Pediatric Concussions for Healthcare Providers: When child’s play is anything but

Introduction
There has been increasing coverage of sports-related concussions lately, both in the lay press and the medical literature. Much of that coverage has focused on concussions in children and teens, as their brains are still developing and potentially more liable to long-term effects from concussions. While this is still a controversial subject, opinions have shifted over the last decade, with many professional societies agreeing that concussions are a significant problem and that more aggressive steps need to be taken to prevent and manage them. What is a concussion and how is it managed? When is it safe for a child to return to the playing field? What benefit do helmets and other protective equipment provide? Should contact sports be avoided altogether? What is a concussion? What sports are most commonly involved?

A concussion, also known as mild traumatic brain injury, is a head injury that causes temporary loss of brain function. This is usually caused by a by a direct blow to the head, face or neck or elsewhere on the body with an impulsive force transmitted to the head. Impairment is usually functional, not structural in nature. Football has the highest rate of concussion for the high school male, while soccer and basketball have the highest rates for the high school female. Rugby, ice hockey and lacrosse also have an elevated concussion risk but are less studied than the more commonly played sports. Females have a higher incidence of concussion within the same sports compared to males.

What are the signs and symptoms of concussions? How are they managed?
Concussions result in signs and symptoms centered around four aspects: 1) physical 2) cognitive 3) emotional and 4) sleep activity. Headache is the most frequently reported symptom. Other common symptoms include nausea, vomiting, dizziness, memory loss, sleep disturbance, light/noise sensitivity and feeling “slow” or “foggy”. Symptom onset is variable; it may not occur until several hours after the episode.

Loss of consciousness (which occurs 10% of the time), severe nausea/vomiting, or an abnormal neurological exam warrant referral to an emergency department for further work-up that may include neuroimaging.

In the immediate post-concussion period, once more serious head/neck injuries are ruled out, athletes are often given the Maddocks scale to determine their mental state with questions relating to the game, the score and the athlete’s location. If a concussion is suspected, the athlete should be removed from the game and monitored closely for the next several hours. In the absence of more severe symptoms, the American Academy of Pediatrics currently recommends managing athletes on a case-by-case basis depending on the severity of symptoms. This often entails repeat evaluations over the course of days to weeks until the athlete is completely symptom free. The current mainstay of treatment is both physical and cognitive rest, as increased cognitive and physical activity can worsen symptoms in the immediate post-concussive period. This often requires temporary leaves from school or reduction in school day/workload. Medications are not recommended unless to treat specific symptoms such as headache, sleep disturbance, or nausea. Athletes should not return to sports until they are asymptomatic. This often takes less than a week, but longer time periods are required for pediatric and adolescent athletes compared to high school and college aged athletes.

What are the long-term effects and complications of concussions?
The long-term effects and complications of concussions are some of the most worrisome for parents, teachers and coaches, but unfortunately there is a lack of long-term prospective studies in this area. Numerous available studies have shown that concussions have an additive affect, with athletes who have experienced 2 or more concussions experiencing lower grades and abnormal neuropsychiatric testing compared to their peers. They are also more likely to have had a significant event during a concussion such as loss of consciousness, amnesia or confusion.

Young athletes are also at risk of second impact syndrome, which occurs when a concussed athlete sustains further head trauma before their injury is fully healed. This can lead to significant swelling in the brain and even death. For this reason, it is imperative that athletes not return to the field until completely symptom-free.

Finally, athletes are also at risk of post-concussion syndrome, which occurs when cognitive, physical or emotional symptoms last longer than expected, which can occur anywhere from 6 weeks to 3 months or more.

How can concussions be prevented? What is the role of protective gear?
Helmets in football have not been thought to reduce the incidence of concussions, although newer helmets have shown promise in reducing the risk of concussion up to 30% relative to conventional models. The data on newer helmets is still preliminary, however, and further testing is needed. Mouth guards in sports have not been shown to be effective in reducing the risk of concussions.

Helmets used in skiing, snowboarding and ice hockey (especially with full face shield helmets) have been shown to be effective in reducing concussion risk. Helmets have also been evaluated in soccer but have not shown a consistent benefit. Heading the ball is thought to be safe if proper technique is used.

It is still up to the athlete and his/her parents to decide which sports to pursue and whether to avoid contact sports. Some parents and athletes may face the difficult decision to retire from sports after a concussion. There is no clear-cut guideline for this, but some experts recommend ceasing sports activity altogether after 3 or more concussions in a season, or if post-concussive symptoms last longer than 3 months.

References:
1. http://www.healthychildren.org/English/health-issues/injuries-emergencies/sports-injuries/pages/Concussions.aspx
2. http://www2.aap.org/sections/schoolhealth/ECarchiveseptember11.html
3. http://pediatrics.aappublications.org/content/126/3/597.full#sec-24
4. http://www.uptodate.com/contents/concussion-and-mild-traumatic-brain-injury

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