What’s the latest on concussions in children?

It’s been a while since I’ve written about concussions in children, so I want to share with you some updates on the subject. The term concussion itself is centuries old, but even forty ago when I was in training the actual definition of concussion was vague. What was usually meant was that the patient got hit on the head and either lost memory or consciousness briefly, or at least wasn’t quite himself for some period of time afterward. These days we’re more precise than that, but concussion is still an inexact term. This is mainly because of our ignorance of the subtleties of how the brain works and how it responds to injury. Estimates are there are around three million concussions in children each year.

The formal definition of concussion is a transient interruption in brain function. By implication, various scans of the brain, such as CT scans or MRI scans, show no abnormalities. Since all the imaging studies are normal, defining concussion is necessarily imprecise. I’m sure one day we’ll have some kind of test that detects the reason for the symptoms of concussions, but right now we don’t have such a thing — concussion is an entirely clinical diagnosis, meaning there’s no specific test for it. The list of symptoms that can come from a concussion is a long one. Headache, dizziness, vomiting, and ringing in the ears are common. Various behavioral changes are also common, such as lethargy, difficulty concentrating, and irritability. The overwhelming majority of children who suffer a concussion, especially a mild one, recover completely. But around a fifth or so of children who have had severe concussions continue to have problems many months afterward.

There are several traditional systems for grading concussions. A commonly used one was published in 1997 the American Academy of Neurology. It was based on a grading system that ranged from Grade I (no loss of consciousness) up to Grade III (loss of consciousness, no memory of the event). You will still see this system quoted in many places but in 2013 the Academy revised their guidelines to stress the continuous spectrum of concussions and focus on the neurological examination of the child rather than memory or not of events. A major focus of the new guidelines was on sports and when an athlete can safely return to play, a common practical issue for young athletes. They emphasized that the younger the child, the more conservative the approach should be. Children who suffer a concussion are much more likely to suffer another, and potentially much more severe brain injury if they have a blow to the head before the symptoms of the first one have completely cleared. So-called second impact syndrome is a particular fear; I have seen a death from that. This is the important concept: a concussion is a form of brain injury. Some experts want to discard the term concussion completely in favor of something like mild traumatic brain injury. Old sports terms, such as “having your bell rung,” tend to downplay this reality. The wealth of recent research about chronic traumatic encephalopathy in football players, even those at the college level, demonstrates the long-term risks of repetitive blows to the head, even those not sufficiently severe to cause immediate symptoms. It is important to know that research on various kinds of helmets have not shown any benefit, at least yet. What has been shown is that early removal from contact sports makes concussions heal faster. Contact sports like football and hockey carry the highest risk, but as the image above shows, other sports like soccer and volleyball are often associated with blows to the head. And in those sports no helmets are worn. Here’s the bottom line, from Dr. Jeffrey Kutcher of the University of Michigan Medical School:

If in doubt, sit it out, . . . Being seen by a trained professional is extremely important after a concussion. If headaches or other symptoms return with the start of exercise, stop the activity and consult a doctor. You only get one brain; treat it well.

The American Academy of Neurology has an excellent resource page here, where you can find much useful information about concussions.


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