Seattle's Child: What To Do If Your Child Suffers a Concussion

November 2007

What To Do If Your Child Suffers a Concussion

We didn’t think anything of it when my daughter’s car wasn’t parked at our house. We figured she was still at the barn where she rode her horse.

After a couple of hours, we called the barn to see if she’d left. We were told that she’d been thrown from her horse on a cross-country jump. Her helmet took the brunt of the force, but still she was dazed, confused and nauseous and her head hurt. Another mother drove her home and left her to sleep, but did not call us to tell us what had happened.

My daughter took an aspirin before she lay down. When we went to her room, we found her sleeping, and it was very difficult to rouse her. We took her to the emergency room where she was diagnosed with a concussion and given a CAT scan. Finding nothing seriously wrong, the doctor sent her home with instructions for us to watch her that night to make sure she could be roused and to monitor her during the week to see if symptoms got worse. Our usually super-organized girl forgot school assignments and appointments for the next few days, but slowly improved.

Following the doctor’s advice, she skipped an important cross-country event the next weekend. She got back in the saddle in about two weeks.

A concussion is the most common form of mild traumatic brain injury, and is caused by a bump, blow or jolt to the head. It is a temporary loss of brain function, with or without loss of consciousness. Our experience illustrates several points about what to do to prevent a concussion and how to deal with it after it happens – as well as some examples of what not to do.

Dr. Tony Woodward, medical director of Emergency Services at Children’s Hospital and Regional Medical Center in Seattle, outlines three phases of handling concussions:

• Prevention
• Recognition
• Willingness to stop the activity and get medical evaluation

PREVENTION

In younger kids, concussions are most often caused by falls from monkey bars or other playground equipment (heights) or falls off skateboards or bicycles, Woodward says. In older kids, the main causes are impacts sustained in football, soccer, wrestling and hockey.

“The key is to wear helmets, make sure there’s adequate supervision, and make sure kids’ activities are appropriate for their ages and abilities,” he summarizes. He especially emphasizes wearing bicycle helmets, because two-thirds of riders who die from bike injuries die of head injuries and two-thirds of those can be prevented if the rider wears a helmet.

In high school sports, boys’ football has the highest rate of concussion, followed by girls’ soccer, boys’ soccer and girls’ basketball. A new study conducted by researchers at Ohio State University and Nationwide Children’s Hospital found that in sports played by both girls and boys, girls are much more likely to suffer serious brain injuries. According to data provided by 425 certified athletic trainers across the United States for the 2005-06 school year, girls are 1.5 times more likely to suffer concussions playing basketball and almost three times more likely to suffer them playing soccer. Girls also take longer to get back on the field following a blow to the head.

Researchers can only speculate about reasons. One theory is that boys have larger heads and stronger neck muscles for better shock absorption. It’s also possible that girls are reporting injuries more often, while boys may be more likely to and ignore symptoms and continue playing.

RECOGNITION

If a child loses consciousness after hitting his head, it’s obvious that he’s suffered a concussion. However, he’s also probably suffering from a concussion if he exhibits the signs listed in a new “Heads Up: Concussion in High School Sports Guide for Coaches” published by the Centers for Disease Control’s National Center for Injury Prevention and Control (NCIPC). Dr. Frederick Rivara, professor of pediatrics at the University of Washington and Children’s Hospital and founding director of the Harborview Injury and Prevention and Research Center in Seattle, says these guidelines can be applied by any adult concerned about a child, of any age, who has hit his head.

Signs observed by coaching staff or other supervising adults:

• Appears dazed or stunned
• Is confused about assignment
• Forgets plays
• Is unsure of game, score or opponent
• Moves clumsily
• Answers questions slowly
• Loses consciousness
• Shows behavior or personality changes
• Can’t recall events prior to or after the hit

Symptoms reported by the athlete (or child):

• Headache
• Nausea
• Balance problems or dizziness
• Double or fuzzy vision
• Sensitivity to light or noise
• Feeling sluggish
• Feeling foggy or groggy
• Concentration or memory problems
• Confusion

Vomiting – especially more than once – is another indication of concussion not listed in the report. Sometimes symptoms are not obvious at the time of impact, but may show up in the following days.

