Mild traumatic brain injury (mTBI) is common in children aged < 5 years, however, less is known about their experience of post-concussive signs and symptoms. This systematic review aims to identify post-concussive signs and symptoms experienced by preschool children up to 12 months post-injury, and to review the methods used to report this data. Relevant findings, including rates, progression, and possible predictors of post-concussive signs and symptoms were also identified. Databases (Ovid MEDLINE, EMBASE, PsycInfo, PubMed, Scopus) and reference lists were searched for relevant articles, which were screened based on specified criteria. Eleven articles met the inclusion criteria, being original studies published in English and presenting data on post-concussive signs and symptoms specific to preschool children with mTBI. Most reviewed studies investigated acute presentations of mTBI, and identified that preschool children demonstrate post-concussive symptoms (PCS) similar to other age groups. Post-traumatic amnesia duration of approximately one day was reported in preschool children following mTBI, as were changes in mood and behavior during the recovery period. Parents were the main informants, with data obtained through either interview or questionnaire. Review findings highlight the lack of empirical data regarding the presentation and progression of PCS in preschoolers following mTBI and evidence on how to best manage this group during recovery.
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Albicini, M., & McKinlay, A. (2014). Mild traumatic brain injury: A review of terminology, symptomatology, clinical considerations and future directions. In Traumatic Brain Injury (pp. 3–22). Croatia: InTech.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). American Psychiatric Association.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association.
Andersson, E. E., Sejdhage, R., & Wage, V. (2012). Mild traumatic brain injuries in children between 0–16 years of age: A survey of activities and places when an accident occurs. Developmental Neurorehabilitation, 15(1), 26–30. https://doi.org/10.3109/17518423.2011.633570
Barlow, K. (2016). Postconcussion Syndrome: A Review. Journal of Child Neurology, 31(1), 57–67. https://doi.org/10.1177/0883073814543305
Barlow, K., Crawford, S., Stevenson, A., Sandhu, S. S., Belanger, F., & Dewey, D. (2010). Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics, 126(2), e374–e381. https://doi.org/10.1542/peds.2009-0925
Beauchamp, M. H., Landry-Roy, C., Gravel, J., Beaudoin, C., & Bernier, A. (2017). Should young children with traumatic brain injury be compared with community or orthopedic control participants? Journal of Neurotrauma, 34(17), 2545–2552. https://doi.org/10.1089/neu.2016.4868
Bernard, C., McKinlay, A., Krieser, D., Ponsford, J. (2019). Postconcussive symptoms following mild TBI and extracranial injury: What are the contributing factors? Journal of the International Neuropsychological Society 1–13 https://doi.org/10.1017/S1355617719001279
Bernard, C., McKinlay, A., Krieser, D., Testa, R., & Ponsford, J. (2017a). Acute post-concussive symptoms in young children. Brain Injury, 31(11), 1414–1421. https://doi.org/10.1080/02699052.2017.1350999
Bernard, C., Ponsford, J., McKinlay, A., McKenzie, D., & Krieser, D. (2016). Predictors of Post-Concussive Symptoms in Young Children: Injury versus Non-injury Related Factors. Journal of the International Neuropsychological Society, 22, 793–803. https://doi.org/10.1017/S1355617716000709
Bernard, C., Ponsford, J., McKinlay, A., McKenzie, D., & Krieser, D. (2017b). Do concussive symptoms really resolve in young children? Journal of Head Trauma Rehabilitation, 32(6), 413–424. https://doi.org/10.1097/HTR.0000000000000298
Bressan, S., & Babl, F. E. (2016). Diagnosis and management of paediatric concussion. Journal of Paediatrics and Child Health, 52(2), 151–157. https://doi.org/10.1111/jpc.12967
Carroll, L. J., Cassidy, J. D., Holm, L., Kraus, J., & Coronado, V. G. (2004). Methodological issues and research recommendations for mild traumatic brain injury: The WHO collaborating centre task force on mild traumatic rain injury. Journal of Rehabilitation Medicine, 43, 113–125. https://doi.org/10.1080/16501960410023877.
Case, M. E. (2008). Inflicted traumatic brain injury in infants and young children. Brain Pathology, 18(4), 571–582. https://doi.org/10.1111/j.1750-3639.2008.00204.x
Catroppa, C., & Anderson, V. (2011). Pediatric Traumatic Brain Injury (TBI): Overview. In M. R. Schoenberg & J. G. Scott (Eds.), The Little Black Book of Neuropsychology: A Syndrome-Based Approach (pp. 765–786): Springer.
