Characterizing Hospitalizations for Pediatric Concussion and Trends in Care

From 2007 to 2014, approximately 15% of children admitted to PHIS hospitals for TBI were admitted primarily for concussion. Since almost all children had a head AIS score of 2 and an ISS ≤ 4, our data suggest that most children had an associated loss of consciousness and that concussion was the only injury sustained, respectively. This study identified important subgroups that necessitated inpatient care but are rarely the focus of concussion research (eg, toddlers and those injured due to a motor vehicle collision). Most children (83.3%) received medications to treat common postconcussive symptoms (eg, pain and nausea), with almost half receiving 3 or more medication classes. Factors associated with the development of postconcussive syndrome (eg, female sex and adolescent age)^4,21 were significantly associated with hospitalization of 2 or more days and ED revisit within 30 days of admission. In the absence of evidenced-based guidelines for inpatient concussion management, we identified significant trends in care, including increased use of specific pain [ie, oral and IV nonsteroidal anti-inflammatory drugs (NSAIDs)] and antiemetic (ie, ondansetron) medications and decreased use of head CT. Given the number of children admitted and receiving treatment for concussion symptomatology, influences on the decision to deliver specific care practices, as well as the impact and benefit of hospitalization, require closer examination.

Our study extends previous reports from the PHIS database by characterizing children admitted for concussion.¹ We found that children admitted for concussion had similar characteristics to the broader population of children who sustain concussion (eg, school-aged children, male, and injured due to a fall or during sports).^1,3,22 However, approximately 20% of the cohort were less than 5 years old, and less is known regarding appropriate treatment and outcomes of concussion in this age group.²³ Uncertainty regarding optimal management and a young child’s inability to articulate symptoms may contribute to a physician’s decision to admit for close observation. Similar to Blinman et al., we found that a substantial proportion of children admitted with concussion were injured due to a motor vehicle collision,³ suggesting that although sports-related injuries are responsible for a significant proportion of pediatric concussions, children injured by other preventable mechanisms may also be incurring significant concussive injuries. Finally, the majority of our cohort was from an urban core, relative to a rural area, which is likely a reflection of the regionalization of trauma care, as well as variations in access to health care.

Although most children recover fully from concussion without specific interventions, 20%-30% may remain symptomatic at 1 month,^3,4,21,24 and children who are hospitalized with concussion may be at higher risk for protracted symptoms. While specific individual or injury-related factors (eg, female sex, adolescent age, and injury due to motor vehicle collision) may contribute to more significant postconcussive symptoms, it is unclear how inpatient management affects recovery trajectory. Frequent sleep disruptions associated with inpatient care²⁵ contradict current acute concussion management recommendations for physical and cognitive rest²⁶ and could potentially impair symptom recovery. Additionally, we found widespread use of NSAIDs, although there is evidence suggesting that NSAIDs may potentially worsen concussive symptoms.²⁶ We identified an increase in medication usage over time despite limited evidence of their effectiveness for pediatric concussion.^27–29 This change may reflect improved symptom screening^4,30 and/or increased awareness of specific medication safety profiles in pediatric trauma patients, especially for NSAIDs and ondansetron. Although we saw an increase in NSAID use, we did not see a proportional decrease in narcotic use. Similarly, while two-thirds of our cohort received IV medications, there is controversy about the need for IV fluids and medications for other pediatric illnesses, with research demonstrating that IV treatment may not reduce recovery time and may contribute to prolonged hospitalization and phlebitis.^31,32 Thus, there is a need to understand the therapeutic effectiveness and benefits of medications and fluids on postconcussion recovery.

Neuroimaging rates for children receiving ED evaluation for concussion have been reported to be up to 60%-70%,^1,22 although a more recent study spanning 2006 to 2011 found a 35-%–40% head CT rate in pediatric patients by hospital-based EDs in the United States.³³ Our results appear to support decreasing head CT use over time in pediatric hospitals. Hospitalization for observation is costly¹ but could decrease a child’s risk of malignancy from radiation exposure. Further work on balancing cost, risk, and shared decision-making with parents could guide decisions regarding emergent neuroimaging versus admission.

This study has limitations inherent to the use of an administrative dataset, including lack of information regarding why the child was admitted. Since the focus was to describe inpatient care of children with concussion, those discharged home from the ED were not included in this dataset. Consequently, we could not contrast the ED care of those discharged home with those who were admitted or assess trends in admission rates for concussion. Although the overall number of concussion admissions has continued to remain stable over time,¹ due to a lack of prospectively collected clinical information, we are unable to determine whether observed trends in care are secondary to changes in practice or changes in concussion severity. However, there has been no research to date supporting the latter. Ethnicity was excluded due to high levels of missing data. Cost of stay was not extensively analyzed given hospital variation in designation of observational or inpatient status, which subsequently affects billing.³⁴ Rates of neuroimaging and ED revisit may have been underestimated since children could have received care at a non-PHIS hospital. Similarly, the decrease in the proportion of children receiving neuroimaging over time may have been associated with an increase in children being transferred from a non-PHIS hospital for admission, although with increased regionalization in trauma care, we would not expect transfers of children with only concussion to have significantly increased. Finally, data were limited to the pediatric tertiary care centers participating in PHIS, thereby reducing generalizability and introducing selection bias by only including children who were able to access care at PHIS hospitals. Although the care practices we evaluated (eg, NSAIDs and head CT) are available at all hospitals, our analyses only reflect care delivered within the PHIS.

Concussion accounted for 15% of all pediatric TBI admissions during our study period. Further investigation of potential factors associated with admission and protracted recovery (eg, adolescent females needing treatment for severe symptomatology) could facilitate better understanding of how hospitalization affects recovery. Additionally, research on acute pharmacotherapies (eg, IV therapies and/or inpatient treatment until symptoms resolve) is needed to fully elucidate the acute and long-term benefits of interventions delivered to children.