Archive for the ‘Pediatrics’ Category

Background Television in the Homes of US Children

October 1, 2012 Comments off

Background Television in the Homes of US Children

Source: Pediatrics

OBJECTIVE: US parents were surveyed to determine the amount of background television that their children are exposed to as well as to isolate demographic factors associated with increased exposure to background television. After this, we ask how certain home media practices are linked to children’s background television exposure.

METHODS: US parents/caregivers (N = 1454) with 1 child between the ages of 8 months and 8 years participated in this study. A nationally representative telephone survey was conducted. Parents were asked to report on their child’s exposure to background television via a 24-hour time diary. Parents were also asked to report relevant home media behaviors related to their child: bedroom television ownership, number of televisions in the home, and how often a television was on in the home.

RESULTS: The average US child was exposed to 232.2 minutes of background television on a typical day. With the use of multiple regression analysis, we found that younger children and African American children were exposed to more background television. Leaving the television on while no one is viewing and children’s bedroom television ownership were associated with increased background television exposure.

CONCLUSIONS: Although recent research has shown the negative consequences associated with background television, this study provides the first nationally representative estimates of that exposure. The amount of exposure for the average child is startling. This study offers practitioners potential pathways to reduce exposure.

The Role of Herd Immunity in Parents’ Decision to Vaccinate Children: A Systematic Review

September 1, 2012 Comments off

The Role of Herd Immunity in Parents’ Decision to Vaccinate Children: A Systematic Review
Source: Pediatrics

BACKGROUND AND OBJECTIVE: Herd immunity is an important benefit of childhood immunization, but it is unknown if the concept of benefit to others influences parents’ decisions to immunize their children. Our objective was to determine if the concept of “benefit to others” has been found in the literature to influence parents’ motivation for childhood immunization.

METHODS: We systematically searched Medline through October 2010 for articles on parental/guardian decision-making regarding child immunization. Studies were included if they presented original work, elicited responses from parents/guardians of children <18 years old, and addressed vaccinating children for the benefit of others.

RESULTS: The search yielded 5876 titles; 91 articles were identified for full review. Twenty-nine studies met inclusion criteria. Seventeen studies identified benefit to others as 1 among several motivating factors for immunization by using interviews or focus groups. Nine studies included the concept of benefit to others in surveys but did not rank its relative importance. In 3 studies, the importance of benefit to others was ranked relative to other motivating factors. One to six percent of parents ranked benefit to others as their primary reason to vaccinate their children, and 37% of parents ranked benefit to others as their second most important factor in decision-making.

CONCLUSIONS: There appears to be some parental willingness to immunize children for the benefit of others, but its relative importance as a motivator is largely unknown. Further work is needed to explore this concept as a possible motivational tool for increasing childhood immunization uptake.

A Systematic Review of Vocational Interventions for Young Adults With Autism Spectrum Disorders

August 31, 2012 Comments off

A Systematic Review of Vocational Interventions for Young Adults With Autism Spectrum Disorders
Source: Pediatrics

BACKGROUND AND OBJECTIVE: Many individuals with autism spectrum disorders (ASDs) are approaching adolescence and young adulthood; interventions to assist these individuals with vocational skills are not well understood. This study systematically reviewed evidence regarding vocational interventions for individuals with ASD between the ages of 13 and 30 years.

METHODS: The Medline, PsycINFO, and ERIC databases (1980–December 2011) and reference lists of included articles were searched. Two reviewers independently assessed each study against predetermined inclusion/exclusion criteria. Two reviewers independently extracted data regarding participant and intervention characteristics, assessment techniques, and outcomes, and assigned overall quality and strength of evidence ratings based on predetermined criteria.

RESULTS: Five studies were identified; all were of poor quality and all focused on on-the-job supports as the employment/vocational intervention. Short-term studies reported that supported employment was associated with improvements in quality of life (1 study), ASD symptoms (1 study), and cognitive functioning (1 study). Three studies reported that interventions increased rates of employment for young adults with ASD.

CONCLUSIONS: Few studies have been conducted to assess vocational interventions for adolescents and young adults with ASD. As such, there is very little evidence available for specific vocational treatment approaches as individuals transition to adulthood. All studies of vocational approaches were of poor quality, which may reflect the recent emergence of this area of research. Individual studies suggest that vocational programs may increase employment success for some; however, our ability to understand the overall benefit of supported employment programs is limited given the existing research.

