Concussions: What you need to know

While it's important to rest an injured brain, what kid can actually sit in a dark room for hours? Here’s how to help get your kid up and running (and playing) again.

Photo: Roberto Caruso

Carter and Cash know they’re not supposed to slide down the banister. But as soon as their mom, Christella Morris, turns her back, they do it anyway. The boys, ages five and six, also like to climb doorways, scale the porch railing and launch themselves over the couch. “I’m not a helicopter parent,” says Morris, who is used to seeing her boys fall down and bounce right back. So the first time Cash hit his head really hard, she knew right away something was wrong.

It happened two years ago, when Cash was in junior kindergarten in Bowmanville, Ont. He collided with two other children while playing tag at recess, and he hit his head on the pavement. By the time Morris saw Cash in the school office, his face was grey, he was sleepy and he was having trouble focusing his eyes. On the way to the hospital, he threw up in the car. They waited more than five hours in the ER before seeing the doctor, who did a brief physical exam, gave Morris a pamphlet on how to treat a concussion and sent them home. “I was flabbergasted,” says Morris. “I felt like we were getting the brush-off. I thought concussions were a big deal, but the doctor didn’t seem all that concerned.”

Concussions are a big deal. They are a type of traumatic brain injury that affects how the brain works. While they might not be as immediately life-threatening as skull fractures, or bleeding in or around the brain, concussions can have a lasting impact, including memory problems, recurring headaches and mood disorders. Plus, there are the worrying initial symptoms—headaches, nausea, dizziness and fatigue are among the most common—to deal with. An increasing number of kids are showing up at their family doctors’ offices and emergency rooms with suspected concussions, which researchers think is at least partly due to a greater awareness among parents of the risks. A 2014 study published in the journal Paediatrics and Child Health found that in Ontario between 2003 and 2010, there was about a 70 percent increase in concussion-related medical visits by school-age kids and youth.

Falls are the leading cause of head injuries for kids. In 2012, researchers discovered most of those accidents are like Cash’s—they occur at home or at school. It’s scary to see your toddler do a face plant or your kindergartner fall from that tree she’s finally brave enough to climb. But how do you know when your kid is OK? When should you worry? And if you decide to go to the hospital, what do you do if, as in Morris’s case, the doctor sends you home without a clear plan to help your kid get better?

When to suspect a concussion
In the first few minutes after Cash bumped his head, he seemed fine, his teachers told Morris. In fact, he didn’t start complaining of a headache or acting lethargic until about 20 minutes after his fall. This isn’t uncommon: Concussion symptoms can often take a while to appear. The old advice suggested that as long as a child hadn’t been knocked out cold, a concussion was unlikely—we now know that isn’t true. Daniel Rosenfield, a paediatric trauma fellow and emergency room doctor at the Hospital for Sick Children in Toronto says most kids he diagnoses with concussions never lost consciousness.

Rosenfield says when he’s explaining a concussion diagnosis to parents, he emphasizes that although a concussion is the mildest type of traumatic brain injury, it is still a brain injury and needs to be taken seriously. Concussions are challenging to diagnose because doctors can’t really see them. There is no definitive medical test for a concussion, which, unlike more severe brain trauma, doesn’t show up on a CT or MRI scan, though new research from Western University in London, Ont., suggests one day a blood test could help diagnose the condition. “There’s no bleeding or obvious swelling in the brain, so I often tell patients it’s like a bruise to the brain,” he says. Plus, there’s still no scientific consensus on exactly what happens when you get a concussion. One theory is that the brain, which is surrounded by fluid, jiggles and bumps up against the skull, but research into the “how” of concussions is ongoing.

If you’re worried your kid might have a concussion, it’s important to monitor her for 72 hours for any of the common symptoms, including headache, dizziness, nausea and vomiting, drowsiness, seeming “out of it,” irritability, emotional changes and physical imbalance. If you notice any of these signs, or if your kid fell from a height of more than three feet, hit her head in a car accident, has a “goose egg” bump or has any bleeding from the head, ears or nose, see your doctor.

For Toronto mom Janine Druery, whose daughter, Nora, sustained a concussion after an accident at school (a bathroom stall door fell off its hinges, trapping her underneath), the earliest signs she might have a concussion were that she was throwing up and complaining of a headache. By the time they got to the hospital, Druery’s daughter was nodding off in her lap. “I went up to the nurses and told them, ‘I have a six-year-old with a head injury who can’t stay awake,’ and they got me in to see a doctor quickly,” she says.

