such as amnesia, nausea, or dizziness (Cook, Bartholomew, Hardy, & Ondeck, 2017).

Evidence also indicates that the pediatric population may experience more protracted recovery periods than adults (Caine, Purcell, & Maffulli, 2014; Fehr et al., 2019; Guskiewicz & Valovich-McLeod, 2011; McCrory et al., 2013). If one considers full recovery as return to baseline with absence of self-reported and measured deficits, most concussion symptoms in all age groups resolve within 7 to 14 days from an uncomplicated injury (Manzanero et al., 2017; McCrory et al., 2013). Although multiple factors, such as pre-morbid conditions, severity of injury, and concussion history, can influence recovery time, 70% to 80% of children with mTBI do not show significant symptoms after 1 to 3 months (CDC, 2016d). It should be noted that the CDC recommends follow up with a neurologist if symptoms persist after 4 to 6 weeks with standard care (CDC, 2018).

According to McCrory and colleagues (2017), adolescents appear to be more vulnerable than both younger and older age groups. Evidence is emerging to indicate that adolescent athletes exhibit more and prolonged concussion symptoms than collegiate or adult athletes (Giza & Hovda, 2014; Manzanero et al., 2017; McBride, 2012). Conversely, in a study by Ransom and colleagues (2015), adolescents recovering from a concussion suffered more adverse academic effects and school-related problems compared with their younger counterparts at the elementary level. A logical explanation for this disparity may be that adolescents often experience numerous academic and social pressures that may be aggravated by the disruptive effects of adverse concussion symptoms and by restrictions imposed during the recovery process.