In March 2013, for the first time since 1997, the American Academy of Neurology (AAN) issued new guidelines for management of concussion. Given that three of my son’s soccer teammates sustained concussions just this fall, either from heading balls or from colliding with other players, I am glad to see more attention being given to this issue.
What is a concussion?
Concussion is a brain injury that alters brain function. It is most often the result of a blow or forceful jolt to the head. Symptoms can be either obvious or very subtle, which can sometimes make diagnosis difficult. A concussion can occur during a head injury even if the injured person does not lose consciousness or have any abnormalities big enough to show up on CT scan or MRI.
The following is a list of worrisome concussion symptoms from the American Academy of Pediatrics:
nausea or vomiting
dizziness or balance problems
double or blurry vision
sensitivity to light
sensitivity to noise
feeling dazed or stunned
feeling mentally “foggy”
confused or forgetful about recent events
slow to answer questions
changes in mood—irritable, sad, emotional, nervous
sleeping more or less than usual
trouble falling asleep
Concussion and sports
Most common causes of concussion in children are sports-related, and most in collision sports such as football and rugby, followed closely by soccer and hockey. Soccer and basketball account for the most sports-related concussions in girls. Bike riding without a helmet is also risky. A simple fall and bump of the head on a sidewalk can cause a concussion.
New American Academy of Neurology recommendations
The new guidelines call for a much more conservative approach to children’s head injuries (i.e., high school and younger). Studies have now shown that young people, as well as people who have had a concussion in the past, take longer to recover from a concussion.
A history of prior concussion increases the risk for future concussion. The biggest risk period for re-concussion is within 10 days after the first injury. And we do know that repeated head injuries can have long-term effects on brain function.
The AAN recommends that high school and college coaches and trainers be taught how to perform a five-minute concussion assessment immediately following the injury, while still on the sidelines. Such an on-the-spot test includes assessment of memory (e.g., what is the date? What did you have for dinner last night?) as well as of other symptoms. There is a Standardized Assessment of Concussion tool that coaches already use, but now they are urged to use it more widely in the general population. The validity of this assessment tool, however, has not been tested in children younger than high school age.
What do these guidelines mean for our children?
These recommendations probably don’t mean any big changes, except for re-emphasizing that—when it comes to head injuries in children—it is better to err on the side of caution.
So, if your child sustains a significant blow to the head, even if they seem fine and did not pass out, the safest route is to pull them from their activity and observe them for at least 24 hours. If there are any concerns for possible concussion, they should be seen by a licensed health care provider before returning to activity.
As one of the co-authors of the new guidelines put it, “If in doubt, sit it out.” For many, this won’t necessarily mean complete rest. If the child is symptom free at rest, they can participate in activities if they don’t cause symptoms such as headache or dizziness. And the activity itself must not carry a risk of concussion. For example, a soccer player could probably do some running and footwork drills if they feel well enough, but shouldn’t scrimmage or play a game for 10 to 14 days if there is a concern about concussion.
Don’t rely on an injured person’s evaluation of him- or herself
This is an important point. Many people who have sustained a concussion say later on that they weren’t able to assess their condition accurately just after the injury. That is, they didn’t recognize that something was wrong with them, or the fact that they didn’t feel like themselves.
If you have any concerns, you should discuss this with your child’s doctor before the child returns to activities.