From the American Academy of Pediatrics: Circumcision Policy Statement

August 29, 2012 Comments off

From the American Academy of Pediatrics: Circumcision Policy Statement
Source: Pediatrics

Male circumcision is a common procedure, generally performed during the newborn period in the United States. In 2007, the American Academy of Pediatrics (AAP) formed a multidisciplinary task force of AAP members and other stakeholders to evaluate the recent evidence on male circumcision and update the Academy’s 1999 recommendations in this area. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV. The American College of Obstetricians and Gynecologists has endorsed this statement.

Weight Status Among Adolescents in States That Govern Competitive Food Nutrition Content

August 14, 2012 Comments off

Weight Status Among Adolescents in States That Govern Competitive Food Nutrition Content
Source: Pediatrics


To determine if state laws regulating nutrition content of foods and beverages sold outside of federal school meal programs (“competitive foods”) are associated with lower adolescent weight gain.


The Westlaw legal database identified state competitive food laws that were scored by using the Classification of Laws Associated with School Students criteria. States were classified as having strong, weak, or no competitive food laws in 2003 and 2006 based on law strength and comprehensiveness. Objective height and weight data were obtained from 6300 students in 40 states in fifth and eighth grade (2004 and 2007, respectively) within the Early Childhood Longitudinal Study–Kindergarten Class. General linear models estimated the association between baseline state laws (2003) and within-student changes in BMI, overweight status, and obesity status. Fixed-effect models estimated the association between law changes during follow-up (2003–2006) and within-student changes in BMI and weight status.


Students exposed to strong laws at baseline gained, on average, 0.25 fewer BMI units (95% confidence interval: −0.54, 0.03) and were less likely to remain overweight or obese over time than students in states with no laws. Students also gained fewer BMI units if exposed to consistently strong laws throughout follow-up (β = −0.44, 95% confidence interval: −0.71, −0.18). Conversely, students exposed to weaker laws in 2006 than 2003 had similar BMI gain as those not exposed in either year.


Laws that regulate competitive food nutrition content may reduce adolescent BMI change if they are comprehensive, contain strong language, and are enacted across grade levels.

Physical Punishment and Mental Disorders: Results From a Nationally Representative US Sample

July 2, 2012 Comments off

Physical Punishment and Mental Disorders: Results From a Nationally Representative US Sample (PDF)
Source: Pediatrics

BACKGROUND: The use of physical punishment is controversial. Few studies have examined the relationship between physical punishment and a wide range of mental disorders in a nationally representative sample. The current research investigated the possible link between harsh physical punishment (ie, pushing, grabbing, shoving, slapping, hitting) in the absence of more severe child maltreatment (ie, physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, exposure to intimate partner violence) and Axis I and II mental disorders.

METHODS: Data were from the National Epidemiologic Survey on Alcohol and Related Conditions collected between 2004 and 2005 (N = 34 653). The survey was conducted with a representative US adult population sample (aged ≥20 years). Statistical methods included logistic regression models and population-attributable fractions.

RESULTS: Harsh physical punishment was associated with increased odds of mood disorders, anxiety disorders, alcohol and drug abuse/dependence, and several personality disorders after adjusting for sociodemographic variables and family history of dysfunction (adjusted odds ratio: 1.36–2.46). Approximately 2% to 5% of Axis I disorders and 4% to 7% of Axis II disorders were attributable to harsh physical punishment.

CONCLUSIONS: Harsh physical punishment in the absence of child maltreatment is associated with mood disorders, anxiety disorders, substance abuse/dependence, and personality disorders in a general population sample. These findings inform the ongoing debate around the use of physical punishment and provide evidence that harsh physical punishment independent of child maltreatment is related to mental disorders.

