Sex Matters: Timing of Concussion Recovery in Children

Source: Beauchamp MH, Tang K, Ledoux A-A, et al for the Pediatric Emergency Research Canada A-CAP Study Team. Optimal recovery following pediatric concussion. JAMA Netw Open. 2025;8(3):e251092; doi: 10.1001/jamanetworkopen.2025.1092.Investigators from multiple institutions in Canada conducted a study to evaluate the recovery trajectory toward optimal functioning in children after concussion. Study participants were patients 8–16 years old evaluated for concussion at 1 of 5 pediatric emergency departments in Canada between September 2016 and July 2019. Standardized criteria were used for a diagnosis of concussion. A control group of children with orthopedic injury (OI) without head trauma also were enrolled as a control group. Participants in both the concussion and OI groups had follow-up study visits 10 days, 3 months, and 6 months after their injury. At each visit, multiple questionnaires were administered to assess functioning across 4 domains: motor-physical, cognitive, socio-emotional, and resilience-support. Specific measures from each domain were identified to assess optimal functioning. Ultimately, 11 measures were used to define optimal functioning. At each visit, the number of measures for which the score was above a specified threshold was determined for each participant. With this schema, each participant was assigned an optimal functioning score of 0–11 at each study visit. Regression analyses were used to assess the association of 3 main variables: time, group (OI or concussion), and sex, with optimal functioning.A total of 633 children with concussion and 334 with OI were enrolled. The median age of patients in the concussion and OI groups was 12.0 and 12.5 years, respectively. The proportion of participants contributing evaluable data across time points ranged from 71.1% to 85.7%. At the 10-day follow-up, the median optimal functioning score was 4.0 for children with concussion and 6.0 for those in the OI groups. Scores at 3 and 6 months for participants in the 2 groups were 6.0 and 7.0, respectively, for those with concussion, and 7.0 and 7.0, respectively, for patients in the OI group. In the multivariate model, time (P <0.001), group (P <0.001), and sex (P <0.001) all were significant predictors of optimal functioning scores. At the 10-day follow-up, optimal functioning scores were significantly lower in those with concussion compared to patients with OI, in both females (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.16, 0.36) and males (OR, 0.37; 95% CI, 0.26, 0.53). At 3 months, females with concussion had lower scores that those with OI (OR, 0.57; 95% CI, 0.35, 0.93), but there was no significant difference between groups in males. By 6 months post-injury, there were no significant differences in optimal functioning scores between the concussion and OI groups in either females or males. Among those with concussion, optimal functioning scores were significantly lower for females than males at the 3-month and 6-month visit.The authors conclude the recovery of optimal functioning after concussion took 3 months or longer, especially in females.Dr Bechtel has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Concussion causes considerable morbidity in childhood;1 thus, understanding recovery trajectories for children and adolescents with concussion is important.The current researchers investigated recovery trajectories following concussion or OI in children aged 8 to 16 years. The study authors found that children with concussions had lower optimal functioning scores than those with OI, especially early in recovery. Optimal functioning improved over time, with most children recovering from concussion within 3 to 6 months. Females with concussion showed slower recovery compared to males, with significant differences persisting up to 3 months and 6 months post injury. Time was the strongest factor associated with recovery, followed by injury type and sex. Thus, the clinical implication is that recovery from concussion may take longer than the commonly cited 1-month timeframe for symptom resolution,2 especially for girls. Anticipatory guidance and reassurance to families ought to account for the possibility of prolonged recovery.However, the current study had several minor limitations. First, using patient self-reported measures may introduce bias, as these were not objectively measured. Second, the sample was recruited from urban hospitals and may not represent the broader population that may present in primary care or urgent care settings. Finally, the findings are applicable only to children and adolescents 8–16 years old; recovery trajectories for younger children and older adolescents may be different from than that of the study population.Pediatric concussion recovery is heterogeneous, with most children achieving optimal functioning within 3 to 6 months. Recovery trajectories vary by time, sex, and injury type, underscoring the need for comprehensive assessments and individualized care. (See AAP Grand Rounds. 2024;51[6]:64.)3Although the current authors made a laudable effort to quantify 'optimal functioning,' we would add a further word of caution to interpretation of the study findings. How well did females, as compared to males, comply with recent recommendations for concussion management, which stressed early return to school and physical activity?3

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