At the hospital, the doctors’ first priority is to rule out a more serious brain injury. When Rosenfield sees a child with a suspected traumatic brain injury in the ER, he asks the parents how the injury happened, whether the child passed out and how the child has been acting since. He then does a physical exam, looking at the child’s skull and pupils, and testing reflexes. If the kid is old enough to respond verbally, he’ll ask her some questions to assess whether her mental processes and memory are working well. If she seems to be functioning normally, doesn’t have any signs of fracture and didn’t lose consciousness, then a severe brain injury is extremely unlikely and a scan isn’t necessary. “A CT scan requires exposing children to a lot of radiation,” he says. “We avoid doing one unless we really need to.”

About a year after Cash’s concussion, Morris’s younger son, Carter (who was three at the time), was racing home, holding hands with his big brother, when he slammed his head into the brick wall of their house. He threw up about 10 minutes later and then continued to vomit every 20 minutes or so. The doctor ordered a CT scan to rule out any severe brain or skull damage. It was the middle of the night by the time he went in for the scan, and Carter slept through the whole thing. He was sent home after his results came back normal, but if your kid is vomiting repeatedly or has lost consciousness at any point, doctors may also want to keep him at the hospital for monitoring. In Druery’s case, doctors admitted Nora and watched her for eight hours before sending her home.

Treatment and Recovery
After a concussion, kids need to let their brains rest. That means cutting out as much unnecessary physical, mental and emotional stimulation as possible for 24 to 48 hours after an injury and then gradually reintroducing moderate physical and cognitive activity only once symptoms have improved. Rosenfield says that when adults get a concussion, doctors tell them to basically stay in a dark room doing nothing for the first 24 to 48 hours, but he knows that isn’t practical advice for a four-year-old. The main thing is to keep your kid home from school and to have him refrain from doing any vigorous physical activity or having screen time until those initial symptoms improve. The days of prescribing “bedroom jail” for kids with concussions are behind us, says Nick Reed, a clinician scientist, co-director of the Concussion Centre and an occupational therapist at Holland Bloorview Kids Rehabilitation Hospital in Toronto. Like Rosenfield, he advises parents to be very conservative in the first 24 to 48 hours after a concussion, but after that, it’s fine to allow kids to continue doing small amounts of the activities they enjoy—a short TV show, a walk around the block, a limited amount of time with a favourite video game—to keep them from feeling isolated, anxious or depressed, which can worsen symptoms. “If a TV show helps make a child happy, that’s better than being locked away, doing nothing.” Complete rest and isolation can in fact do more harm than good; some recent studies have found moderate levels of physical activity are even beneficial for kids recovering from concussions. The key, Reed says, is not to overdo it with any one type of stimulation and to keep an eye out for symptoms that worsen when your kid tries different activities.

This flexible approach is welcome news for any parent who has attempted to force a young child with a concussion to take it easy. “Trying to keep a four-year-old calm and still is impossible,” says Morris, who found it especially hard to keep her boys from bouncing off the walls without resorting to screens. “We already limit TV, but to have to take it away completely—that’s basically the worst thing in the world for them,” she says.

Reed tells kids and parents to think of the brain like a “tank of gas,” full of the fuel you need to do everything in a day: walking down the street, going to school, playing, watching TV, reading. He explains that when you have a concussion, “there’s an energy crisis, because your brain needs lots of energy to heal, so we need to cut down on the other things we do to keep that tank as full as possible.”

After her sons’ concussions, Morris tried to encourage quiet activities, like looking at books or drawing, and when they did watch a little TV, she chose slow-paced shows made for younger kids that seemed less stimulating and easier to follow. Both times, her main priority was making sure they weren’t jumping around or wrestling each other while trying to recover. She was right to be wary of letting her sons get physical too soon. Sustaining a second concussion before your brain has healed can result in more severe damage to the brain and longer-lasting symptoms than the initial concussion.

Rosenfield says parents should keep kids home from school and out of sports and other physical activities until symptoms are gone. That can be easier to figure out with older kids, who can tell you how they’re feeling, he says. With younger children, it is often up to the parents’ assessment of whether they’re “acting normal.” If you’re uncertain or the symptoms aren’t improving after a few days, it’s important to consult your doctor. Reed and Rosenfield recommend resuming school and activities gradually—a half-day of school, avoiding stressful tests, light exercise—and taking more time off if symptoms return.