Injuries Associated With Bottles, Pacifiers, and Sippy Cups in the United States, 1991–2010

May 18, 2012 Comments off
Source:  Pediatrics
To describe the epidemiology of injuries related to bottles, pacifiers, and sippy cups among young children in the United States.
A retrospective analysis was conducted by using data from the National Electronic Injury Surveillance System for children <3 years of age treated in emergency departments (1991–2010) for an injury associated with a bottle, pacifier, or sippy cup.
An estimated 45 398 (95% confidence interval: 38 770–52 026) children aged <3 years were treated in emergency departments for injuries related to these products during the study period, an average of 2270 cases per year. Most injuries involved bottles (65.8%), followed by pacifiers (19.9%) and sippy cups (14.3%). The most common mechanism was a fall while using the product (86.1% of injuries). Lacerations comprised the most common diagnosis (70.4%), and the most frequently injured body region was the mouth (71.0%). One-year-old children were injured most often. Children who were aged 1 or 2 years were nearly 2.99 times (95% confidence interval: 2.07–4.33) more likely to sustain a laceration compared with any other diagnosis. Product malfunctions were relatively uncommon (4.4% of cases).
This study is the first to use a nationally representative sample to examine injuries associated with these products. Given the number of injuries, particularly those associated with falls while using the product, greater efforts are needed to promote proper usage, ensure safety in product design, and increase awareness of American Academy of Pediatrics’ recommendations for transitioning to a cup and discontinuing pacifier use.

Pharmacy Communication to Adolescents and Their Physicians Regarding Access to Emergency Contraception

March 29, 2012 Comments off

Pharmacy Communication to Adolescents and Their Physicians Regarding Access to Emergency Contraception (PDF)
Source: Pediatrics

OBJECTIVE: Emergency contraception (EC) is an effective pregnancy prevention strategy. EC is available without a prescription to those aged 17 years or older. The objective of this study was to assess the accuracy of information provided to adolescents and their physicians when they telephone pharmacies to inquire about EC.

METHODS: By using standardized scripts, female callers telephoned 943 pharmacies in 5 US cities posing as 17-year-old adolescents or as physicians calling on behalf of their 17-year-old patients. McNemar tests were used to compare outcomes between adolescent and physician callers.

RESULTS: Seven hundred fifty-nine pharmacies (80%) indicated to adolescent callers, and 766 (81%) to physician callers, that EC was available on the day of the call. However, 145 pharmacies (19%) incorrectly told the adolescent callers that it would be impossible to obtain EC under any circumstances, compared with 23 pharmacies (3%) for physician callers. Pharmacies conveyed the correct age to dispense EC without a prescription in 431 adolescent calls (57%) and 466 physician calls (61%). Compared with physician callers, adolescent callers were put on hold more often (54% vs 26%) and spoke to self-identified pharmacists less often (3% vs 12%, P < .0001). When EC was not available, 36% and 33% of pharmacies called by adolescents and physicians respectively offered no additional suggestions on how to obtain it.

CONCLUSIONS: Most pharmacies report having EC in stock. However, misinformation regarding who can take EC, and at what age it is available without a prescription, is common. Such misinformation may create barriers to timely access.

Stair-Related Injuries to Young Children Treated in US Emergency Departments, 1999–2008

March 15, 2012 Comments off

Stair-Related Injuries to Young Children Treated in US Emergency Departments, 1999–2008
Source: Pediatrics

OBJECTIVE: The objective of this study was to investigate the epidemiologic characteristics and secular trends of stair-related injuries among children aged <5 years treated in US emergency departments.

METHODS: A retrospective analysis was conducted of data from the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission from 1999 through 2008 by using sample weights to estimate national numbers and rates of stair-related injuries.

RESULTS: An estimated 931 886 children aged <5 years were treated for stair-related injuries from 1999 through 2008, averaging 93 189 injuries per year and 46.5 injuries per 10 000 population annually. The number of injuries per year decreased significantly by 11.6% from 1999 to 2008. The rate of stair-related injuries also decreased significantly from 53.0 to 42.4 per 10 000 population from 1999 to 2008. Soft tissue injuries accounted for 34.6% of cases. Approximately three-fourths (76.3%) of children had injuries to the head and neck region, and 2.7% of patients were hospitalized. Children who were being carried at the time of injury accounted for 24.5% of injuries among children <1 year and were more than 3 times more likely to be hospitalized than children injured by other mechanisms.

CONCLUSIONS: Stair-related injuries are on the decline but still represent an important source of injury to young children. Increased prevention efforts are needed, including parental education and improved stairway design, to decrease stair-related injuries among young children.

