Editor’s Note: This story was first published in November 2007. In the last three years, regulations and recommendations on removing a child from play and allowing him to return to a sport have become more stringent. These stricter requirements are included in the article below, updated February 2011.
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 given a CAT scan and diagnosed with a concussion. Finding nothing seriously wrong, such as a brain bleed, 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. Experts now believe she should have stayed away from the sport for longer than that to avoid a possible repeat blow to the head.
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 Seattle Children’s Hospital, 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 hockey, girls’ soccer, boys’ soccer and girls’ basketball. A recent 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 ignore symptoms and continue playing.
More concussions are occurring among younger children, according to a study on “Emergency Department Visits for Concussion in Young Child Athletes” prepared by the American Academy of Pediatrics (AAP) and published in September 2010. Although organized team sport participation declined from 1997 to 2007, emergency department visits for concussions for 8- to 13-year olds doubled (this age group accounts for 40 percent of all ED visits for concussion). Leading activities were snow-skiing and snowboarding, bicycling and playground activities.
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 “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 Seattle Children’s Hospital and founding director of the Harborview Injury and Prevention and Research Center in Seattle, says these guidelines should be known by adults dealing with athletes and used for a child of any age, who has hit his head.
Signs of concussions 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 possible concussion. 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 to 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. The AAP officially made that recommendation in September 2010, following publication of a new clinical report, “Sport-Related Concussion in Children and Adolescents.”
“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.”
This recommendation was codified into Washington state law with passage of the Zackery Lystedt Law in 2009. Young athletes who are suspected of sustaining a concussion or head injury must be removed from play and will not be allowed to return until they have written clearance from a licensed health-care provider. The law was named for a 16-year-old Maple Valley boy who suffered a traumatic head injury while playing football in 2006. He was allowed to return to play in the second half, and collapsed on the field shortly after the game ended. After emergency brain surgery, he remains in a wheelchair and requires full-time care.
Under the law, the rule is: “When in doubt, sit them out.”
If a child gets back up on a bike or back out on the field too soon, he may injure himself again because his concentration and balance are poor.
If there are signs of symptoms suggestive of a serious brain injury, the doctor may order a CAT scan to see if there is evidence of bleeding inside the skull, brain swelling or serious skull fracture. If this occurs, a small portion of patients will need medical intervention with surgery or drugs, Woodward says.
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. “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. There is no evidence proving the safety or efficacy of any medication in the treatment of a concussion, according to AAP guidelines.
We were right not to let her participate in a much-anticipated cross country meet the weekend after the concussion.
When Is It Safe to Go Back to the Activity?
Symptoms of a concussion usually resolve in seven to 10 days, but some athletes may take weeks or months to fully recover, according to the AAP report.
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.
Children should not go back to a sport until a medical professional gives permission and they are asymptomatic, Woodward and the AAP recommendations say. (Although the Zackery Lystedt Law makes this mandatory for athletes in organized sports, parents will need to enforce the recommendation for children in individual sports or activities.)
“They may feel OK until they run around, and then feel bad again. They need to be asymptomatic when rested and when active,” Woodward clarifies. Doctors recommend a gradual return to play with gradually increasing exercise, Rivara adds. “Any return of symptoms means the person needs to stop that activity and go back to the prior step.”
The AAP recommendations also note that physical and cognitive exertion, such as homework, playing video games, using a computer or watching TV may worsen symptoms, and parents should closely watch their children for the concussive symptoms listed above. Dr. Monique Burton, interim chief of Sports Medicine at Seattle Children’s, also emphasizes the need for both physical and cognitive rest, including modifications in school, strictly limited screen time and no sports, PE or extra activities on the side – “only doing the things you need to do to function as a person.”
The biggest danger of returning too soon is the risk of second impact syndrome, in which a second concussion occurs before the first concussion is properly healed. “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 can result in swelling and an increase of pressure within the skull, leading to coma or death. Second impact syndrome is rare, but can be fatal or result in severe disabling injuries.
Even without second impact syndrome, the cumulative effect of repeated concussions may be serious cognitive impairment, Rivara says. Harborview’s Injury and Prevention Research Center is conducting a study on long-term disability from children receiving head injuries, but no conclusions are available at this time. The AAP recommends that “retirement from contact sports should be considered for an athlete who has sustained multiple concussions, or who has suffered post-concussive symptoms for more than three months.”
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.
