New pediatric concussion guidelines – what you need to know

By: RICHARD HASKELL

Whoever said, “Youth is wasted on the young,” was probably envious of all their energy and exuberance!

Indeed, these attributes are ones that children and adolescents seem to have in abundance, clearly demonstrated by the myriad of physical activities and contact sports they enjoy both on and off the playground. As healthy as these activities are – and they should most definitely be encouraged – there is always the danger of injuries, including broken bones, sprained ligaments or tendons, and, probably the most serious of all, trauma to the head.

What we’ve known up to now

Head injuries fall into two categories, external and internal. While an external injury may appear more frightening, it is actually considerably less dangerous than an internal injury. There may be heavy bleeding followed by a ‘goose bump’, which eventually disappears within a few days or a week.

Internal injuries can include a fractured skull, torn blood vessels, or damage to the brain. They are considerably more serious and can lead to a brain injury or a loss of life. Concussions are the most common type of internal head injury. Derived from the Latin concutere (to shake violently), the word concussion is defined as “a traumatic brain injury which may alter the way the brain functions.”

Concussions can be caused by any blow to the head, face, neck or anywhere the body that results in a sudden jarring of the head. A person doesn’t need to be knocked out or lose consciousness to have had a concussion. Immediate symptoms may include headaches, difficulty falling or staying asleep, nausea, dizziness, confusion, issues with concentration, memory and problems with balance and coordination. These symptoms can last anywhere from a few minutes to several weeks after the injury.

According to Dr. Sherilyn Driscoll, a physician with the Mayo Clinic in Boston, concussions in children and adolescents can lead to serious health risks, particularly if the symptoms aren’t noticed immediately after the injury.

The risk magnifies if a person returns to physical activity too soon after the injury before the trauma has had time to heal. Worse, a second incident of head trauma shortly after the first may result in brain swelling, a condition known as Second Impact Syndrome (SIS). Once a child has suffered an initial concussion, he or she has a much higher risk of sustaining another, and the effects of multiple concussions over the years can be cumulative. There can be dire consequences. Rowan Stringer, an Ottawa high school rugby player died as a result of SIS shortly after a game in May of 2013.

Recent Findings

In June, 2014, Dr. Roger Zemek, a scientist at Ottawa’s Children’s Hospital in Eastern Ontario, presented the first guidelines on the effects of concussions on children and adolescents. Zemek teamed up with the Ontario Neurotrauma Foundation and chaired a 30-member panel, which reviewed 4000 papers with the latest evidence about concussions in children.

Stemming from Zemek’s conclusions were three recommendations for children suffering from concussions:

• longer rest periods
• no physical activity for up to 30-days
• a limited amount of time devoted to cognitive brain activity with limited or no recreational time spent on television or computer games.

The guidelines recommend that if a player demonstrates a concussion-like symptom such as vomiting or a failed memory test, he or she should be removed from the game immediately.  Another discovery: researchers found that in addition to the usual physical symptoms, young people also frequently experienced signs of irritability, sadness and anxiety following a concussion.

Zemek wrote in an email to BIST:

In my opinion, concussion has only been recognized as potentially serious in the recent past since there was so little concussion research even just five-years ago.  When we looked at all of the published literature, there was extremely limited high quality concussion research in children and teenagers more than 5 and 10 years back. Like in so many other illnesses, children are not just little adults.  

10-year-old Sam Barton became one of the 900 children and teens who show up with a concussion at the Children’s Hospital of Eastern Ontario emergency room last year after he banged his head on the floor during gym class. Without any signs of brusing or nausea, Sam’s parents took him to the ER after he complained of a headache.

Tests soon confirmed that Sam had a conscussion. The knock had also affected Sam’s ability to concentrate. Sam was lucky. Zemek’s findings show that only one in four medical practitioners are using concussion tools to measure the severity of injuries and to track recovery.

Zemek writes:

For parents, caregivers, teachers and coaches, the guidelines provide a ‘one-stop shop‘ in order to best monitor and manage ongoing symptom management, specifically the stepwise ‘return-to-learn’ and ‘return-to-play’ tools.  

For parents, the guidelines offer suggested alternative activities since their child may be unable to play sports while recovering, and also offer step-wise advice on how to return to school.

For teachers, the guidelines include templates letters that could be used to implement doctor-school communication describing recommended level of activities to facilitate communication with the school.   

For coaches and schools, the guidelines provide resources in order to improve the whole community response to concussion recognition and management, and offer tools to track recovery and to ensure safe removal from play in the event of a suspected concussion. 

The guidelines include a pocket Concussion Recognition Tool for use in schools by coaches and parents. The toolkit outlines various symptoms (such as loss of consciousness, convulsions, problems with balance or headaches) and which steps to take following an injury (such as removing the player from the game, checking his or her memory, or calling an ambulance).

 

 

 

 

 

 

 

 

What to do if your child has a head injury

There are a number of steps you should follow should you think your child has suffered a concussion. If he or she has any of the following symptoms, call 911:

• unconsciousness for more than a few minutes
• abnormal breathing
• obvious serious wound
• bleeding or clear fluid from the nose, ear, or mouth
• disturbance of speech or vision
• pupils of unequal size
• weakness or paralysis
• neck pain or stiffness
• seizure

If your child is unconscious:

• do not try to move your child in case there is a neck or spine injury
• call for help

If your child is conscious:

• do your best to keep your child calm and still
• if there’s bleeding, apply a clean or sterile bandage
• do not attempt to cleanse the wound, which may aggravate bleeding and/or cause serious complications if the skull is fractured
• do not apply direct pressure to the wound if you suspect the skull is fractured
• do not remove any object that’s stuck in the wound

Finally …

Concussions are serious matters, not to be taken lightly. If you suspect a child, colleague, or player has suffered a head injury, insist he or she seek medical attention immediately. Rest – both physical and mental – is crucial. If not treated, concussions can lead to much more serious issues such as SIS or acquired brain injuries.

The brain is a complex and marvellous organ, we human beings can’t exist without it, and young brains are particularly vulnerable. So let’s give it the respect it deserves. Indeed, concussions are more than “just a bump on the head.”