Evidence Base for Medical Authority (Pediatrician) Decision Support - Youth Football Scenarios Project Overview and Goals Adolescents prefer independent decision making and rely on authoritative information and evidence to consider alternative options recommended by caregivers. Coaches are often not informed of concussions due to heading frequency in football. For example, the Scottish Football Association advises “low priority heading for youth” - 14s and 15s are to practice not more than one heading session per week. However, this has not been implemented and a coaching club typically has three sessions in one week. To assist this age group in assessing risk, the participation of sports authorities, academic authorities, and medical authorities is required, who in turn, may be supported by available research evidence base. An informed ecosystem will ensure young athletes know when to report a concussion and prioritize optimal health for smooth transition into emerging adulthood. This project is intended to inform of concussions from heading in youth football. The education is based on a comprehensive literature review based on evidence from the past five years.

1. Evidence Base for Medical Authority (Pediatrician) Decision
Support - Youth Football Scenarios
Safia Fatima Mohiuddin
Researcher and Scientific Writer
Contact Information: safia_fatima@yahoo.com; safia.fatima@gmail.com;
+91 8019202091

2. Evidence Base for Medical Authority (Pediatrician) Decision Support
Youth Football Scenarios
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Overview of Concussion Reporting and Management
● The first step to concussion prevention is to follow recommended
regulations in heading that is age-appropriate (for example, in 14s and
15s, heading practice is not recommended more than once per week).
● In youth football, a suspected concussion that happens in a coaching
club is observed by a bystander, coach, caregiver, or player and
reported to the coach. The coach removes the player from play.
● Then the player is referred to a pediatrician who assesses the condition
of the player and makes the necessary referrals.
● Care coordination and management for concussions is undertaken
based on globally relevant protocols.
● The pediatrician in consultation with the specialist care team finally
makes the decision to return to sport (RTS) and return to learn (RTL).
● Thereafter, the academic institution and caregivers at the residential
setting have to support the player to full recovery as advised by the
pediatrician (such as reduction in screen time, rest, or
physician-supervised exercise).
● Baseline testing is done before and after season to check the cognitive
profile of a player and the pediatrician or specialist physician is
involved in interpreting the results.
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4. Evidence Base for Medical Authority (Pediatrician) Decision Support
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Information to Assist in Pediatric Decision Making
Handout (Baseline Testing Protocols for Coaches, Team Physician, and
Athlete Reference): Identification and Baseline Testing for
Concussions
Covers:
1. CDC "Heads Up" Concussion Guidelines
2. Scottish Concussion Identification Guidelines
3. Understanding and Measuring Brain Strain On Field
4. Importance of Baseline Testing
5. Popular Baseline Testing Tools
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eBook and Research Paper (Thematic Analysis for RTS Decision-Support):
RTS with Certainty
[Evidence Base for Balanced Decision-Making Pertaining to Youth
Participation, Safety, and Efficacy]
Covers:
Chapter 1 - Introduction and Overview...................................................................4
Background Information........................................................................................ 4
Target Audience................................................................................................... 5
Methodology Used................................................................................................ 5
Chapter 2 - Inferences on Influencers.................................................................... 6
Part 1: Coach and Referee Involvement...................................................................6
Part 2: Player Characteristics................................................................................. 7
Part 3: Drill Intensity............................................................................................ 9
Part 4: Physician / Clinician Role........................................................................... 10
Part 5: Parent Involvement.................................................................................. 12
Part 6: Use of Protective Equipment...................................................................... 14
Part 7: Heading Incidence....................................................................................15
Part 8: Other Injury Incidence.............................................................................. 18
Part 9: Race and Ethnicity....................................................................................19
Part 10: Age and Gender..................................................................................... 21
Part 11: Ball Characteristics................................................................................. 22
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Chapter 3 - Inferences on Consequence................................................................24
Part 1: Brain Health............................................................................................ 24
Part 2: Neck Injuries........................................................................................... 26
Part 3: Cardiac Performance.................................................................................26
Part 4: Postural Control....................................................................................... 26
Part 5: Emergency Department Visits.................................................................... 27
Chapter 4- Inferences on Measurement............................................................... 28
Part 1: Strain Based Metrics................................................................................. 28
Part 2: Kinematics Analysis.................................................................................. 28
Part 3: Artificial Intelligence................................................................................. 31
Part 4: Brain Metrics........................................................................................... 32
Chapter 5 - Inferences on Intervention.................................................................35
Part 1: Behavioral Interventions........................................................................... 35
Part 2: Regulation...............................................................................................36
Part 3: Player Protection...................................................................................... 36
Part 4: Machine Learning and Data Science............................................................ 36
Part 5: Exercise Intervention................................................................................ 38
Part 6: Timely and Appropriate Care......................................................................39
