Pediatric Concussion Management in the Emergency Department: A National Survey of Parents

Voter Support for Policies Associated With Child Health as National Campaign Priorities

Importance

Policies that are associated with child health are rarely included in platforms of candidates for national political office. Candidates may underrecognize voter support for such priorities or perceive that such policy issues are not sufficiently divisive to appeal to partisan voters. Key policy questions associated with child health may be considered by the next Congress, including the consistency of Medicaid coverage across states and restoring the recently lapsed refundable child tax credit.

Objective

To examine voter support for candidates regarding policies that are associated with child health.

Design, Setting, and Participants

This nationally representative survey of registered US voters 18 years or older was conducted from March to April 2024 and included a survey-based randomized experiment to evaluate the association of message framing with voter support.

Exposures

Messages conveying distinct rationales for Medicaid reform and refundable child tax credit.

Main Outcomes and Measures

Likely or definite support for candidates.

Results

In this sample (unweighted N = 2014; 1015 women [51.0%]), most respondents indicated they would likely or definitely vote for candidates who expressed strong support for all tested policies: extreme risk protection order (79.5%), school threat assessment (73.1%), expanded childcare (69.6%), refundable child tax credit (66.6%), federalization of Medicaid (66.0%), paid parental leave (65.5%), free school meals (65.6%), safe firearm storage and enforcement (62.9%), preventing Medicaid disenrollment for children younger than 6 years (61.9%), universal free preschool (61.6%), and summer nutrition programs (57.9%). More women than men expressed support for all tested policies. Strong majorities of Democrat and Independent voters would support candidates who endorsed child-focused policies; fewer than 50% of Republican voters expressed such support, except for the extreme risk protection order and school threat assessment. Variations in framing language regarding consistent Medicaid coverage across states were not associated with amplified or diminished voter support. Framing the refundable child tax credit as benefiting "hard-working" vs "low-income" families garnered significantly more support among men (67.0% vs 59.0%), privately insured individuals (72.0% vs 64.4%), and Republicans (54.6% vs 43.0%; all P < .05).

Conclusions and Relevance

The study results suggest that most voters favor candidates who strongly support policies that are associated with child health. Voter support differs substantively by gender and political party affiliation and may be associated with language choices in messaging about policy change.

Navigating uncertainty: exploring parents' knowledge of concussion management and neuropsychological baseline testing

Introduction

Parents play an important role in preventing and managing sport-related concussions among youth sport participants. Research indicates that parents understand the severity and consequences associated with the injury but gaps exist in their knowledge of its management. Neuropsychological baseline testing (NBT) is a modality that has gained interest in youth sport to purportedly better manage concussion injuries. Little is known about parents' perspectives on the use of NBT in the management process.

Methods

The present qualitative study used Protection Motivation Theory as a guiding framework and employed focus groups (N = 2) with parents (N = 11) to gain insight into parents' perceptions and experiences with concussion management, specifically focusing on NBT.

Results

Inductive Content Analysis developed a core theme of navigating uncertainty. Participants expressed uncertainty about the nature of concussion and its management process, where concussion was not always easy to identify, youth were not always reliable reporters, and there was no prescribed or proscribed path for recovery. Personal experience and concussion management policy provided participants with a degree of certainty in managing concussions. Participants gave NBT mixed reviews in potentially promoting greater certainty but also held reservations about its usefulness in concussion management.

Discussion

We discuss findings relative to existing knowledge and theory in youth sport concussion and identify implications for practice.

Multidomain Predictors of Protracted Recovery following Concussion among 5- to 9-Year-Old Patients: A Preliminary Study

OBJECTIVE

To determine which components from a multidomain assessment best predict protracted recovery in pediatric patients with a concussion.

STUDY DESIGN

A prospective cohort of patients aged 5-9 years who presented within 21 days of concussion to a specialty clinic were categorized into normal (≤30 days) and protracted (>30 days) recovery. Participants provided demographic and medical history information, and completed the Child Sport Concussion Assessment Tool-5 symptom report and balance assessment, the Vestibular/Ocular Motor Screen-Child (VOMS-C), and the Pediatric Immediate Post-concussion Assessment and Cognitive Testing. Univariate logistic regressions (LR) were used to inform a follow-up forward stepwise LR to identify the best predictors of protracted recovery. Receiver operating characteristic analysis of the area under the curve (AUC) was used to identify which predictors retained from the LR model best discriminated recovery.

