Every year, almost half a million children across the United States visit emergency rooms for concussions. But recent studies find that number may undercount just how many kids really have concussions.

In fact, a study published in the June 20 edition of the journal Pediatrics estimates that the number of concussions among those 18 years old and younger is higher, possibly between 1.1 million and 1.9 million annually.

Currently, national rates of concussion from the Centers for Disease Control and Prevention are based on emergency room visits only. However, very few concussion diagnoses actually happen in the ER. According to researchers, more than half a million children with concussions were not seen in the ER or by a physician at all.

Analyzing data from three national databases tracking concussion -- MarketScan , the National Electronic Injury Surveillance System and the National High School Sports Related Injury Surveillance System -- researchers in the new study found that between 115,000 and 167,000 children's concussions were diagnosed in the ER. Doctor visits accounted for just 378,000 concussion diagnoses. The vast majority of children's concussions, between half a million and a million, were seen by an athletic trainer.

Another study done this year of the Children's Hospital of Philadelphia system evaluated more than 8,000 youth concussion diagnoses and found that 82% were made in a doctor's office; just 12% of diagnoses were made in the ER.

The bottom line is that most kids are getting diagnosed outside the emergency room, and as a result, the number of concussions among children may be much higher than thought.

'We aren't looking in the right places'

According to the CDC, which helped fund and support the research from Children's Hospital of Philadelphia, that study "highlights a substantial gap in how the United States currently estimates the nation's burden of pediatric concussions, and underscores the need for better surveillance."

Kristy Arbogast , lead author of the paper, said, "If, as a country, we're relying on [emergency room visits], we're probably missing a meaningful majority of [concussions] that we aren't counting because we aren't looking in the right places to count."

President Obama's 2017 budget includes a request for $5 million to establish and oversee a National Concussion Surveillance System that would track concussions through a national household telephone survey system.

Arbogast is a scientific director at the Center for Injury Research and Prevention at the Children's Hospital of Philadelphia. She and her team looked at concussion diagnoses in that hospital's system, which, along with the hospital and doctors' practices, includes two urgent-care centers.

They found that while there tends to be a lot of concern about concussion among high school athletes and older children, a third of concussion diagnoses happened in children younger than 12. Children under the age of 4 were most likely to get their diagnoses in the ER, while older children were more likely to go to a pediatrician's office.

Despite concerns over underreporting, Arbogast believes that the findings were very positive, because pediatricians were being utilized over ERs.

She said that concussion diagnoses can be very nuanced and that ERs weren't always best equipped to diagnose them. "Until we get objective measures of concussion -- we don't have a blood test; we don't have an X-ray -- we believe a pediatrician is best suited to diagnose a concussion because of its subjective nuance presentation."

Dr. Ari Brown, a pediatrician and author of "Expecting 411," agreed: "Families can and should utilize their child's primary care provider first for most of these injuries. Most children do not need an imaging study. They just need a thorough medical evaluation, education on brain rest and return to play/learning, and follow-up to ensure the injury has resolved."

When should you go to the hospital?

Tamara McLeod, director of the athletic training program at A.T. Still University in Missouri, said there are some red flags that warrant an ER trip, including:

if the child's mental status is deteriorating

if the child can't carry on a coherent conversation

if the child continues to vomit

if their eyes aren't tracking and they can't keep their gaze on you

"With children, any loss of consciousness, you probably want to have them evaluated in the ER," McLeod said.

However, Dr. Jordan Metzl, a sports medicine specialist at the the Hospital for Special Surgery in New York, said the ER should not be the first stop.

"The ER is very expensive, not a cost-efficient way of doing care," he said. Instead, Metzl advises to first talk to your health care provider.

Metzl said recent awareness of concussions has heightened parents' concern about the issue. "The end result is this almost hysteria about this injury. ... The vast majority of young athletes [conditions] resolve within less than a day and never have any problems the rest of their lives."

But Metzl added that "concussion is a serious injury when it happens. ... For a long time in the sports medicine world, we probably didn't do nearly good enough job taking care of it."

Source: CNN