Conclusion............................................................................................................ 40
Acronyms Used..................................................................................................... 41
References............................................................................................................43
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eBook and Research Paper (Background Information and Resource List for
Pediatrician and Concussion Care Team): The Pediatrician's
Hummingbird
[Exploring Injury Profiles, Navigating & Measuring Patient Journey for
Pediatric Concussion Management in Youth Football]
Covers:
Part 1: Adolescence & Emerging Adulthood, the Developing Brain,
and Trauma
Traumatic Brain Injury..........................................................................................11
Emerging Adulthood, Brain Function, and Trauma................................................ 11
Brain Injury and High Risk Behavior...................................................................... 12
TBI in Childhood and Emerging Adulthood..............................................................12
Nature of Trauma in Soccer Heading......................................................................12
Brain Injury in Adolescence and Academic Outcomes........................................... 12
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TBI in Adolescence - Onset, Mechanism, Physical Injuries, and Academic Performance. 13
Persistence, Academic Outcomes, and Emerging Adulthood...................................... 14
TBI in Adolescence, High School Exiting, and Future Productivity...............................14
TBI in Adolescence and Development Outcomes...................................................17
TBI in Adolescence and Family Resilience............................................................... 17
Trauma, Emerging Adulthood, and Developmental Trajectories..................................17
Positive and Negative Trajectories in Emerging Adulthood....................................18
Emerging Adulthood as a Cultural Concept........................................................ 18
Elements of the Emerging Adulthood Trajectory................................................. 18
Chronic Illness in Emerging Adulthood.............................................................. 19
Risk Factors and Protective Factors in Emerging Adulthood.................................. 20
Perspectives on Incidence of Concussions............................................................ 21
American Academy of Pediatrics Concussion Incidence Trends...................................21
Increased Concussion Incidence may be due to Increased Reporting..........................24
Recurrent Concussion Risk in Children and Adolescents....................................... 24
Systematic Review Findings Indicate Four Times Higher Risk.................................... 24
Intrinsic and Extrinsic Factors Affecting Risk of Recurrent Concussion.........................25
Concussions, Multiple Health Domains, and the Need for Physician Oversight...... 26
Brain Injury Criteria in Sports...............................................................................27
Summary of Injury Profiles in Youth Football....................................................... 29
Part 2: Navigating and Measuring the Sports Related Concussion
(SRC) Patient Journey
Introduction to Pediatric Trauma Management.....................................................44
Pediatric Trauma Informed Care........................................................................... 45
AAP Guidelines for Pediatric Trauma Informed Care................................................. 45
Trauma Informed Care in Child health Systems - AAP Policy Statement...................... 47
Patient Journey Overview in Multidisciplinary Pediatric SRC Management............48
Concussion Clinical Care Guidelines Update.......................................................... 50
CHEO (2022) - Peds Concussion........................................................................... 50
Section A, B, and C of Living Guideline with 16 Clinical Domains.......................... 50
Living Guideline Post Concussion Information Sheet........................................... 52
5P Score for Referral to a Multidisciplinary Concussion Team................................52
Peds Concussion Recommendation Summary for Parents, Youth, Teachers,
Caregivers, and Athletes.................................................................................53
360 Concussion - Advances in Concussion Care...................................................... 54
Brain Injury Foundation Concussion Guidelines....................................................... 55
CDC Guideline for mTBI Diagnosis and Management in Children................................55
CDC mTBI Management Guidance for Sports Medicine Providers............................... 56
Mapping Patient Flow in Pediatric Trauma............................................................... 57
Background Information on Pediatric Trauma Care..............................................57
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Significance of the Research Study...................................................................57
Description of the Level I Trauma Care Setting...................................................57
Description of Process Mining Approach and Key Deductions................................ 59
Emergency Management Protocols........................................................................ 60
Overview of Emergency Management............................................................... 60
The CATCH Rule in Emergency Management...................................................... 61
Severe TBI Management in Pediatric Patients.....................................................61
Brain Trauma Foundation Coma Guidelines................................................... 61
Research-Based Severe Pediatric TBI Management Plan................................. 63
Ophthalmologist Guidelines for Pediatric Trauma................................................ 71
Ocular Trauma in Children..........................................................................71
Pre-Ophthalmologist Ocular Trauma Management..........................................71
Trauma Management for Pediatric Ophthalmic Conditions............................... 72
Individual Approach to Managing Ocular Trauma in Pediatric Population............72
Evidence Base for ICU Nutritionist for Improved Brain Injury Outcomes.................73
Trauma Care Guidelines for Low Resource Contexts................................................. 78
Detailed Prehospital Care Guidelines with Perspectives for LMICs..........................78
Pediatric Trauma Care in Low Resource Settings.................................................80
Pre-Hospital Systems Triage....................................................................... 81
Emergency Department Management.......................................................... 81
Surgical Management................................................................................ 82
Adapted Traumatic Brain Injury Evaluation and Management for LMICs............ 82
Specific Injury Management Protocols for LMICs............................................83
Rehabilitation Protocols....................................................................................... 88