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Contemporary Ethical Issues in Human Milk-Banking in the United States

November 24, 2011 Comments off

Contemporary Ethical Issues in Human Milk-Banking in the United States
Source: Pediatrics

Donor human milk has been used in the United States for >90 years, but recent advances in human milk science and laboratory techniques have led to increasing use of this resource. Pediatricians began using donor human milk in the 1900s in response to anecdotal observation that premature infants had better health outcomes when receiving their own mothers’ milk. Since then, a formalized human milk-banking system developed in the mid-1980s and distributed >1 million ounces of pasteurized donor human milk in 2008. Despite growth in the use of pasteurized donor human milk, there is little discussion in the medical literature regarding the ethical considerations of collection and use of this resource. Key ethical considerations include issues surrounding medical decision-making and informed consent, increasing the limited supply of human milk, how ethically to allocate this scarce resource, and concerns linked to the marketing of a human milk.

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Temperature of Foods Sent by Parents of Preschool-aged Children

October 20, 2011 Comments off

Temperature of Foods Sent by Parents of Preschool-aged Children (PDF)
Source: Pediatrics

Objective: To measure the temperatures of foods in sack lunches of preschool-aged children before consumption at child care centers.

Methods: All parents of 3- to 5-year-old children in full-time child care at 9 central Texas centers were invited to participate in the study. Foods packed by the parents for lunch were individually removed from the sack and immediately measured with noncontact temperature guns 1.5 hours before food was served to the children. Type of food and number of ice packs in the lunch sack were also recorded. Descriptive analyses were conducted by using SPSS 13.0 for Windows.

Results: Lunches, with at least 1 perishable item in each, were assessed from 235 parent-child dyads. Approximately 39% (n = 276) of the 705 lunches analyzed had no ice packs, 45.1% (n = 318) had 1 ice pack, and 88.2% (n = 622) of lunches were at ambient temperatures. Only 1.6% (n = 22) of perishable items (n = 1361) were in the safe temperature zone. Even with multiple ice packs, the majority of lunch items (>90%) were at unsafe temperatures.

Conclusions: These results provide initial data on how frequently sack lunches sent by parents of preschool-aged children are kept at unsafe temperatures. Education of parents and the public must be focused on methods of packing lunches that allow the food to remain in the safe temperature zone to prevent foodborne illness.

Profanity in Media Associated With Attitudes and Behavior Regarding Profanity Use and Aggression

October 20, 2011 Comments off

Profanity in Media Associated With Attitudes and Behavior Regarding Profanity Use and Aggression (PDF)
Source: Pediatrics

Objective: We hypothesized that exposure to profanity in media would be directly related to beliefs and behavior regarding profanity and indirectly to aggressive behavior.

Methods: We examined these associations among 223 adolescents attending a large Midwestern middle school. Participants completed a number of questionnaires examining their exposure to media, attitudes and behavior regarding profanity, and aggressive behavior.

Results: Results revealed a positive association between exposure to profanity in multiple forms of media and beliefs about profanity, profanity use, and engagement in physical and relational aggression. Specifically, attitudes toward profanity use mediated the relationship between exposure to profanity in media and subsequent behavior involving profanity use and aggression.

Conclusions: The main hypothesis was confirmed, and implications for the rating industry and research field are discussed.

Policy Statement—Climatic Heat Stress and Exercising Children and Adolescents

October 5, 2011 Comments off

Policy Statement—Climatic Heat Stress and Exercising Children and Adolescents (PDF)
Source: Pediatrics

Results of new research indicate that, contrary to previous thinking, youth do not have less effective thermoregulatory ability, insufficient cardiovascular capacity, or lower physical exertion tolerance compared with adults during exercise in the heat when adequate hydration is maintained. Accordingly, besides poor hydration status, the primary determinants of reduced performance and exertional heat-illness risk in youth during sports and other physical activities in a hot environment include undue physical exertion, insufficient recovery between repeated exercise bouts or closely scheduled same-day training sessions or rounds of sports competition, and inappropriately wearing clothing, uniforms, and protective equipment that play a role in excessive heat retention. Because these known contributing risk factors are modifiable, exertional heat illness is usually preventable. With appropriate preparation, modifications, and monitoring, most healthy children and adolescents can safely participate in outdoor sports and other physical activities through a wide range of challenging warm to hot climatic conditions.

