OBJECTIVES: To determine if recommending strict rest improved concussion recovery and outcome after discharge from the pediatric emergency department (ED).METHODS: Patients aged 11 to 22 years presenting to a pediatric ED within 24 hours of concussion were recruited. Participants underwent neurocognitive, balance, and symptom assessment in the ED and were randomized to strict rest for 5 days versus usual care (1-2 days rest, followed by stepwise return to activity). Patients completed a diary used to record physical and mental activity level, calculate energy exertion, and record daily postconcussive symptoms. Neurocognitive and balance assessments were performed at 3 and 10 days postinjury. Sample size calculations were powered to detect clinically meaningful differences in postconcussive symptom, neurocognitive, and balance scores between treatment groups. Linear mixed modeling was used to detect contributions of group assignment to individual recovery trajectory.RESULTS: Ninety-nine patients were enrolled; 88 completed all study procedures (45 intervention, 43 control). Postdischarge, both groups reported a 20% decrease in energy exertion and physical activity levels. As expected, the intervention group reported less school and after-school attendance for days 2 to 5 postconcussion (3.8 vs 6.7 hours total, P , .05). There was no clinically significant difference in neurocognitive or balance outcomes. However, the intervention group reported more daily postconcussive symptoms (total symptom score over 10 days, 187.9 vs 131.9, P , .03) and slower symptom resolution.CONCLUSIONS: Recommending strict rest for adolescents immediately after concussion offered no added benefit over the usual care. Adolescents' symptom reporting was influenced by recommending strict rest. WHAT'S KNOWN ON THIS SUBJECT:Expert consensus recommends rest after concussion with stepwise return to activity. Animal and retrospective human data suggest that early mental and physical activity may worsen outcome. There are no pediatric studies testing the efficacy of recommending strict rest after concussion. WHAT THIS STUDY ADDS:Recommending strict rest postinjury did not improve outcome and may have contributed to increased symptom reporting. Usual care (rest for 1-2 days with stepwise return to activity) is currently the best discharge strategy for pediatric mild traumatic brain injury/concussion. Dr Thomas developed the study concept and design, obtained funding, supervised the study, acquired data, analyzed and interpreted data, and drafted and revised the manuscript; Dr Apps assisted with study concept and design, supervised the study, provided technical support, analyzed and interpreted data, and critically revised the manuscript; Dr Hoffmann assisted with study design, analyzed data, provided statistical expertise, and critically revised the manuscript; Dr McCrea assisted with study design, analyzed and interpreted data, provided technical support, and critically revised the manuscript; Dr Hammeke assisted with study concept and ...

Background: To assess whether monthly home visits from trained volunteers could improve infant feeding practices at age 12 months, a randomised controlled trial was carried out in two disadvantaged inner city London boroughs. Methods: Women attending baby clinics with their infants (312) were randomised to receive monthly home visits from trained volunteers over a 9-month period (intervention group) or standard professional care only (control group). The primary outcome was vitamin C intakes from fruit. Secondary outcomes included selected macro and micro-nutrients, infant feeding habits, supine length and weight. Data were collected at baseline when infants were aged approximately 10 weeks, and subsequently when the child was 12 and 18 months old. Results: Two-hundred and twelve women (68%) completed the trial. At both follow-up points no significant differences were found between the groups for vitamin C intakes from fruit or other nutrients. At first follow-up, however, infants in the intervention group were significantly less likely to be given goats' or soya milks, and were more likely to have three solid meals per day. At the second follow-up, intervention group children were significantly less likely to be still using a bottle. At both follow-up points, intervention group children also consumed significantly more specific fruit and vegetables. Conclusions: Home visits from trained volunteers had no significant effect on nutrient intakes but did promote some other recommended infant feeding practices. Trial registration: Current Controlled Trials ISRCTN55500035Nutrition in early life is a key determinant of growth, development and health status, both in childhood and later adult life. Current UK recommendations advise all mothers to exclusively breastfeed for 6 months, and to delay introducing solids until at least 6 months. [3][4][5] Data from national surveys show that infant feeding practices in the UK are, however, highly variable.6 7 The 2005 Infant Feeding Survey indicated some encouraging trends with 76% of mothers across the UK initiating breastfeeding. However, rates fell steeply after a few weeks and less than 1% of mothers were exclusively breastfeeding at 6 months.6 Stark social inequalities were evident, with breastfeeding rates highest amongst older, middle-class and educated mothers. The 2005 survey also reported that 51% of mothers had introduced solids by 4 months and only 2% had delayed introducing solids until 6 months. Mothers giving solids when babies were 4-6 months were more likely to provide commercially prepared foods (85%) than home prepared (51%), and only 46% had given fruit. 6A substantial body of research has evaluated interventions aimed at increasing the initiation, and to lesser extent, the duration of breastfeeding.8 9 In contrast, very few well-designed studies have evaluated interventions focusing on the later stages of infant feeding beyond breastfeeding. 10Recent National Institute of Health and Clinical Excellence (NICE) guidance has highlighted the paucity o...

IMPORTANCE Recovery from concussion generally follows a trajectory of gradual improvement, but symptoms can abruptly worsen with exertion. This phenomenon is poorly understood. OBJECTIVES To characterize the incidence, course, and clinical significance of symptom exacerbations (spikes) in children after concussion. DESIGN, SETTING, AND PARTICIPANTS This secondary analysis of clinical trial data analyzes 63 eligible participants prospectively recruited from an emergency department who were asked to complete a postconcussion symptom scale and record their activities in a structured diary for the next 10 days. They completed standardized assessments of symptoms (postconcussion symptom scale), cognition (Immediate Post-Concussion Assessment and Cognitive Testing), and balance (Balance Error Scoring System) 10 days following the injury. Eligible participants were aged 11 to 18 years and sustained a concussion (according to the Centers for Disease Control and Prevention criteria) that did not result in an abnormal computed tomography scan or require hospital admission. The trial was conducted from May 2010 to December 2012, and the analysis was conducted from November 2015 to February 2016. MAIN OUTCOME AND MEASURE The occurrence of symptom spikes, defined as an increase of 10 or more points on the postconcussion symptom scale over consecutive days. RESULTS Of the 63 participants, there were 41 boys (65.1%) and 22 girls (34.9%), and the mean (SD) age was 13.8 (1.8) years. Symptom spikes occurred in one-third of the sample (20 participants [31.7%]). Symptom spikes tended to partially resolve within 24 hours. An abrupt increase in mental activity (ie, returning to school and extracurricular activities) from one day to the next increased the risk of a symptom spike (relative risk, 0.81; 95% CI, 0.21-3.21), but most symptom spikes were not preceded by a documented increase in physical or mental activity. Patients with symptom spikes were initially more symptomatic in the emergency department and throughout the observation period but did not differ from the group without symptom spikes on cognition or balance 10 days following injury. CONCLUSIONS AND RELEVANCE Certain patients appeared susceptible to high and variable symptom reporting. Symptom spikes may not themselves be detrimental to recovery. The present findings support clinical guidelines for adolescents to return to school and activities gradually after concussion. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01101724

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In comparison with prior published data collected from 1999 to 2004, utilization and duration of SFWPs were higher in the current study samples (99.3% vs 60.3% of athletes reported an SFWP; mean duration, 6.1 vs 3.2 days), and athletes were withheld from sports for more days than previously reported (12.3 vs 7.4 days). Rate of same-season repeat concussion was equivalent to that of prior published data. The findings support improved adherence to clinical management guidelines through increased utilization of SFWPs after SRC.