Guidelines for Communication & Swallowing Disorders in Pediatric TBI.................. 88
Physical Therapy Clinical Practice Guidelines...................................................... 91
CDC Protocol for Neuropsychologists................................................................ 92
Physiotherapy in Concussion Rehabilitation........................................................93
Chiropractor Role and Contribution in Concussion Care....................................... 94
Chiropractor Contribution to Concussion Care............................................... 94
Role of Chiropractor in Concussion Management............................................97
Occupational Therapy Guidelines......................................................................98
Occupational Therapy and Play Practice Guideline..........................................98
Pediatric Occupational Therapy in School Settings......................................... 99
Otolaryngologist Guidelines........................................................................... 100
Radiologist Guidelines in Identifying Trauma.................................................... 102
Identification and Characterization of Head Trauma Imaging Evaluation..........102
CDC Neuroimaging Guidelines for Pediatric mTBI and Advanced Imaging
Biomarkers............................................................................................ 103
Audiologist Guidelines for Pediatric TBI........................................................... 105
Pediatric TBI from Audiology Perspective.................................................... 105
The Role of the Audiologist....................................................................... 105
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Audiologist Screening.............................................................................. 106
Audiologic Assessment in Pediatric TBI.......................................................106
Treatment Approaches............................................................................. 107
Balance System Disorders........................................................................ 107
American Academy of Audiology Practice Guidelines and Standards............... 108
Optometrist Pediatric Guidelines.....................................................................108
The Inclusion of Optometrists in Post - Concussion Care............................... 108
AOA Comprehensive Guideline for Pediatric Eye and Vision Examination......... 109
Oculomotor Behavior as a Biomarker for Diagnosing TBI.............................. 110
Psychiatrist Involvement in Pediatric TBI......................................................... 110
Risk Assessment of Mental Health Conditions Following Concussion................110
Mental Health Conditions following TBI.......................................................111
Mood and Anxiety Conditions following Pediatric mTBI..................................111
Barriers and Facilitators for Psychiatric Referrals among Family Physicians...... 112
Recreation Therapy following Brain Injury........................................................113
Possible Roles of Social Workers Following TBI................................................. 114
Guidelines for Making Specialist Referrals for Pediatric TBI.................................115
Ophthalmology Referral Guidelines............................................................ 115
Return to Sports (RTS) Concussion Protocol.....................................................115
Return to Learn (RTL) Concussion Protocol...................................................... 115
Concussion Service Delivery Models (SDMs) and Cost Analysis...........................116
Generalist-Based Services.................................................................................. 116
Specialist Based Services................................................................................... 117
Web / Telemedicine Services...............................................................................117
Cost of Care..................................................................................................... 118
Social determinants of Health in Diagnosing and Managing Concussions............ 119
Evidence on Pediatric TBI Outcomes...................................................................120
Health-Related Quality of Life (HR QoL) after SRC................................................. 120
Persistent Post Concussion Symptoms (PPCS) Characteristics..................................121
Concussion Outcomes with Concomitant ADHD..................................................... 121
Effect of SRC on Cognitive Function..................................................................... 122
Post-Concussion Physical Activity and Positive Outcomes........................................ 123
Rest Based Concussion Management.................................................................. 124
Mental Health Outcomes Following Concussion......................................................124
Altered Brain Structure and Function Following Concussion..................................... 126
Sleep Quality Following Concussion..................................................................... 127
Headaches Following Pediatric Concussion............................................................ 128
Visio-Vestibular and Oculomotor Outcomes...........................................................128
Academic Outcomes after SRC............................................................................129
Parental Experiences following Pediatric Concussion...............................................130
Behavioral and Emotional Outcomes.................................................................... 130
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Health Services Utilization..................................................................................131
Outcome Measures..............................................................................................133
Biopsychosocial Models................................................................................. 134
CanPedCDE Framework.................................................................................134
Treatment Adherence......................................................................................... 135
Concussion Quality Measurement....................................................................... 135
Neurology Quality Improvement..........................................................................135
Best Practices in Trauma Surgery........................................................................ 136
More Information................................................................................................138
Abbreviations and Terms Used............................................................................141
Bibliography........................................................................................................143
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Detailed Notes for Human Resource Personnel / Physician
/ Physician Assistant
The Problem with Concussions and Sub Concussions among Youth
Football Athletes
● Research evidence indicates that heading leads to concussions and
subclinical concussions that are asymptomatic. Concussions lead to
transient loss of function, inflammation, and brain injury sequelae
overtime.