Recurrence Risk for Autism Spectrum Disorders: A Baby Siblings Research Consortium Study

August 18, 2011 Comments off

Recurrence Risk for Autism Spectrum Disorders: A Baby Siblings Research Consortium Study (PDF)
Source: Pediatrics

Objective: The recurrence risk of autism spectrum disorders (ASD) is estimated to be between 3% and 10%, but previous research was limited by small sample sizes and biases related to ascertainment, reporting, and stoppage factors. This study used prospective methods to obtain an updated estimate of sibling recurrence risk for ASD.

Methods: A prospective longitudinal study of infants at risk for ASD was conducted by a multisite international network, the Baby Siblings Research Consortium. Infants (n = 664) with an older biological sibling with ASD were followed from early in life to 36 months, when they were classified as having or not having ASD. An ASD classification required surpassing the cutoff of the Autism Diagnostic Observation Schedule and receiving a clinical diagnosis from an expert clinician.

Results: A total of 18.7% of the infants developed ASD. Infant gender and the presence of >1 older affected sibling were significant predictors of ASD outcome, and there was an almost threefold increase in risk for male subjects and an additional twofold increase in risk if there was >1 older affected sibling. The age of the infant at study enrollment, the gender and functioning level of the infant’s older sibling, and other demographic factors did not predict ASD outcome.

Conclusions: The sibling recurrence rate of ASD is higher than suggested by previous estimates. The size of the current sample and prospective nature of data collection minimized many limitations of previous studies of sibling recurrence. Clinical implications, including genetic counseling, are discussed.

Secondhand Smoke Exposure and Neurobehavioral Disorders Among Children in the United States

July 20, 2011 Comments off

Secondhand Smoke Exposure and Neurobehavioral Disorders Among Children in the United States
Source: Pediatrics

Objectives: The association between parent-reported postnatal secondhand tobacco smoke exposure in the home and neurobehavioral disorders (attention-deficit/hyperactivity disorder, learning disabilities, and conduct disorders) among children younger than 12 years in the United States was examined using the 2007 National Survey on Children’s Health. Excess neurobehavioral disorders attributable to secondhand smoke (SHS) exposure in the home in 2007 were further investigated.

Methods: The methods used in this study were multivariable logistic regression models that accounted for potential confounders and complex survey designs to evaluate associations.

Results: A total of 6% of 55 358 children (aged < 12 years), corresponding to a weighted total of 4.8 million children across the United States, were exposed to SHS in the home. The weighted prevalence and 95% confidence intervals of each of the children's neurobehavioral outcomes were 8.2% (7.5–8.8) with learning disabilities, 5.9% (5.5–6.4) with attention-deficit/hyperactivity disorder, and 3.6% (3.1–4.0) with behavioral and conduct disorders. Children exposed to SHS at home had a 50% increased odds of having ≥2 childhood neurobehavioral disorders compared with children who were not exposed to SHS. Boys had a significantly higher risk. Older children, especially those aged 9 to 11 years, and those living in households with the highest poverty levels were at greater risk. In absolute terms, 274 100 excess cases in total of these 3 disorders could have been prevented if children had not been exposed to SHS in their homes.

Conclusions: The findings of the study, which are associational and not necessarily causal, underscore the health burden of childhood neurobehavioral disorders that may be attributable to SHS exposure in homes in the United States.

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Grandparents Driving Grandchildren: An Evaluation of Child Passenger Safety and Injuries

July 20, 2011 Comments off

Grandparents Driving Grandchildren: An Evaluation of Child Passenger Safety and Injuries
Source: Pediatrics

Objectives: To compare restraint-use practices and injuries among children in crashes with grandparent versus parent drivers.

Methods: This was a cross-sectional study of motor vehicle crashes that occurred from January 15, 2003, to November 30, 2007, involving children aged 15 years or younger, with cases identified via insurance claims and data collected via follow-up telephone surveys. We calculated the relative risk of significant child-passenger injury for grandparent-driven versus parent-driven vehicles. Logistic regression modeling estimated odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for several child occupant, driver, vehicle, and crash characteristics.