Crowe, L., Babl, F., Anderson, V., & Catroppa, C. (2009). The epidemiology of paediatric head injuries: Data from a referral centre in Victoria, Australia. Journal of Paediatrics and Child Health, 45(6), 346–350. https://doi.org/10.1111/j.1440-1754.2009.01499.x
Crowe, L., Catroppa, C., Anderson, V., & Babl, F. (2012). Head injuries in children under 3 years. Injury, 43(12), 2141–2145. https://doi.org/10.1016/j.injury.2012.07.195
Crowe, L., Hearps, S., Anderson, V., Borland, M., Phillips, N., Kochar, A., & Furyk, J. (2018). Investigating the variability in mild traumatic brain injury definitions: A prospective cohort study. Archives of Physical Medicine and Rehabilitation, 99(7), 1360–1369. https://doi.org/10.1016/j.apmr.2017.12.026
Dewan, M. C., Mummareddy, N., Wellons, J. C. I., & Bonfield, C. M. (2016). Epidemiology of global pediatric traumatic brain injury: qualitative review. World Neurosurgery, 91, 497–509. https://doi.org/10.1016/j.wneu.2016.03.045.
Ewing-Cobbs, L., Cox, C. S., Clark, A. E., Holubkov, R., & Keenan, H. T. (2018). Persistent postconcussion symptoms after injury. Pediatrics, 142(5), e20180939. https://doi.org/10.1542/peds.2018-0939
Ewing-Cobbs, L., Kramer, L., Prasad, M., Canales, D. N., Louis, P. T., Fletcher, J. M., & Cheung, K. (1998). Neuroimaging, physical, and developmental findings after inflicted and noninflicted traumatic brain injury in young children. Pediatrics, 102(2), 300–307. https://doi.org/10.1542/peds.102.2.300
Ewing-Cobbs, L., Levin, H. S., Fletcher, J. M., Miner, M. E., & Eisenberg, H. M. (1990). The Children’s orientation and amnesia test: relationship to severity of acute head injury and to recovery of memory. Neurosurgery, 27(5), 683–691. https://doi.org/10.1227/00006123-199011000-00003.
Falk, A.-C., Cederfjäll, C., Von Wendt, L., & Klang, B. (2006). Are the symptoms and severity of head injury predictive of clinical findings three months later? Acta Paediatrica, 95(12), 1533–1539. https://doi.org/10.1080/08035250600731957
Falk, A.-C., Von Wendt, L., & Söderkvist, B. K. (2009). The specificity of post-concussive symptoms in the pediatric population. Journal of Child Health Care, 13(3), 227–238. https://doi.org/10.1177/1367493509336691
Faul, M., Xu, L., Wald, M. M., & Coronado, V. G. (2010). Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
Güzel, A., Hiçdönmez, T., Temizöz, O., Aksu, B., Aylanç, H., & Karasalihoglu, S. (2009). Indications for brain computed tomography and hospital admission in pediatric patients with minor head injury: How much can we rely upon clinical findings? Pediatric Neurosurgery, 45(4), 262–270. https://doi.org/10.1159/000228984
Hajek, C. A., Yeates, K. O., Taylor, H. G., Bangert, B., Dietrich, A., Nuss, K. E., & Wright, M. (2010). Agreement between parents and children on ratings of post-concussive symptoms following mild traumatic brain injury. Child Neuropsychology, 17(1), 17–33. https://doi.org/10.1080/09297049.2010.495058
Hearps, S., Takagi, M., Babl, F., Bressan, S., Truss, K., Davis, G., & Rausa, V. (2017). Validation of a score to determine time to postconcussive recovery. Pediatrics, 139(2), e20162003. https://doi.org/10.1542/peds.2016-2003
Hooper, S. R., Alexander, J., Moore, D., Sasser, H. C., Laurent, S., King, J., & Callahan, B. (2004). Caregiver reports of common symptoms in children following a traumatic brain injury. NeuroRehabilitation, 19(3), 175–189. https://doi.org/10.3233/NRE-2004-19302
Iverson, G. L., & Lange, R. T. (2011). Mild Traumatic Brain Injury. In M. R. Schoenberg & J. G. Scott (Eds.), The Little Black Book of Neuropsychology: A Syndrome-Based Approach (pp. 697–719): Springer.
