Pediatric Emergency Medicine Physicians' Perspectives of Concussion in Young Children

Study objective: Traumatic brain injury (TBI) during early childhood (before 6 years) is prevalent, accounting for rising rates of emergency department visits. These injuries may lead to postconcussive symptoms, which may be subtle and difficult to diagnose in young children. Inadequate discharge counseling may lead to prolonged duration of symptoms and possible developmental delays. We aimed to explore pediatric emergency medicine (PEM) physicians' perspectives on "concussion" terminology, diagnosis, and management, specifically in a young child with mild TBI.

Methods: We conducted semistructured interviews using open-ended questions involving a hypothetical scenario. We recruited currently practicing PEM physicians by a snowball sampling method. A research team recorded, transcribed, and analyzed the interviews. Using social constructionism as the philosophical framework, we developed and refined codes and derived themes until reaching thematic saturation. Peer debriefing with an expert collaborator aided with revisions of themes.

Results: A single PEM researcher interviewed 13 participants. Three primary themes emerged. Our first theme identified the role of guidelines and tools in the diagnostic workup. Most participants utilized a clinical prediction tool for neuroimaging but no clinical symptom scales. Our second theme described the difficulties and inconsistencies in the approach to diagnosis of concussion, largely due to young age, lack of verbal skills and unreliable examinations. Our last theme focused on the difficulty in providing clear discharge instructions to parents. Many participants described difficulty providing activity restrictions, instead allowing self-modulation, and lack of counseling for educational tasks.

Conclusions: Variability exists among PEM physicians in diagnosis and management of concussions in young children. Discomfort with lack of reliability of symptoms and underappreciation of typical early childhood characteristics may account for findings. Educational initiatives, age-appropriate clinical tools and treatment-guided outcomes research are needed to guide PEM physicians in the care of young children with head injuries.