● Young athletes may face worse health outcomes due to the effect of
cumulative subclinical concussions (repeated head impacts) such
as problems with myelination and difficulty transitioning from
adolescence into emerging adulthood due to unhealed trauma.
● When an athlete experiences a concussion following another during a
short period there is an increased risk of second impact syndrome
with catastrophic consequences and increased mortality risk.
● Other common injuries requiring medical attention through the
developmental period include Anterior Cruciate Ligament (ACL)
injuries and growth plate injuries.
● Stress during emerging adulthood must be mitigated to protect
normal development processes
○ These processes promote synaptic pruning, myelination,
alterations in neurotransmitter density, white and gray matter
differentiation, programmed cell death, gliogenesis, and
synaptogenesis.
○ The normal progression of these processes protects against
impulsivity, risk-taking behaviors, novelty seeking, and
emotional instability during the critical adolescence period.
○ Pediatric oversight during this period protects against major
chronic diseases and psychosocial impairments.
○ Emerging adults (EAs) in post secondary education have
difficulty with persistence (meeting minimal academic standards
in post secondary education), and EAs with TBI have higher risk
of dropout. Neurorehabilitation following injury promotes the
attainability of a diploma.
Why Stakeholders Must be Informed
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Stakeholders of this youth football ecosystem must be informed:
● To reduce risk
● To encourage concussion reporting
● To initiate preventive mechanisms
● To lead the young athlete to full recovery and successful
sportsmanship.
What Stakeholders Can do to Promote Positive Health Outcomes
among Youth Football Athletes
A change in attitude to organize the game around the best interests of every
athlete is needed with the participation of stakeholders of the soccer /
football ecosystem:
● The coaches and sports organizations who implement rules,
initiate rule change, help prevent concussions, and report concussions.
● The pediatricians and concussion care team who reward for
reporting concussions in an age-specific manner, diagnose, monitor,
and rehabilitate concussions and sub concussions, engage in clinical
decision making during baseline testing, make referrals for
rehabilitation services, issue return to sport (RTS) and return to learn
(RTL) clearance, and advise academic authorities until child’s
successful return to full academic workload.
● The academicians and caregivers, who under the oversight of the
pediatrician, implement gradual return to learn (RTL) protocol, initiate
educational initiatives to inform students and caregivers of concussion
risk and consequences, and report any new concussion cases to the
pediatrician.
Project Overview and Goals
Adolescents prefer independent decision making and rely on authoritative
information and evidence to consider alternative options recommended by
caregivers. Coaches are often not informed of concussions due to heading
frequency in football. For example, the Scottish Football Association advises
“low priority heading for youth” - 14s and 15s are to practice not more than
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14. Evidence Base for Medical Authority (Pediatrician) Decision Support
Youth Football Scenarios
____________________
one heading session per week. However, this has not been implemented and
a coaching club typically has three sessions in one week.
To assist this age group in assessing risk, the participation of sports
authorities, academic authorities, and medical authorities is required, who in
turn, may be supported by available research evidence base. An informed
ecosystem will ensure young athletes know when to report a concussion and
prioritize optimal health for smooth transition into emerging adulthood.