RESULTS

The final sample included 68 patients (7.52 ± 2.3 years; 56% male), 36 (52.9%) with normal and 32 (47.1%) with protracted recovery. Results of the LR to identify protracted recovery were significant (P < .001) and accounted for 39% of the variance. The model accurately classified 78% of patients, with days to first clinic visit (OR, 1.2; 95% CI, 1.1-1.4; P = .003) and positive VOMS-C findings (OR, 8.32; 95% CI, 2.4-28.8; P < .001) as significant predictors. A receiver operating characteristic analysis of the AUC of this 2-factor model discriminated protracted from normal recovery (AUC, 0.82; 95% CI, 0.71-0.92; P < .001).

CONCLUSIONS

Days to first clinic visit and positive findings on the VOMS-C were the most robust predictors of protracted recovery after concussion in young pediatric patients.

Factors Associated With Parental COVID-19 Vaccination Acceptance

As the coronavirus pandemic continues to impact families and children, understanding parental attitudes and likely acceptance of the COVID-19 vaccine is essential. We conducted a statewide survey with a representative sample of parents in Tennessee focused on COVID-19 and influenza vaccine acceptance and perspectives. Data from 1066 parents were analyzed using weighted survey methods to generalize results to the state of Tennessee. About 53% of parents reported a likelihood to vaccinate their children against COVID-19, and 45% were likely to vaccinate their child against COVID-19 and influenza. Female parents were less likely to vaccinate their children against COVID-19, but the strongest predictor of likely COVID-19 vaccine acceptance was influenza vaccine acceptance (adjusted odds ratio = 5.46; 95% confidence interval: 3.20-9.30). Parental acceptance of COVID-19 vaccines for children is closely tied to influenza vaccine acceptance. Public health approaches to maximize vaccine uptake could focus on children who have not been receiving influenza vaccines.

Epidemiology of Pediatric Basketball Injuries Presenting to Emergency Departments: Sex- and Age-Based Patterns

Background:

There is limited epidemiologic data on pediatric basketball injuries and the comparison of these injuries before and after adolescence and between male and female athletes.

Purpose:

To assess common sex- and age-based injury patterns in pediatric basketball players.

Study Design:

Descriptive epidemiology study.

Methods:

Injury data from the National Electronic Injury Surveillance System (NEISS) and participation data from the National Sporting Goods Association were used to complete this study. Data on pediatric basketball injuries between January 2012 and December 2018 in patients aged 7 to 11 years (childhood) and 12 to 17 years (adolescence) were extracted and used to calculate national injury incidence rates with 95% CIs. Sex and age group patterns were examined utilizing Pearson chi-square tests. Z tests were conducted for the comparison of injury rates between female and male athletes in each age group and overall injury rate across age groups.

Results:

An average of 9582 basketball injuries were reported annually in the NEISS, which calculated to an annual national estimate of 294,920 injuries. The most common diagnoses were ankle strain/sprain (17.7%), finger strain/sprain/fracture (12.1%), concussion/head injury (9.4%), knee strain/sprain (4.5%), and facial laceration (3.3%). There was a significant increase in injury prevalence in adolescents (12- to 17-year-old category: 238,678 injuries per year) when compared with childhood (7- to 11-year-old category: 56,242 injuries per year) (P < .0001). Concussions/head injuries occurred at a high rate in childhood, second only to finger strain/sprain/fracture, and at a similar rate in females and males (injuries per 100,000 athlete-days: 4.9 [95% CI, 3.1-6.7] vs. 5.9 [4.3-7.5], respectively; P = .41). From childhood to adolescence, injury prevalence increased for all areas and across both sexes, except for female finger strain/sprain/fracture; however, the rate of increase for concussion/head injuries and knee injuries was significantly higher in female compared with male athletes (P < .0001 for both). In adolescents, ankle injuries were the most common injury overall.