Keenan, H. T., & Bratton, S. L. (2006). Epidemiology and outcomes of pediatric traumatic brain injury. Developmental Neuroscience, 28(4–5), 256–263. https://doi.org/10.1159/000094152
Keenan, H. T., Runyan, D. K., Marshall, S. W., Nocera, M. A., & Merten, D. F. (2004). A population-based comparison of clinical and outcome characteristics of young children with serious inflicted and noninflicted traumatic brain injury. Pediatrics, 114(3), 633–639. https://doi.org/10.1542/peds.2003-1020-L
Kirkwood, M. W. (2015). Pediatric validity assessment. NeuroRehabilitation, 36(4), 439–450. https://doi.org/10.3233/NRE-151232
Kirkwood, M. W., Peterson, R. L., Connery, A. K., Baker, D. A., & Grubenhoff, J. A. (2014). Postconcussive symptom exaggeration after pediatric mild traumatic brain injury. Pediatrics, 133(4), 643–650. https://doi.org/10.1542/peds.2013-3195
Klonoff, H. (1971). Head injuries in children: Predisposing factors accident conditions, accident proneness and sequelae. American Journal of Public Health, 61(12), 2405–2417.
Kraus, J. F., Black, M. A., Hessol, N., Ley, P., Rokaw, W., Sullivan, C., & Marshall, L. (1984). The incidence of acute brain injury and serious impairment in a defined population. American Journal of Epidemiology, 119(2), 186–201. https://doi.org/10.1093/oxfordjournals.aje.a113737
Kraus, J. F., Fife, D., Cox, P., Ramstein, K., & Conroy, C. (1986). Incidence, severity, and external causes of pediatric brain injury. American Journal of Diseases of Children, 140(7), 687–693. https://doi.org/10.1001/archpedi.1986.02140210085032
Kristman, V. L., Borg, J., Godbolt, A. K., Salmi, L. R., Cancelliere, C., Carroll, L. J., & Cassidy, J. D. (2014). Methodological Issues and Research Recommendations for Prognosis After Mild Traumatic Brain Injury: Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Archives of Physical Medicine and Rehabilitation, 95(3), S265–S277. https://doi.org/10.1016/j.apmr.2013.04.026
Lah, S., David, P., Epps, A., Tate, R., & Brookes, N. (2019). Preliminary validation study of the Sydney Post-Traumatic Amnesia Scale (SYPTAS) in children with traumatic brain injury aged 4 to 7 years. Applied Neuropsychology: Child, 8(1), 61–69. https://doi.org/10.1080/21622965.2017.1381100
Lalonde, G., Bernier, A., Beaudoin, C., Gravel, J., & Beauchamp, M. H. (2020). Factors contributing to parent–child interaction quality following mild traumatic brain injury in early childhood. Journal of Neuropsychology, 14(1), 98–120. https://doi.org/10.1111/jnp.12179
Landry-Roy, C., Bernier, A., Gravel, J., & Beauchamp, M. (2018). Executive functions and their Relation to sleep following mild traumatic brain injury in preschoolers. Journal of the International Neuropsychological Society, 24, 769–780. https://doi.org/10.1017/S1355617718000401.
Ledoux, A.-A., Tang, K., Yeates, K. O., Pusic, M. V., Boutis, K., Craig, W. R., & Gioia, G. A. (2019). Natural progression of symptom change and recovery from concussion in a pediatric population. JAMA Pediatrics, 173(1), 1–11. https://doi.org/10.1001/jamapediatrics.2018.3820
Lumba-Brown, A., Yeates, K. O., Sarmiento, K., Breiding, M. J., Haegerich, T. M., Gioia, G. A., & Timmons, S. D. (2018). Centers for disease control and prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatrics, 172(11), e182853–e182853. https://doi.org/10.1001/jamapediatrics.2018.2853.
Mayer, A. R., Quinn, D. K., & Master, C. L. (2017). The spectrum of mild traumatic brain injury: A review. Neurology, 89(6), 623–632. https://doi.org/10.1212/WNL.0000000000004214
McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., & Vos, P. E. (2017). Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine, 51, 838–847. https://doi.org/10.1136/bjsports-2017-097699
McKinlay, A. (2012). Injury in preschool-age children. In M. W. Kirkwood & K. O. Yeates (Eds.), Mild traumatic brain injury in children and adolescents: From basic science to clinical management (pp. 361–373). Guilford Press.
