Unique symptom presentation in pediatric concussions highlights the need for individualized diagnosis protocols
By Emily Sugg. This article was initially published in the 1/15/26 Edition of our Concussion Update newsletter; please consider subscribing.
A recent study published in Brain Injury by Jonathan Santana and colleagues found that pediatric concussion characteristics differ significantly with age. Specifically, older children and adolescents were more likely to be injured through sports, and reported significantly more headache, neck pain, sensitivity to sound, feeling slowed down, difficulty remembering, fogginess, and low energy. Conversely, children under 8 tended to sustain concussions through non-sport mechanisms (most commonly falls) and reported fewer symptoms overall. That younger children reported lower symptom burden could be due to lesser injury severity or to clinicians’ reliance on parental reports of observable symptoms, as young children may struggle to describe some symptoms, given their developmental stage.
These findings emphasize that clinicians cannot use a one-size-fits-all concussion protocol, especially for children under eight years old. The authors stress the dearth of diagnostic tools for children under age 8 and, therefore, the challenge for clinicians to recognize the differing symptoms of younger patients. As approximately 1.8 million concussions in the pediatric population (or mild traumatic brain injuries (mTBIs)) occur annually, this lack of tailored diagnostic tools affects a meaningful proportion of young children in the United States. Younger children exhibit unique symptoms, such as changes in appetite, increased dependence or clinginess, bedwetting, or stomachaches. These symptoms are not included on a standardized symptom checklist, but are relevant for preschoolers.
In this prospective study, data were collected on 333 pediatric concussion patients seen in several orthopedic sports medicine clinics affiliated with an LA-based hospital system from 2012 to 2023. The authors divided participant data into three age groups: 0-7 years, 8-12 years, and 13-18 years. Each group was given a concussion symptom questionnaire and a standardized physical examination, which included a neurological exam, balance testing, and a vestibulo-ocular motor screen test (assessing eye movement and balance). Patients were asked to recall immediate symptoms during the first 24 hours after their concussion as well as current symptoms during their visit.
Dr. Santana and his colleagues found that the most striking symptom reports came from the younger patient group (under age 8). Compared to the older age groups, patients under age 8 were less likely to report physical or visio-vestibular (including balance-related) symptoms and even less likely to report cognitive, emotional, or sleep problems. Differences in developmental stage and vocabulary, especially among the youngest age group, may contribute to the lower number of reported symptoms. For patients under age 13, parents helped to fill out the concussion symptom checklist; for the youngest or those unable to fill out the form, parents filled out the entirety of the symptom checklist. The authors note that younger children may not yet have the vocabulary to describe specific symptoms, and their parents may miss less obvious ones. This is supported by previous studies’ conclusions that parental questionnaire observed symptom scores are much lower in younger populations.
Additionally, there is an absence of a recommended concussion symptom checklist for patients under age 8, and the new Sport Concussion Office Assessment Tool, the SCOAT6, is not recommended for children under age 8. The study authors suggest that their findings contribute to developing a diagnostic tool tailored to the unique needs of younger patients.