Conclusion:

Ankle injuries continue to be the most predominant pediatric basketball injury. However, disproportionate rates of both knee and concussion/head injuries in female athletes during adolescent basketball are of concern and have implications for injury prevention.

Symptom Burden, School Function, and Physical Activity One Year Following Pediatric Concussion

OBJECTIVES

To characterize symptom burden, school function, and physical activity in youth 1 year following acute concussion and those with subsequent repeat concussion.

STUDY DESIGN

Secondary analysis of Predicting Persistent Postconcussive Problems in Pediatrics prospective, multicenter cohort study conducted in 9 Canadian emergency departments. Participants were children between ages 5 and 18 years who presented consecutively ≤48 hours of concussion and agreed to participate in a post hoc electronic survey 1 year after injury. Outcomes were assessed using a standardized 25-question symptom scale derived from the Post-Concussion Symptom Inventory-Parent; school function and physical activity outcomes were queried. The primary outcome was total symptom score 1 year following concussion, defined as the number of symptoms experienced more than before injury.

RESULTS

Of 3052 youth enrolled in the Predicting Persistent Postconcussive Problems in Pediatrics study, 432 (median [IQR] age, 11.5 [9,14] years; 266 [62%] male) completed the 1-year survey; 34 respondents reported a repeat concussion. Following acute concussion, youth were more likely to be symptom-free than following repeat concussion (75% vs 50%; difference = 25% [95% CI 8-41]; P = .002) and to have recovered fully (90% vs 74%; difference = 17% [95% CI 5-34]; P = .002) after 1 year. Although physical symptoms were less 1 year after initial emergency department presentation for both groups (P < .001), youth with a repeat concussion reported greater headache persistence (26% vs 13%; difference = 13% [95% CI 1,31]; P = .024). Both groups returned to their normal school routine (100% vs 95%; difference = 5% [95% CI -5 to 8; P = .618). Youth without repeat concussion more frequently returned to normal physical activities (98% vs 85%; difference = 13% [95% CI 4-28]; P < .0001) and sport (95% vs 82%; difference = 13% [95% CI 3-29]; P = .009).

CONCLUSIONS

Most youth are symptom-free and fully recovered 1 year following concussion. Some children with repeat concussion have worse outcomes and have delays in returning to normal school routines and sport.

Time to Authorized Clearance from Sport-Related Concussion: The Influence of Healthcare Provider and Medical Facility

CONTEXT

Return-to-play following sport-related concussion(SRC) requires authorized clearance from a healthcare provider(HCP). Variability in HCPs and facilities where athletes seek care may influence return time.

OBJECTIVE

Determine the initial examiner, HCPs that authorize clearance, and medical facilities authorizing clearance among high school student-athletes following SRC, and compare authorized clearance time by HCPs and medical facilities.

DESIGN

Prospective Cohort Study.

SETTING

High school.

PATIENTS OR OTHER PARTICIPANTS

Student-athletes(n=16,001) with SRC participating in STATE-XXX High School Athletic Association(XHSAA)-sponsored athletics.

MAIN OUTCOME MEASURE(S)

Frequencies of initial examiner and authorized clearance for each HCP(Doctor of Osteopathic Medicine(DO), Doctor of Medicine(MD), Nurse Practitioner(NP), Physician Assistant(PA)) and medical facility (Neurologist's Office, Team Physician, Primary Care Physician or Pediatrician's Office(PCP), Hospital, Urgent/Ready Care) for each SRC case. Kaplan-Meier curves and Peto tests evaluated differences in median time to authorized clearance between HCPs and facilities. Only cases with a follow-up authorized clearance date(80.3%, n=12,856) were included in authorized clearance and time to return analyses.

