Heads up: concussions

What you need to know about children and concussions

Wrap your brain around this: Your child could sustain a concussion without you ever realizing it. “In most concussions — four out of five — the person is not knocked out,” explains Karen Johnston, a neurosurgeon and director of the concussion program at the McGill University Sports Medicine Centre in Montreal. Important to know because overlooking a concussion can delay recovery and increase the odds of suffering a second injury.

So the next time your kid collides with another player on the rink, or your toddler tumbles down the porch steps, how can you tell whether she might have a concussion? Come to think of it, what is a concussion, anyway? Here’s what every parent should know:

Q: What is a concussion?

A: A concussion is an injury that impairs the brain’s ability to process and retain information. It doesn’t involve bleeding or fluid buildup in the brain, so most concussions won’t show up on most X-rays or CAT scans. Concussions can be either simple or complex, with about 90 percent in the former category — meaning that the brain is back to normal within seven to 10 days.

Q: What causes a concussion?

A: A sharp knock on the noggin or even an indirect hit, like one to the neck, face or body that suddenly jars the head and bounces the brain against the skull. “The underlying process of injury in concussion is not entirely known” says paediatrician Laura Purcell, president of the Canadian Paediatric Society’s sport and exercise group. What is clear, however, is that “a concussion affects the way the brain thinks and processes information.”

According to Johnston, you should be on the alert any time you witness or hear about a hit that looks or sounds scary. Have your child stop what she’s doing right away. (Warning: If a child loses consciousness, or suffers a seizure, call 911.)
Q: What should I watch for?

A: “The child may appear a bit dazed or glassy-eyed, and seem unaware of what’s going on,” notes Purcell. Other clues include confused speech, vomiting and poor balance or coordination.

Still, not every kid with a concussion shows these signs and, if he does, the signals may be subtle. A child may be reluctant to tell you he’s feeling off for fear of being pulled out of the game — or he might believe he’s OK to play because concussion fogs judgment. So ask about specific symptoms, such as headache, dizziness, nausea or stomach ache, blurred vision, ringing in the ears, and feeling dazed, stunned or sleepy. And remember, sometimes symptoms don’t show up for 24 to 48 hours — so your child should take it easy for a day or two after a hard hit to the head, even if he seems OK.

Q: Is there a test parents can perform?

A: Ask some simple questions to determine whether your child is experiencing memory loss. For example, if the hit occurs during a hockey game, you might ask her about something that happened some minutes or hours before the jolt, such as how she got to the arena or what she had for breakfast. Forgetting such facts is a stronger signal of concussion than if she draws a blank on what happened immediately before or after hitting her head.

A questionnaire called SCAT (Sidelines Concussion Assessment Tool) can help: Athletes score their symptoms on a scale of zero to six. Download a copy from thinkfirst.ca. You can even make extra copies for your child’s coach.

Q: I think my child may have a concussion. What now?

A: Your child should see a doctor as soon as possible.

Q: What will the doctor look for?

A: He will first want to rule out a more serious head injury — say a skull fracture or a buildup of blood between the brain and skull. That means looking for clues, such as weakness, loss of feeling on one side of the body or unequal eye movements. If the exam turns up anything suspicious, he will usually order a CAT scan.

The doctor will also take a careful history: how the injury happened and the symptoms the child is experiencing. Some simple tests (for example, naming the months of the year in reverse order or recounting details of a significant event such as a recent birthday party) help the physician gauge how much impact the concussion is having on the brain’s day-to-day operations, and thus determine whether the concussion is severe.

Q: If the doctor diagnoses a concussion, should I wake my child up every two hours?

A: No, this tradition is dying out. “Doctors no longer advise waking the patient every couple hours. What they need is sleep,” says Johnston. “They should be checked overnight, however, for unusual breathing (shorter or faster), vomiting or moaning.” And it actually has nothing to do with concussion: It’s done to check whether a head injury is more serious than it first appeared. These days, many doctors will keep a child under observation in the hospital for several hours if there’s even a slim chance that any problems could arise.

Nonetheless, parents should watch for danger signs like any worsening of symptoms such as headache, nausea or confusion. “Often we’ll recommend letting kids sleep and checking on them occasionally in the middle of the night,” notes Purcell. “If there’s any concern about how they’re breathing, or if they’re making noises in their sleep, then try to wake them.”
Q: How is a concussion treated?

A: One word: rest. Physical — and even mental — exertion can draw out recovery. “A kid will probably need a couple days off school until things have settled down,” says Johnston. Video games, computer work, rough-housing, sports and other exercise are also temporarily off the table. Your child’s doctor will map out a step-by-step return to normal activities, starting 24 hours after the symptoms disappear: for instance, taking a walk or playing hide-and-seek on day one, followed by kicking a ball around the backyard 24 hours later, and so on. “If at any point you do have a return of symptoms, you’ve got to go back to zero” to head off long-term problems, says Francois Belanger, medical director of Emergency at Alberta Children’s Hospital.

“Persistent symptoms can have a huge impact — a child who can’t go back to school for the rest of the semester may end up losing the year,” Johnston observes. “We don’t take any chances with kids. When in doubt, sit them out.”

Q: What are the chances of multiple concussions?

A: A concussion slows your reflexes, thereby increasing the likelihood of another injury — and returning to play too soon prolongs symptoms. Also, if your child hasn’t fully recovered, a second blow deals more than a double-whammy: Less force is required to cause reinjury and, in some cases, permanent damage can result.

If it seems your child is prone to concussions, you may want to seek advice from a sports medicine physician or neurologist with expertise in the area.

After all, it’s better to miss a few games than sit out the season!
The way doctors think about concussion has changed significantly since 2001, when experts from around the world put their heads together at the first International Symposium on Concussion in Sport. Here’s how:

Then
• If symptoms didn’t appear immediately, doctors believed kids were in the clear.

Now
• Doctors recognize that symptoms may not appear until 12 to 48 hours after an injury.

Then
• It was thought that loss of consciousness meant the concussion was severe.

Now
• Most concussions don’t involve any loss of consciousness.

Then
• Concussions were graded from one to three, according to symptom severity.

Now
• Concussions are classified as simple or complex according to how long symptoms take to resolve (categorized after the fact).

Then
• Kids whose symptoms cleared up within 15 minutes (grade one) were allowed to resume play immediately.

Now
• Experts recommend that ALL kids with a suspected concussion see a doctor immediately.

Then
• Doctors asked orientation questions (What day is it? or Where are you?) to help diagnose concussion.

Now
• There’s more emphasis on sequence questions. (What period is it? or Working backwards, name the months of the year.)

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