‘If in doubt, sit them out’
CHEO unveils world’s first guidelines for children with concussions
Sam Barton was doing what children do every day — playing in gym class — when “somebody fell on somebody,” in his father’s words, and the 10-year-old banged his head on the floor.
There were no visible bumps or bruises, no signs of nausea, but Sam complained of a headache and feeling off, so his parents took him to the doctor. There he was diagnosed with a probable concussion. Tests he did later, as part of research at the Children’s Hospital of Eastern Ontario, confirmed that not only did he have a concussion but that the knock had affected his ability to concentrate and his muscle strength, among other things.
Sam, now 11, is one of hundreds of local children who suffer from concussions every year — 900 of them show up at the CHEO emergency room alone.
They are more common in children and youths than in adults — one in 70 children brought to the emergency room is there because of a concussion, and an estimated 10 to 20 per cent of hockey players between nine and 17 have at least one head injury a year. But pediatric concussions have always been less well understood.
That should change with the release Wednesday of the firstever comprehensive guidelines for pediatric concussions, developed by a team led by Dr. Roger Zemek, a scientist at the CHEO, along with the Ontario Neurotrauma Foundation.
The guidelines — the first of their kind in the world — are meant to help doctors, nurses, parents, teachers, coaches and community workers recognize the signs of concussion in children and youth, as well as what to do when they identify one, how it should be treated and when a child is ready to return to school and sports.
The researchers also suggest that children and adolescents involved in high-risk sports have baseline neurological testing done — as professional hockey players do — to use as a measuring stick for recovery if that child has a concussion.
One of the key pieces of advice is to remove children from play as soon as a concussion is suspected, with the underlying message: “If in doubt, sit them out.”
That is crucial, said Zemek, because a second concussion before the brain has recovered can have “devastating consequences.” Second impact syndrome, as it is known, resulted in the death of Ottawa high school rugby player Rowan Stringer after a game in May 2013.
The Ottawa Carleton District School Board is in the process of developing concussion guidelines, one of the recommendations from Zemek’s group.
The guidelines released Wednesday include pocket-sized assessment tools that list signs and symptoms of concussion — including everything from loss of consciousness to fatigue, headache, sensitivity to light and difficulty concentrating.
The printable lists include red flags that call for urgent medical assessment, including vomiting, seizure and severe or increasing headache.
“We are all aware that there is no such thing as a minor concussion. A head injury is a head injury,” said Sam’s father, Michael Barton.
But, he added, parents need some reasonable guidelines for what to look for and “the path for return to play.”
“Everyone wants to do right by their child, but they don’t want to be overly cautious.”
The tools come at a time when there have been growing calls for better research and policies on youth concussions, as evidence mounts about the long-term damage done by sports-related head injuries.
Last month, U.S. President Barack Obama called for more robust research into youth concussions.
Zemek and his team surveyed hundreds of health providers and reviewing 4,000 papers with the latest evidence about concussions in children in order to come up with the guidelines.
Although many sports organizations have developed their own over the years, Zemek said it was important to have comprehensive guidelines with the most up-todate science because concussions don’t just happen in hockey rinks or playing fields, but also in their backyards, the playground, recreation centres and at school. And, although many doctors are getting better at recognizing signs of concussion in children, only a minority base their recommendations about return to school and sports on the latest and best evidence, said Zemek.
That includes that children need a “thinking rest” as well as physical rest to recover from a concussion, including eliminating — or severely limiting — “screen time” until symptoms improve, as well as stopping or limiting homework until symptoms are gone.
“It was fascinating to see how recommendations have changed over time.
Years ago children were told to rest after concussion, which means something entirely different today with the onset of technology — now, rest also includes a break from screen time,” said Zemek.
Too much activity — both physical and cognitive — can make it more difficult for the brain to recover from an injury, said Zemek.
“Think of your brain as a battery. If normal is being full, after a concussion it is down at 50 per cent strength. The brain needs time to get fully charged.”
Where doctors used to only consider a concussion serious if a patient had lost consciousness or suffered amnesia, medical science now knows that each concussion is different.
In some cases, Zemek said, a patient can have a brief loss of consciousness, but all symptoms are resolved in a couple of weeks. In other cases with no loss of consciousness, it could take longer for symptoms to resolve.
One of the keys to managing concussions is understanding that a wide range of symptoms, including irritability, sadness and fatigue can be signs that the brain has not yet healed.
Once symptoms have resolved, the child or adolescent should gradually return to school, sports and other activities — and if symptoms return they should return to physical and mental rest. The guidelines can be found at: www.onf.org/documents/guidelines-for-pediatric-concussion and www.concussionsontario.org/guidelines-for-pediatric-concussion