Pediatric Pearls: Post-Concussion Symptom Trajectories

An 11-year-old girl recently sustained a concussion during field hockey practice. Since then, she has been experiencing headaches and her mother has noticed that she seems more irritable than usual. She asks if these symptoms are related to Jennifer's concussion, and if so, how long they will last.

How would you advise your patient?

(Answer and discussion on next page)

Jessica L. Tomaszewski, MD, is a pediatrician in the Division of General Pediatrics/Primary Care in the Department of Pediatrics at Nemours duPont Pediatrics, Jessup Street, in Wilmington, DE.

Answer: PCS trajectories vary with age and sex.

Post-concussion symptoms (PCSs) are cognitive, physical, and affective symptoms, such as headaches and irritability that occur in around 30% of children who experience a mild traumatic brain injury (mTBI). These symptoms can last for several months, though there is limited understanding regarding protective or vulnerable factors that could assist with predictive care.

The Research

The researchers examined parent ratings of PCSs in a prospective, longitudinal cohort study of recovery from pediatric mTBI compared with an orthopedic injury (OI) group. 

Patients were recruited into 3 groups—mTBI (n = 119), complicated mTBI (n = 110), and orthopedic injury (n = 118)—from emergency departments. Pre-injury demographics along with child and family characteristics were captured through retrospective surveys completed by caregivers. 

Using multivariable linear models, predictors of PCSs were examined at 3, 6, and 12 months after injury in children aged 4 to 8 years, 9 to 12 years, and 13 to 15 years.

The Results

PCS trajectories varied with age and sex. Adolescents had elevated PCSs that improved, whereas young children had lower initial symptoms but did not improve as significantly. Girls had elevated symptoms across all time points when compared with boys. Overall, post-injury somatic, emotional, and cognitive PCSs were similar in both TBI groups but were quite elevated when compared with the orthopedic injury group.

Vulnerability factors of note included female sex, adolescent age, pre-injury mood problems, lower income, and family discord. Social capital was a protective factor. Pre-existing affective problems such as anxiety and ADHD were significantly associated with post-injury PCSs. 

Notably, despite improvement over time, global outcome questions revealed that 21% of the orthopedic injury group, 39% of the mTBI group, and 46% of the complicated mTBI group continued to act differently 1 year after injury.

The study reveals the persistence of PCSs, particularly in girls, and that there is a significant difference in trajectory by age. It also highlights the potential persistence of symptoms in those children with underlying affective disorders. 

Bottom Line—With 1 million to 2 million US children sustaining a concussion from sports and recreation annually, it is important to identify factors that influence recovery and quality of life. As we further understand this data, this may lead to better family education and allocation of health resources.


Ewing-Cobbs L, Cox Jr CS, Clark AE, Holubkov R, Keenan HT. Persistent post-concussion symptoms after injury. Pediatrics. 2018;142(5). doi:10.1542/peds.2018-0939