Concussions: When to Worry

January 25, 2011

Nicole McCoy, MD, Daniel R. Neuspiel, M.D., M.P.H.,

You're sitting at your child's soccer game and notice he collides with another player and gets up slowly, looking dazed. Or, at the playground, you watch as your toddler falls from the monkey bars and hits her head on the slightly frozen ground. She lies there for a second trying to get her bearings, then gets up slowly, acting dizzy. What should you do?

A concussion is a forceful bump, blow or jolt to the head or body that results in rapid movement of the head. This is accompanied by a change in behavior, thinking and physical functioning. A concussion can be anything from a "ding," to "getting your bell rung," or even to loss of consciousness.

Warning Signs

Concussions can occur in many different settings, including car accidents, organized sports, recreational sports, homes and playgrounds. You may not be able to see any obvious signs of damage to your child's head, but may notice that he or she is acting differently.

It is important to notice the signs and symptoms, so you are able to quickly recognize a concussion, tell your child's physician and track your child's improvement. The signs and symptoms can be broken down into four categories: difficulty thinking, physical symptoms, emotional changes and changes in sleep pattern. Problems with thinking include difficulty concentrating, difficulty following directions and remembering. Physical symptoms include headache, nausea, vomiting, dizziness, blurred vision and sensitivity to light and noise. Emotional changes include irritability, sadness, nervousness and anxiety. Changes in sleep pattern include increased or decreased amount of sleep, trouble falling asleep and drowsiness.

Symptoms that should worry you and warrant a prompt trip to the closest hospital or emergency department are a progressively worsening headache, repeated vomiting, difficulty arousing the child, seizures, slurred speech or unsteadiness when standing up.

Many parents do not know where to start when it comes to identifying and managing concussions. The first thing you should do is remove your child from play and determine what symptoms are occurring. Athletes should never return to play on the same day of a concussion. It is important to seek medical attention regardless of the severity of the concussion. Your child's physician or the emergency department can provide a medical evaluation, including a formal assessment of your child's symptoms. The tools and standardized forms your physician uses can guide recommendations for management at home and return to play, especially if your child is an athlete.

Rest is Important

It is also important to involve the coach, athletic trainer, teacher and school nurse to get additional opinions about symptoms and improvement. If your child experiences any of the warning signals of a more serious concussion, you should go to the nearest emergency department for further evaluation. Close follow up with your physician should be planned, and your child should not return to school or sports until cleared by the physician.

Management guidelines for concussions recommend a step-wise return to play dependant on the child's symptoms. The first step is physical and mental rest until the child has no more symptoms. This includes refraining from video games, watching intense movies, reading, working on a computer, and any physical activity until all symptoms have completely resolved.

At this point, the guidelines advise increasing the intensity of exercise from light aerobic exertion all the way to return to sports competition, along with a gradual return to school work. If your child's symptoms recur at any time during the step-wise return to play, the guidelines recommend returning to step one: strict physical and mental rest.

The duration of the steps should be no less than 24 hours but may be increased as recommended by your physician or in combination with the coach or athletic trainer. Bottom line: Your child should not return to play or intense school work until he or she is completely symptom free.

The prevention of concussions encompasses home and car safety, and safe sports. Make sure your child is always properly restrained in the car with a car seat, booster seat or seat belt to prevent automobile-related concussions. Children should never ride on ATVs. Prevention at the playground includes making sure the surface under play equipment is shock absorbing, like mulch or rubber, and that the equipment is in good condition.

At home prevention can include using safety gates on stairs, using rubber mats in bath tubs and safety proofing windows.

For organized and recreational sports, it is important to make sure your child is wearing the proper appropriately fitting protective gear at all times, including approved, well-fitted safety helmets for bicycling, skateboarding, riding scooters and roller skating.

Talk with your pediatrician for more advice on preventing and treating head injuries. For more information on concussions, go to www.cdc.gov/concussion/index.html.

Dr. Nicole McCoy is a pediatric resident at Levine Children's Hospital. Dr. Daniel Neuspiel is director of ambulatory pediatrics at Levine Children's Hospital and medical director of Myers Park Pediatrics.