Woodward points out that monitoring by an adult is especially needed for young children because they won’t self-report symptoms. Additionally, “kids in sports have a motivation not to be hurt because they want to keep playing,” he says. They will deny or downplay symptoms and insist they feel fine. “It’s really important for parents and coaches to be vigilant.” He advises having the child count backward from 100 or remember a sequence of numbers to test his mental acuity.

WILLINGNESS TO STOP THE ACTIVITY
AND GET MEDICAL ATTENTION

A child who exhibits any of the symptoms of concussion should stop playing and be evaluated by a medical professional, Rivara, Woodward and other experts agree.

“Sometimes, players, parents and other school officials wrongly believe that it shows strength and courage to play injured,” the NCIPC guide notes. “Don’t let athletes persuade you that they’re ‘just fine’ after they have sustained any bump, blow or jolt to the head.”

If a child gets back up on a bike or back out on the field, he may injure himself again because his concentration and balance are poor.

Our handling of our daughter’s concussion was correct in that she was wearing a helmet, there was an adult supervisor in the area, and she immediately stopped the activity. However, it was dangerous to have let her fall into a deep sleep because she could have slipped into a coma. “Most kids with a head injury would want to go to sleep,” Woodward says. “It is important that they be observed for some time. Keep an eye on them to make sure they can be aroused.” Doctors recommend such vigilance for 24 hours.

It was also dangerous for our daughter to have taken aspirin, as aspirin and ibuprofen inhibit the ability of blood to clot and could have resulted in bleeding in the brain.

If symptoms are severe, the doctor may order a CAT scan to see if there is evidence of an epidural hematoma – a blood clot between the cranium bone and the dura (the fibrous covering of the brain). Blood can then put pressure on the brain. If this occurs, a small portion of patients will need medical intervention with surgery or drugs, Woodward says.

Most children with a concussion get back to normal within two weeks.

WHEN IS IT SAFE TO GO BACK TO THE ACTIVITY?

Even though the most serious symptoms of concussion show up in the first 24 hours, parents can expect to see more crying, irritability and forgetfulness in the week following the injury, Woodward says. If the symptoms get worse, the child should return to the doctor.

In our daughter’s case, we were right not to let her participate in a much-anticipated cross country meet the weekend after the concussion.

Children should not go back to a sport until a medical professional gives permission and they are asymptomatic, Woodward summarizes. “They may feel OK until they run around, and then feel bad again. They need to be asymptomatic when active,” he clarifies.

Beyond that, there are no consistent guidelines for when it’s safe to return to an activity: some sports experts say one week; some say two. The biggest danger of returning too soon is the risk of second impact syndrome. “If the player has a minor head injury, and then another one within a certain period of time, it can have devastating consequences,” Rivara says.

The catch is that the period of time the brain needs to recover may be minutes, hours, days or weeks. The second impact may be small, but it results in swelling and an increase of pressure within the skull, leading to coma or death. Second impact syndrome is rare, but it is fatal 50 percent of the time.

Even without second impact syndrome, there is evidence that the cumulative affect of repeated concussions is serious cognitive impairment, Rivara says. Harborview’s Injury and Prevention Research Center will begin a study soon on long-term disability from children receiving head injuries, but at the moment there is very little data on it. Researchers at the University of Pittsburgh Medical Center have begun studying whether concussions affect young people’s brains more than they do adults’.

Rivara and Woodward advise parents to err on the side of caution in allowing their child to resume a sport or activity after a concussion.

“Think of your child’s health long-term, not about the sporting event or state championship,” Rivara says.

Wenda Reed is managing editor of Seattle’s Child.

IS HEADING THE BALL IN SOCCER DANGEROUS?

Woodward believes that younger kids playing soccer and “heading” the ball are not at risk for head injuries, although they may be when they are older and hit balls harder.

In a 2000 clinical report on “Injuries in Youth Soccer,” the American Academy of Pediatrics noted that most soccer injuries are to the lower extremities. A study of adult soccer players in Norway, who began playing soccer in youth leagues, showed mild to severe deficits in attention, concentration and memory in 81 percent of the players. The more heading they did in competition, the higher the rate of cognitive loss.

The AAP summarized that “further study is needed before a conclusion can be made about the safety of heading in young soccer players,” and there is still no consensus today.

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