Concussions have become a hot topic in the media and the medical profession.  They can have a significant impact on school, social and family relationships, as well as daily living and sports participation.

A child’s and adolescent’s brain is more vulnerable to head injury.  It has become clear that this common injury has been under recognized, so our thinking about concussion has evolved over the last few years.  Appropriate management of concussion can prevent the increasingly recognized life-threatening and long-term effects from recurrent concussion. State lawmakers and many medical professional organizations, including the American Academy of Pediatrics, have become involved in regulating and advising the management of concussion.  Below I will review the definition of concussion, long-term problems from concussion, assessment of concussion, recent recommendations for return to school and play, and legislative regulations.

What is a Concussion?

 A concussion is a bruise to the brain that occurs when the head is hit or jolted.  It is a significant injury that needs to be taken seriously. If a child has hit his or her head and has any symptoms that could be related to brain function, a parent or coach should consider concussion.  In fact, any symptoms that involve the brain after a head bump could be related to a concussion, with only 10 percent of concussions actually involving loss of consciousness (being knocked out).

The severity of concussion varies and is defined by the course of the concussion symptoms.

• Physical symptoms include: headache, dizziness, lightheadedness, nausea, fatigue (in a funk), noise sensitivity, light sensitivity, and blurred or double vision. 
• Cognitive or thinking symptoms include not thinking straight, fogginess, loss of memory of the event and subsequent forgetfulness, difficulty paying attention, and difficulty keeping up with school.
• Emotional issues include: agitation, feeling nervous, more emotional, and not acting like oneself.

It is important that symptoms of more severe head injury are noted in assessing a child or adolescent with a history of head trauma.  Concerning symptoms that should prompt seeking immediate medical attention include: loss of consciousness, difficulty waking, confusion, difficulty walking, slurred speech, seizures, unable to be comforted and acute changes in behavior.

What should you do if you think a concussion is possible?

• Make sure a coach or another adult is made aware.
• Make sure to have a medical evaluation by a health care provider who is comfortable managing head injuries. He or she will check for the symptoms above and also do a physical exam looking for signs of abnormal brain functioning.
• An X-ray, CAT scan or MRI will not be abnormal because of a concussion, but may be used to evaluate other head injuries.
• Rest as advised is probably the most important part of treatment.  Lying in a dark room may be recommended.
• Follow return to play and school recommendations.
• Make sure you do not hit your head before your brain has clearly healed.

Treatment consists of complete physical and cognitive rest, including: 1) no physical activities that place the child at risk for a recurrent head injury; 2) no school or a reduced workload until the child is symptom free, and 3) activities at home like video gaming and computer use should also be curtailed.

Return to school/life

Rest to allow brain healing is critical.  Rest may include: a leave of absence from school, shortening of the school day, and extra time to complete homework, class work, or tests.  Recognize that the child may not perform as well or learn as well so setting the correct expectations is important.  Typical symptoms last 7-10 days, but can last weeks to months.  Ask your health care provider to help your school understand priorities for recovery.

Can a concussion be serious?

Whenever your brain is injured, it can be serious.  Repeated concussions can lead to permanent brain injury, which can affect any aspect of brain functioning as well as causing increased risk to the brain with minor head bumps.  Some kids need to be kept out of contact sports if they have repeated concussions.  There is also evidence that the ability to think can be effected by recurrent concussions. 

Athletes who sustain second head injuries before symptoms associated with the first injury have fully cleared may experience life-threatening brain injury (second impact syndrome).

Concussion-graduated return to play

The Academy of Pediatrics has recommended the following return-to-play guidelines for children and adolescents who have had a concussion. Each step should last no less than 24 hours.  Only progress to the next step if your child remains symptom free.  If symptoms recur, discontinue the provoking activity.  When asymptomatic for a new 24 hours, return to the prior asymptomatic stage and proceed.

Step One.  No activity. Complete physical and cognitive rest.

Step Two.  Light aerobic activity.  Walking, swimming, stationary bike.  No weight lifting.

Step Three.  Sport-specific exercise.  Running drills/skating drills but no head impact activity.

Step Four.  Non-contact training drills.  Progress to more complex training drills (to include passing drill in football and hockey) and may resume weight lifting.

Step Five.  Full contact practice.  After medical clearance, participate in normal training activities.

Step Six.  Return to game play. 

What is the law?

House Bills 300,334 and 387 of the 96^th assembly in Missouri are related to student athlete brain injuries.  The Bills require education of all students with signature of a concussion education form.  They require clearance by a trained healthcare provide after an athlete has been removed form play for concussion. They also require that schools report impact of concussion incidence on the student athlete.  Each of the high school athletic departments in Missouri is aware of these regulations and has put protocols in place to address the increased concerns about concussion.

Simple rules for concussions should be remembered.  Concussions can be serious injuries to the brain and should be taken care of appropriately.  Children with concussions should rest and avoid further head trauma until they have healed.  Children with concussions need to be cleared by a health care provider before returning to play because it is the best medicine and the law.

For more information on concussions, please visit www.EsseHealth.com.

By David Hartenbach, M.D., Esse Health Pediatrician

Esse Health Creve Coeur Pediatrics

11630 Studt Avenue, Suite 200

Creve Coeur, MO 63141

Phone: 314-567-7337