Results: Children driven by grandparents comprised 9.5% of the sample but resulted in only 6.6% of the total injuries. Injuries were reported for 1302 children, for an overall injury rate of 1.02 (95% CI: 0.90–1.17) per 100 child occupants. These represented 161 weighted injuries (0.70% injury rate) with grandparent drivers and 2293 injuries (1.05% injury rate) with parent drivers. Although nearly all children were reported to have been restrained, children in crashes with grandparent drivers used optimal restraint slightly less often. Despite this, children in grandparent-driven crashes were at one-half the risk of injuries as those in parent-driven crashes (OR: 0.50 [95% CI: 0.33– 0.75]) after adjustment.

Conclusions: Grandchildren seem to be safer in crashes when driven by grandparents than by their parents, but safety could be enhanced if grandparents followed current child-restraint guidelines. Additional elucidation of safe grandparent driving practices when carrying their grandchildren may inform future child-occupant driving education guidelines for all drivers.

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Breastfeeding and Reduced Risk of Sudden Infant Death Syndrome: A Meta-analysis

June 23, 2011 Comments off

Breastfeeding and Reduced Risk of Sudden Infant Death Syndrome: A Meta-analysis (PDF)
Source: Pediatrics

Breastfeeding is protective against SIDS, and this effect is stronger when breastfeeding is exclusive. The recommendation to breastfeed infants should be included with other SIDS risk-reduction messages to both reduce the risk of SIDS and promote breastfeeding for its many other infant and maternal health benefits.

Early Autism Detection: Are We Ready for Routine Screening?

June 23, 2011 Comments off

Early Autism Detection: Are We Ready for Routine Screening? (PDF)
Source: Pediatrics

Background: Autism is a serious neurodevelopmental disorder that has a reportedly rising prevalence rate. The American Academy of Pediatrics recommends that screening for autism be incorporated into routine practice. It is important to consider the pros and cons of conducting autism screening as part of routine practice and its implications on the community. We have explored this question in the context of screening from a scientific point of view.

Method: A literature search was conducted to assess the effectiveness of community screening programs for autism.

Results: Judged against critical questions about autism, screening programs failed to fulfill most criteria. Good screening tools and efficacious treatment are lacking, and there is no evidence yet that such a program would do more good than harm.

Conclusions: On the basis of the available research, we believe that we do not have enough sound evidence to support the implementation of a routine population-based screening program for autism. Ongoing research in this field is certainly needed, including the development of excellent screening instruments and demonstrating with clinical trials that such programs work and do more good than harm.

Pediatric Submersion Events in Portable Above-Ground Pools in the United States, 2001-2009

June 23, 2011 Comments off

Pediatric Submersion Events in Portable Above-Ground Pools in the United States, 2001-2009 (PDF)
Source: Pediatrics

Results: There were 209 fatal and 35 nonfatal submersion cases reported to the commission from 2001 through 2009. The majority (94%) involved children younger than 5 years, 56% involved boys, 73% occurred in the child’s own yard, and 81% occurred during the summer months. The number of submersion events increased rapidly from 2001 to 2005 and then leveled off from 2005 to 2009.

Conclusions: The use of portable pools in residential settings poses a significant risk of submersion-related morbidity and mortality to children, especially in the <5-year-old age group. No single strategy will prevent all submersion deaths and injuries; therefore, layers of protection are recommended. Industry is advised to engage in development of protective devices that are effective and affordable for portable pools, including isolation fencing, pool alarms, and safety covers. A strong and pervasive consumer education campaign is needed to make consumers aware of the dangers of portable pools, because these small, inexpensive, consumer-installed pools may not generate the same sense of risk as an in-ground pool.

Epidemiology of Sudden Death in Young, Competitive Athletes Due to Blunt Trauma

June 23, 2011 Comments off

Epidemiology of Sudden Death in Young, Competitive Athletes Due to Blunt Trauma (PDF)
Source: Pediatrics

In a large community-based national registry, sudden deaths caused by blunt trauma in young athletes aged 21 years or younger were relatively uncommon with 16 or fewer per year, about fourfold less than cardiovascular deaths. These fatalities were most frequent in football, and an important proportion of deaths after head blows in high school football were associated with a recent history of symptomatic concussion.


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