RESULTS

An athletic trainer was at least one of the initial examiners for 71.3%(n=11,404) of cases; 80.2%(n=12,990) had only one initial examiner. There was an association between initial examiner and medical facility providing clearance for athletic director(χ2=52.6, p≤.001, V=.06), athletic trainer(χ2=172.0, p≤.001, V=.12), coach(χ2=161.5, p≤.001, V=.11), DO(χ2=59.4, p≤.001, V= 07), and NP(χ2=10.0, p .03, V=.12). The majority(n=8,218, 63.9%) received clearance by an MD; 70.8%(n=9,099) were cleared at a PCP. Median time to authorized clearance varied by facility(Urgent/Ready Care: 7 days[4,11], Hospital: 9 days[6,14], PCP: 10 days[6,14], Team Physician: 12 days[8,16], Neurologist Office: 13 days[9,20]; p ≤ .001).

CONCLUSIONS

Clearance was frequently provided by an MD and at a PCP. Median time to return to unrestricted participation following SRC varied by HCP and medical facility. Future research should elucidate why differences exist and determine why athletes seek care at different medical facilities.

Factors Influencing Primary Care Follow-Up After Pediatric Mild Traumatic Brain Injury

OBJECTIVE

To identify socioeconomic, demographic, and caregiver factors associated with children attending primary care provider (PCP) follow-up after emergency department (ED) evaluation for mild traumatic brain injury (mTBI).

SETTING

Pediatric trauma center ED.

PARTICIPANTS

Children 8 to 18 years of age sustaining mTBI less than 48 hours prior to an ED visit. Mean age of the 183 participants was 12 years with no significant differences between those who attended follow-up and those who did not in race, ethnicity, insurance provider, or PCP office setting.

DESIGN

Thirty-day longitudinal cohort study.

MAIN MEASURES

Insurance type, PCP practice setting, and a caregiver attitudes survey regarding mTBI recovery and management (5 questions each scored on a 5-point Likert scale). The primary outcome was attending a PCP follow-up visit within 1 month of injury.

RESULTS

Females were more likely than males to attend PCP follow-up (adjusted odds ratio: 2.27 [95% confidence interval: 1.00-5.18]). Increasing scores on the caregiver attitudes survey indicating greater concerns about recovery were significantly associated with attending PCP follow-up (adjusted odds ratio: 1.12 per unit increase in composite score [95% confidence interval: 1.02-1.23]). No other socioeconomic, demographic, or injury characteristics were associated with attending PCP follow-up.

CONCLUSIONS

The ED counseling regarding PCP follow-up of mTBI should stress the importance of follow-up care to monitor recovery and identify presence of lingering symptoms.

Effect of parental pressure on emergency physicians for computerized tomography imaging request in children with head trauma

BACKGROUND

Both minor and major head traumas constitute an important proportion of childhood emergency admissions. In this study, the findings of cranial computed tomography (CCT) scans performed as a result of the parental pressure were evaluated.

METHODS

The frequency and findings of CCT scans performed as a result of parental pressure were examined in a separate subgroup.

RESULTS

A total of 227 patients were included in the study; 158 (69.9%) patients had undergone CCT scans; a pathological finding was detected in 24 (10.6%) of these patients and undergone a consultation by the neurosurgeon (most common finding was isolated linear fracture; n = 12; 50%). The patients undergoing CCT scans were divided in two subgroups: the PECARN group [n = 123 (77.8%)] and the Parental pressure group [n = 33 (22.2%)].

CONCLUSION

One third of the parents of children who presented to the emergency department with head trauma and had no indication for CCT according to PECARN rules insisted on CCT imaging, and none of these cases showed ciTBI, surgical operation, or mortality. None of the patients in the parental pressure group had a history of surgical intervention or mortality within one month after discharge.

Postconcussion Academic Support in Children Who Attend a Primary Care Provider Follow-up Visit after Presenting to the Emergency Department

OBJECTIVE

To examine whether a primary care provider (PCP) follow-up visit after emergency department evaluation of concussion improved the children's likelihood of receiving academic support.

STUDY DESIGN

This was a prospective cohort study. Concussed children, aged 8-18 years, presenting to a regional pediatric trauma center emergency department (n = 160) were contacted 7 and 30 days after injury to gather data on PCP follow-up, symptoms, quality of life, and receipt of academic support instituted after and because of the concussion. Bivariate comparisons of demographics, concussion characteristics, quality of life, and symptoms were made between children who did and did not receive support using independent samples t tests, Wilcoxon rank sum tests, or χ² tests. ORs and 95% CIs were calculated using multivariable logistic regression with backwards elimination to test the association between attending an outpatient follow-up visit and the receipt of academic support for variables where P < .2 in bivariate comparisons.