This project is intended to inform of concussions from heading in youth
football. This education is based on a comprehensive literature review based
on evidence from the past five years.
Author Information
Safia Fatima Mohiuddin
Researcher and Scientific Writer
MSc. Bioinformatics; Graduate Certificate in Healthcare Management (USA)
Training Received for this Project
1. Graduate Certificate in Healthcare Management, Union Graduate
College of Union University, Schenectady, NY, June 2011
2. Public Health 101 Series - Introduction to Public Health, CDC Train,
Nov 2023
3. Public Health 101 Series - Introduction to Epidemiology, CDC Train,
Sept 2023
4. HEADS UP to Youth Sports Coaches: Online Concussion Training, CDC,
Sept 2023
5. HEADS UP Concussion Training for Youth Sports Coaches, CDC, May
2023
6. Risk and Evidence Communication in Public Health, University of
Cambridge - Winton Center for Risk and Evidence Communication, Dec
2023
7. Understanding Traumatic Brain Injury, Wicking Dementia Research and
Education Center, University of Tasmania, Aug 2023
8. WHO-ICRC Basic Emergency Care: approach to the acutely ill and
injured, WHO, Dec 2023
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15. Evidence Base for Medical Authority (Pediatrician) Decision Support
Youth Football Scenarios
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9. Trauma Basics for Youth Workers, Center for Adolescent Studies, July
2023
10. Introduction to Child Psychology, The Open University, Oct 2023
11. An Introduction to Social Work, The Open University, Oct 2023
12. Starting with Psychology, The Open University, Oct 2023
13. Concussion Management Implementation and ImPACT, ImPACT
Applications Inc, Sept 2023
14. ImPACT Pediatric Onboarding Bundle, ImPACT Applications Inc, Sept
2023
15. ImPACT Baseline Test Administration, ImPACT Applications Inc, June
2023
16. Concussion Awareness Training Tool (CATT) - Parent or Caregiver, BC
Injury Research and Prevention Unit, BC Children’s Hospital, Jan 2024
17. Concussion Awareness Training Tool (CATT) - School Professional, BC
Injury Research and Prevention Unit, BC Children’s Hospital, Jan 2024
18. Soccer Practice Basics, Jim Buchanan, Oct 2023
19. Developing as a Youth Football Coach, Anthony Johns, Oct 2023
20. Krausko Football Training Program, KrausKo Sports, Oct 2023
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Copyright © 2023 by Safia Fatima Mohiuddin. All rights reserved.
No part of this content may be reproduced in any form - by electronic, mechanical, or
otherwise, including storage & retrieval systems, without written permission from the
author. All text and images are either in the public domain or copyright of the author.
Disclaimer
This content provides accurate and authoritative information about the subject matter
covered. Facts & opinions are summarized and available as per date of writing indicated.
The author holds no responsibility for the content or evidence summarized or linked in
the text. The inclusion of authors & links does not imply any sort of endorsement. The
author has used the best efforts in preparing this material. However, this does not imply
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disclaims any implied warranties of merchantability or fitness for a particular purpose.
The enclosed content is for the purpose of information & discussion only. It does not act
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when appropriate. No liability or responsibility rests with the author for damage(s) or
loss of profit incurred as a result of implementing the advice(s) mentioned. The advice
and strategies explained in the enclosed content may not be suitable for your situation.
No warranty may be created or extended in written sales materials or by sales
representatives.
About the Author
Safia Fatima Mohiuddin is a researcher and scientific writer with over a decade of
content development experience in Bioinformatics, Health Administration and Safety,
Artificial Intelligence, and Data Science.
About the Initiative
“The Rhythms of Al Musawwir” initiative is for pediatric concussion preparedness. It is a
health education campaign for disseminating information to the football athletic
ecosystem on preventing and managing pediatric concussions (Players, Caregivers,
Coaches, Policy Makers, Baseline Testing Providers, First Responders, Pediatricians,
Multidisciplinary Care Team):
[1] Risk potential, short & long-term consequences of football heading and contact
during sport
[2] Latest international football (heading) safety guidelines
[3] Concussion preparedness for Community First Responders (CFRs)
[4] Trauma-informed clinical guidelines, return-to-sport (RTS) and return-to-learn (RTL)
protocols for pediatricians
[5] Concussion management for the multidisciplinary care team.
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