It can be tough for young athletes to have to sit out game after game, but you can try reminding your kid that even stars like Sidney Crosby have to follow the same protocols. Rosenfield says parents need to remember that “your kid is probably not going to become a professional athlete, but they are definitely going to need a functioning brain as an adult,” so it’s worth erring on the side of caution.

With proper rest and careful monitoring, most kids will fully recover and, with approval from their doctors, can return to school and regular activities within several days or weeks. (It’s different for every kid.) “If given the chance, the brain wants to heal, and it is very resilient,” says Reed. But for about 30 percent of children, concussion symptoms persist beyond four weeks, even if they’ve been resting and doing everything right. Researchers don’t yet understand exactly what causes persistent post-concussive symptoms, but factors like age, gender, concussion history and migraines can put some kids at a higher risk. Reed says children who still have symptoms after four weeks should be referred to a neurologist, paediatrician or occupational therapist who specializes in treating concussions and can develop a more intensive, personalized rehabilitation plan.

Druery took Nora to their family doctor to get advice about going back to school and resuming other activities. The doctor recommended keeping Nora home for at least a few days. She ended up returning to class after a week, but, following the doctor’s recommendation, Druery asked teachers to keep Nora out of phys. ed. and to avoid letting her play on the jungle gym at recess for a few weeks. “Thankfully, she didn’t have any lasting cognitive effects,” she says. Druery continued to watch Nora closely for new symptoms for several weeks after her injury.

Prevention
Since their concussions, Morris has avoided enrolling Cash and Carter in activities with a high risk of head injury. She refuses to sign either one up for hockey, and she switched them into aikido, a martial art that seems like a less “kicky, punchy” alternative to karate and has the added benefit of improving her sons’ balance and body awareness—making them steadier on their feet while they perform their usual daredevil moves at home.

“We constantly remind them they’ve both had concussions and have to take it easy, but to a five-year-old and a six-year-old who don’t feel sick, that doesn’t mean much,” says Morris. Neither of them have shown any signs of long-lasting cognitive issues, but she worries what might happen down the road. “I want my kids to be able to push their limits and be active,” says Morris. “It’s nerve-racking.” Druery says since Nora’s concussion, she also gets nervous when she sees her hanging upside down at the playground and sometimes has to remind herself, You can’t worry about every little thing. “There is a certain amount of risk attached to going to school and just being a kid.”

Reed, who is also a dad of three, says he understands first-hand how scary it can be to see your child take a nasty fall. But the last thing he wants is for parents to stop letting their children be physically active for fear of hurting themselves. Of course it is important for parents to take head injuries seriously, he says, “But we can’t have our kids living in a bubble.”

Do I need to wake my child up through the night?

Doctors used to advise waking kids up every couple of hours through the night after a head injury, but experts says these wake-up calls are no longer recommended. They might actually prevent your child from getting the restorative sleep his brain needs to recover, not to mention cause a lot of unnecessary stress for parents.

Baseline testing

If your kid participates in a high-risk sport like hockey or figure skating, you may have heard about pre-season baseline testing offered by private concussion clinics. The test (which costs around $90) measures your child’s performance on a range of cognitive and physical skills—from balance challenges to a series of neurological tests. Nick Reed, co-director of the Concussion Centre and an occupational therapist at Holland Bloorview Kids Rehabilitation Hospital in Toronto, describes it as “basically, a really boring video game that involves recognizing and responding to shapes and numbers on the screen.” The idea is that if your kid does get a concussion, doctors can compare her results post-injury to her baseline scores, which can help them assess how well she is recovering and when she might be able to participate in the sport again. But many experts say there’s not enough evidence to support it being used for kids. In 2017, Parachute, a charitable organization devoted to preventing injuries, released a statement saying, “Baseline testing is not required for post-injury care of youth athletes with suspected or diagnosed concussion and is not recommended.” Daniel Rosenfield, a paediatric trauma fellow at the Hospital for Sick Children in Toronto, says baseline testing is promising, but more evidence is needed to figure out how and when these types of tests can be used most effectively—they still haven’t been approved for use in the ER.

A version of this article appeared in our March+April 2017 issue with headline, “Handle with care,” p.32-4.

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