RESULTS

Overall, 51.3% (n = 82) received academic support; of these, 84.2% attended a follow-up visit compared with 71.8% of 78 children who attended a follow-up visit but did not receive support (P = .06). Children who received support were more likely to have commercial insurance; experience a sports-related injury mechanism; have parents whose primary language was English; suffer from learning disabilities and migraines; and be non-Hispanic (P < .05). There was no association between attending a follow-up visit and receipt of academic support (adjusted OR 1.83; 95% CI 0.75-4.45).

CONCLUSIONS

Although the majority of children received academic support postconcussion, accommodations were associated with several demographic, medical history, and injury characteristics, but not attending a PCP follow-up visit.

Characteristics and Costs of Pediatric Emergency Department Visits for Sports- and Recreation-Related Concussions, 2006-2014

BACKGROUND

Although concussion-related emergency department (ED) visits increased after the passage of concussion laws, little is known about how the laws may disproportionately impact ED utilization and associated health care costs among children in different demographic groups.

OBJECTIVE

Our aim was to examine the patient and clinical characteristics of pediatric ED visits and associated health care costs for sports- and recreation-related concussions (SRRCs) before and after concussion law enactment.

METHODS

We retrospectively analyzed ED visits for SRRCs by children ages 5-18 years between 2006 and 2014 in the Pediatric Health Information System database (n = 123,220). ED visits were categorized as "pre-law," "immediate post-law," and "post-law" according to the respective state concussion law's effective date. Multinomial logistic regression models were used to assess the impact of the law on ED utilization.

RESULTS

The majority of visits were by males (n = 83,208; 67.6%), children aged 10-14 years (n = 49,863; 40.9%), and privately insured patients (n = 62,376; 50.6%). Female sex, older age, and insured by Medicaid/Medicare were characteristics associated with increased ED visits during the immediate post-law and post-law periods compared to their counterparts. A significant decrease in proportion of imaging use was observed from pre-law to post-law (adjusted odds ratio 0.49; 95% confidence interval 0.47-0.50; p < 0.0001). While annual adjusted costs per ED visits decreased, annual total adjusted costs per hospital for SRRCs increased from pre-law to post-law (p < 0.0001).

CONCLUSIONS

Concussion laws might have impacted pediatric concussion-related ED utilization, with increased annual total adjusted costs. These results may have important implications for policy interventions and their effects on health care systems.

Public Attitudes and Knowledge About Youth Sports Participation and Concussion Risk in an Urban Area

BACKGROUND

Every year, millions of children in the United States participate in youth full-contact sports, which carry concussion risks-the long-term sequelae of which are not well understood. We examined the attitudes and knowledge of adults in Chicago about youth sports participation, concussion risk, and whether physicians should counsel against youth participation in full-contact sports.

METHODS

An anonymous paper survey featuring 13 attitudinal, 13 demographic, and 9 knowledge questions was distributed to a convenience sample of adults ≥18 years in hospital waiting areas and four Chicago parks. Participants were asked to hypothetically consider themselves the parent of a 10-year-old child regarding attitudes towards full-contact sports participation.

RESULTS

Between June 13 and July 27, 2016, 1091 partial or complete valid surveys were collected. Almost half (46%) of respondents would not allow a hypothetical 10-year-old son to play tackle football. The majority (74%) of respondents agreed that it was appropriate for physicians to counsel against youth participation in full-contact sports. Respondents obtained information about concussions from, on average, 2-3 sources, although only 34% received information from physicians. Respondents demonstrated a high concussion knowledge level (average: 6.75 of 9 questions). However, only 39% of respondents correctly answered that the following statement was false: "After a mild concussion, there are usually visible changes on medical imaging".

CONCLUSIONS

Overall, respondents are well-informed about concussions. They are divided about the participation of youth in full-contact sports and are amenable to physician counseling against youth participation in full-contact sports.