McKinlay, A., Ligteringen, V., & Than, M. (2014). A comparison of concussive symptoms reported by parents for preschool versus school-aged children. Journal of Head Trauma Rehabilitation, 29(3), 233–238. https://doi.org/10.1097/HTR.0b013e3182a2dd7f
Mittenberg, W., Wittner, M., & Miller, L. (1997). Postconcussion syndrome occurs in children. Neuropsychology, 11, 447–452.
Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & The PRISMA Group. (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. British Medical Journal, 339, b2535. https://doi.org/10.1136/bmj.b2535
OCEBM Levels of Evidence Working Group*. (2011). The Oxford 2011 Levels of Evidence.
Patsimas, T., Howell, D. R., Potter, M. N., Provance, A. J., Kirkwood, M. W., & Wilson, J. C. (2020). Concussion-symptom rating correlation between pediatric patients and their parents. Journal of Athletic Training, 55(10), 1020–1026. https://doi.org/10.4085/1062-6050-200-19
Paul, A. R., & Adamo, M. A. (2014). Non-accidental trauma in pediatric patients: A review of epidemiology, pathophysiology, diagnosis and treatment. Translational Pediatrics, 3(3), 195–207. https://doi.org/10.3978/j.issn.2224-4336.2014.06.01
Reece, R. M., & Sege, R. (2000). Childhood head injuries: Accidental or inflicted? Archives of Pediatrics & Adolescent Medicine, 154(1), 11–15.
Rocca, A., Wallen, M., & Batchelor, J. (2008). The Westmead Post-Traumatic Amnesia Scale for Children (WPTAS-C) Aged 4 and 5 Years Old. Brain Impairment, 9(1), 14–21. https://doi.org/10.1375/brim.9.1.14
Ruijs, M., Keyser, A., & Gabreels, F. (1992). Assessment of post-traumatic amnesia in young children. Developmental Medicine & Child Neurology, 34(10), 885–892. https://doi.org/10.1111/j.1469-8749.1992.tb11386.x
Sady, M., Vaughan, C., & Gioia, G. (2014). Psychometric characteristics of postconcussion symptom inventory in children and adolescents. Archives of Clinical Neuropsychology, 29, 348–363. https://doi.org/10.1093/arclin/acu014.
Smith, E. B., Lee, J. K., Vavilala, M. S., & Lee, S. A. (2019). Pediatric traumatic brain injury and associated topics: An overview of abusive head trauma, nonaccidental trauma, and sports concussions. Anesthesiology Clinics, 37(1), 119–134. https://doi.org/10.1016/j.anclin.2018.10.002
Stevens, P. K., Penprase, B., Kepros, J. P., & Dunneback, J. (2010). Parental recognition of postconcussive symptoms in children. Journal of Trauma Nursing, 17(4), 178–182. https://doi.org/10.1097/JTN.0b013e3181ff2789
Suskauer, S. J., Rane, S., Reesman, J., & Slomine, B. S. (2018). Caregiver-report of symptoms following traumatic brain injury in a small clinical sample of preschool-aged children. Journal of Pediatric Rehabilitation Medicine, 11(1), 7–14. https://doi.org/10.3233/PRM-160424
Teasdale, G., & Jennett, B. (1974). Assessment of coma and impaired consciousness: A practical scale. The Lancet, 304(7872), 81–84. https://doi.org/10.1016/S0140-6736(74)91639-0
Thickpenny-Davis, K. L., Ogden, J. A., & Fernando, K. (2005). The starship post-traumatic amnesia scale: does it predict outcome after mild to moderate traumatic brain injury in children aged 3 to 7 years? Brain Impairment, 6(2), 101–108. https://doi.org/10.1375/brim.2005.6.2.101.
Thompson, M., & Irby, J. J. (2003). Recovery from mild head injury in pediatric populations. Seminars in Pediatric Neurology, 10(2), 130–139. https://doi.org/10.1016/S1071-9091(03)00021-4
Thurman, D. J. (2016). The epidemiology of traumatic brain injury in children and youths: A review of research since 1990. Journal of Child Neurology, 31(1), 20–27. https://doi.org/10.1177/0883073814544363
Wells, G., Shea, B., O’Connell, D., Peterson, J., Welch, V., Losos, M., & Tugwell, P. (2000). The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Retrieved from http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
World Health Organization. (2016). International Statistical Classification of Diseases and Related Health Problems, 10th Revision (5th ed.). World Health Organization.
