When In Doubt Sit It Out

"We are all aware that there is no such thing as a minor concussion. A head injury is a head injury."
"[Parents need a reasonable guideline on 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."
Michael Barton, Ottawa

Michael Barton's son, Sam, took part in a study that has led to the world's first guidelines for kids with concussions.    Chris Mikula / Ottawa Citizen

"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."
"Think of your brain as a battery. If normal is being full, after a concussion it is down at 50 percent strength. The brain needs time to get fully charged."
Dr. Roger Zemek, scientist at CHEO, and the Ontario Neurotrauma Foundation

Hundreds of children in the Ottawa area suffer from concussions annually, some 900 of whom show up at the Children's Hospital of Eastern Ontario emergency room alone in the space of a year. Concussions are more common an occurrence in children and youths than they are in adults. One in 70 children taken to the emergency room has suffered a concussion. An estimated ten to twenty percent of hockey players between the ages of 9 and 17 suffer at least one head injury a year.

Sixty percent of children coming in to CHEO with concussions are boys. It's estimated that fully one hundred thousand children experience concussions each year in Canada. And now, the first comprehensive guideline for pediatric concussions has been published, meant to help doctors, nurses, parents, teachers, coaches and community workers become familiar with the signs of concussion presenting in children and youth. Instructions relating to how to react when a concussion is identified and proper treatment is also included, including how to judge when a child may return to school and sports.

The guidelines include assessment tools listing signs and symptoms of concussion; everything related from loss of consciousness to fatigue, headache, sensitivity to light, and concentration difficulties. The lists are printable, and accessed at www.onf.org/documents/guidelines-for-pediatric-concussion, and www.concussionsontario.org/guidelines-for-pediatric-concussion. Red flags calling for urgent medical assessment include vomiting, seizure and severe or increasing headache.

Dr. Zemek cautions that one of the key pieces of advice is to take children away from play once a concussion is suspected to have occurred. "If in doubt, sit them out." This is a critical piece of advice, since a second concussion following on the first before the brain has recovered can result in "devastating consequences". Second impact syndrome, as it is termed, led to the death of an Ottawa high school rugby player after a game in May 2013.

Evidence continues to mount about long-term damage resulting from sports-related head injuries. Dr. Zemek and his team surveyed countless health providers, reviewed four thousand papers focusing on the latest evidence relating to children's concussions, which led them to their guidelines. Which reflect the most up-to-date science reflecting the fact that concussions don't just occur in hockey rinks or sport fields, but can occur in a backyard, a playground, recreation centres, and at schoolyards.

Many doctors are improving their abilities to recognize and accurately diagnose signs of concussion, but only a small number realize that children require a "thinking rest" along with a physical rest to recover, which means eliminating or severely limiting computer time until symptoms improve. That includes stopping or limiting homework until concussion symptoms are completely eliminated. Dr. Zemek points out that a patient can experience a brief loss of consciousness with symptoms resolved in a few weeks.

Alternately, there may be no loss of consciousness, yet it might take a longer period of time for symptoms to be resolved and recuperation takes that much longer. A wide range of symptoms exist, including irritability, sadness and fatigue which can signal that the brain has not yet healed. Once symptoms have dissipated entirely the child or adolescent should return gradually to school, sports and other activities.

Should symptoms return, physical and mental rest must be resumed. Where parents were once concerned over concussions resulting from sport activities or accidents in a playground, there was much less awareness of lingering and perhaps dangerous damage that might result. Most doctors simply advised parents years ago, to have the child rest, and during the night wake the child up every few hours to ensure they responded normally.

Knowing more now, we're much more vigilant and careful to ensure that there are no lingering effects. When ten-year-old Sam Barton was playing in his school gym class one day "somebody fell on somebody", with Sam banging his head on the floor. No visible bumps or bruises. But the resulting concussion affected his ability to concentrate, affected his muscular strength, and required intervention to return him to health.