Wrightson, P., McGinn, V., & Gronwall, D. (1995). Mild head injury in preschool children: Evidence that it can be associated with a persisting cognitive defect. Journal of Neurology, Neurosurgery & Psychiatry, 59(4), 375–380. https://doi.org/10.1136/jnnp.59.4.375
Zogg, C. K., Haring, R. S., Xu, L., Canner, J. K., AlSulaim, H. A., Hashmi, Z. G., & Bell, J. M. (2018). The epidemiology of pediatric head injury treated outside of hospital emergency departments. Epidemiology, 29(2), 269–279. https://doi.org/10.1097/EDE.0000000000000791
We would like to acknowledge Poh Chua, Librarian at The Royal Children’s Hospital, Melbourne, for her assistance with the search strategy.
No funding was secured for this study. Joy Noelle Yumul was supported by the Melbourne Research Scholarship from the University of Melbourne. Vicki Anderson was supported by an Australian National Health and Medical Research Council (NHMRC) Senior Research Practitioner Fellowship. Louise Crowe was supported by a NHMRC Early Career Fellowship and the Myer Foundation. The work is also supported by the Victorian Government Operational Infrastructure Fund.
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LC and AM are co-senior authors.
Appendix 1 Examples of the strategy used for literature search in electronic databases
Appendix 1 Examples of the strategy used for literature search in electronic databases
|Scopus||( TITLE-ABS-KEY ( brain-injur* OR head-injur* OR craniocerebral-trauma OR cranio-cerebral-trauma OR concussion OR tbi OR mtbi OR cmtbi OR moderate-tbi OR severe-tbi)) AND ( TITLE-ABS-KEY ( postconcussion OR post-concussion OR postconcussive OR post-concussive OR pcs OR ppcs OR pta OR amnesia OR disorientation OR memory-loss OR loss-of-memory OR confusion OR fogginess OR foggy OR dazed OR altered-mental-state)) AND ( ( TITLE-ABS-KEY ( toddler* OR pre-schooler* OR preschooler* OR kinder OR kinders OR kindergarten* OR kinder-aged OR two-year-old* OR two-years-old* OR three-year-old* OR three-years-old* OR four-year-old* OR four-years-old* OR five-year-old* OR five-years-old*) OR TITLE-ABS-KEY ( 2-year-old* OR 2-years-old* OR 3-year-old* OR 3-years-old* OR 4-year-old* OR 4-years-old* OR 5-year-old* OR 5-years-old* OR aged-two OR aged-2 OR aged-three OR aged-3 OR aged-four OR aged-4 OR aged-five OR aged-5 OR child and/or children))) AND ( LIMIT-TO ( LANGUAGE, "English"))|
1. Brain injuries/ or brain injuries, traumatic/|
2. Craniocerebral trauma/ or head injuries, closed/
3. Brain Concussion/
4. (traumatic-brain-injur* or head-injur* or concussion or tbi or mtbi or moderate-TBI or cmTBI or severe-TBI).tw,kf.
5. Post-Concussion Syndrome/
7. (postconcussion or post-concussion or postconcussive or post-concussive or pcs or ppcs or pta or amnesia or disorientation or memory-loss or (loss adj2 memory) or confusion or fogginess or foggy or dazed or altered-mental-state).tw,kf.
8. (toddler* or pre-schooler* or preschooler* or kinder or kinders or kindergarten* or kinder-aged or two-year-old* or two-years-old* or three-year-old* or three-years-old* or four-year-old* or four-years-old* or five-year-old* or five-years-old* or 2-year-old* or 2-years-old* or 3-year-old* or 3-years-old* or 4-year-old* or 4-years-old* or 5-year-old* or 5-years-old* or aged-two or aged-2 or aged-three or aged-3 or aged-four or aged-4 or aged-five or aged-5 or child and/or children).af.
9. (1 or 2 or 3 or 4) and (5 or 6 or 7) and 8
10. limit 9 to english language
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Yumul, J.N., Crowe, L., Catroppa, C. et al. Post-concussive Signs and Symptoms in Preschool Children: A Systematic Review. Neuropsychol Rev (2021). https://doi.org/10.1007/s11065-021-09518-z
- Preschool children
- Post-concussive symptoms