October 3, 2014

Poll Shows Gaps in Parents’ Knowledge About Concussions

Before their children are allowed to participate in sports, many parents must sign a document acknowledging that they understand concussions and their risks for brain injury. But a new poll on children’s health suggests that even if they know about the risk of concussion, they’re not necessarily capable of handling it properly.

According to the C.S. Mott Children’s Hospital National Poll on Children’s Health, about half of the 912 parents of middle- and high-school children surveyed said they had participated in some kind of concussion education.

  • Nearly 1 in 4 had read a brochure or online information.

  • Seventeen in 100 had watched a video or attended a presentation.

  • Eleven in 100 had signed a waiver form, but had no other educational information.

  • Nearly half had received no concussion education at all.

As you might expect, it was more common for parents of children who play sports to have gotten some kind of concussion education than for parents of nonsports kids (58% vs. 31%).

Some education is better than none, but, according to Sarah J. Clark, associate director of the Mott national poll, “The way the concussion information is delivered is linked to the parents' confidence about managing their child's injury." Clark is also a research scientist at the University of Michigan Department of Pediatrics/University of Michigan Medical School.

"Many schools mandate that a waiver form … be signed, but the danger is that parents will skip over information to get to that required signature line," she said in a news release.

More than 6 in 10 parents who watched a video or a presentation rated it as very useful. About 4 in 10 parents who read a brochure or online information rated that as very useful. Only 11 in 100 parents whose only concussion education was signing a waiver form reported that was very useful.

Parents lacking sufficient information about concussion, and its potential for brain injury, won’t know what to do if their child is injured.

According to the U.S. Centers for Disease Control and Prevention (CDC), nearly 175,000 children are treated every year in U.S. emergency rooms for concussions related to sports or recreational activities, including bicycling, football, playground activities, basketball and soccer.

Although it’s never a minor event, a concussion affects children differently from adults. The healing process is different, and getting more than one concussion in a short period is particularly dangerous for kids.

All parents, but especially those with sports-playing youngsters, should get become informed about what is concussion, how to monitor its symptoms and when to seek medical attention. Until symptoms have subsided, parents should limit the child’s physical activity, and maybe mental activity including homework, to allow the brain to heal. (See our blog, “Getting Back Into the Game After Suffering a Concussion.”) Watch the video from the C.S. Mott Children’s Hospital here.

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August 15, 2014

All-Terrain Vehicles Are Not Toys

Here’s a “Say what?” statistic that should give parents pause: More than half of all teens who have driven an all-terrain vehicle (ATV) have been involved in an accident.

So says research recently published in the Annals of Family Medicine. The report also shows a propensity for teens to engage in several kinds of risky behavior when they ride on an ATV.

As explained on AboutLawsuits.com, researchers from the University of Iowa Carver College of Medicine found that 3 in 4 teenagers in the state of Iowa have driven an ATV and that kids 15 and younger represented 1 in 5 ATV-related deaths.

The findings about the number of teens who had been in crashes were similar to previous studies from other states.

The conclusions were based on a survey of 4,684 youngsters between 11 and 16 taken over 2½ years at 30 different schools throughout Iowa. More than 1 in 3 of the kids who said they’d ridden an ATV reported doing so every day or every week. More than half of the ATV riders said they’d been in at least one accident, and nearly all of them acknowledged having engaged in risky behavior, which was defined as:

  • riding with a passenger (9 in 10 reported doing this);

  • riding on public roads (8 in 10);

  • riding without a helmet (more than 6 in 10).

Six in 10 respondents reported having engaged in all three dangerous behaviors at some point. A scant 2 in 100 said they had engaged in none of them.

According to the ATV Safety Information Center, an initiative of the U.S. Consumer Product Safety Commission, of about 100,000 ATV injuries in 2012, one-quarter were kids younger than 16, and of the 353 ATV fatalities that year, 54 were from that group.

Even for people who are careful, ATVs are dangerous — they’re powerful and can be unstable, especially if they have more riders than they’re built to accommodate.

The most fearsome accidents, of course, involve brain injuries, which, according to the new study, “are among the leading cause of death and disability from ATV crashes. They are more likely to occur on the roadway than off road, even when controlling for helmet use. Helmets are estimated to reduce the risk of fatal ATV-related head injuries by 40% and of nonfatal head injuries by 60% or more.”

To learn more about brain injuries, see our backgrounder.

If you and your family enjoy riding all-terrain vehicles, make sure you follow the safety guidelines provided by the CPSC:

  • Do not drive ATVs on paved roads.

  • Do not allow a child under 16 to drive or ride an adult ATV.

  • Do not drive ATVs with a passenger or ride as a passenger.

  • Always wear a helmet and other protective gear such as eye protection, boots, gloves, long pants and a long-sleeved shirt.

  • Take a hands-on safety training course.

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November 15, 2013

Helmet Claims Don’t Stand Up in Preventing Football Concussions

The topic of sports-related concussions, especially from football, remains front and center among health professionals and any player or parent who cares about his brain function. Equipment manufacturers have jumped aboard the protect-your-head bandwagon, but, as a recent story on USNews.com makes clear, helmet product claims of reducing the risk of injury aren’t borne out by the facts.

We’ve reported on concussion-related brain injury and the ways in which product manufacturers have tried to address it.

Summarizing research presented at a meeting of the American Academy of Pediatrics last month, USNews reported that “… neither the brand nor the age of a helmet is associated with fewer concussions in young athletes, …”

During the 2012 football season, researchers tested a variety of mouth guards and football helmets worn by 1,332 high school football players from 36 different schools. The players had completed a pre-season questionnaire about previous injuries. The athletic trainers reported the number and severity of sports-related concussions throughout the season.

At season's end, no significant difference was found in the frequency of concussions among players, regardless of the brand or age of their helmets. And the severity of the concussions, as measured by the number of days players were absent from play, was no different among players wearing different brands. Among the brands tested were Riddell, Schutt and Xenith.

Many helmets promoted for reducing the risk of concussion are more expensive, so the researchers questioned the wisdom of investing in such equipment.

According to the Centers for Disease Control and Prevention (CDC), more than 173,000 recreation-related traumatic brain injuries to children and adolescents are treated in U.S. emergency departments in the United States every year. Boys between 10 and 19 who play football are far more likely to suffer such injuries. Nearly 3 in 4 ER visits for brain trauma are among males, and most often involve football or bicycling. The recent research showed that about 40,000 sports-related concussions occur in U.S. high schools every year.

Although helmets reduce the risk of skull fractures and scalp injuries, the researchers doubt that they’ll ever be able to protect athletes completely from concussions and brain injuries. That’s not likely, as the chief researcher told USNews, "because the brain is floating freely inside the skull, I think most experts doubt whether it is possible to ever develop a helmet design that can prevent concussion."

Gregory Myer, director of research for the Division of Sports Medicine at Cincinnati Children's Hospital Medical Center, said it's difficult to protect the brain from the outside, especially when you add mass to an athlete's head with a helmet.

"That's why we've seen no reduction in the number of concussions from the development of any helmet," he told USNews.

You can prevent the incidence and severity of concussions by increasing peripheral vision to enable a player to avoid or prepare for a collision, and by improving neck strength. But Myer said it's possible that helmets could increase the risk of concussions.

That comes from a sense of invincibility—some players might be less fearful if they’re wearing a helmet they believe has protective powers that it doesn’t.

"They're more likely to use their head as a weapon," Myers told USNews. "If you took that away, athletes would never lead with their head."

Learn more about concussions on HealthyChildren.org, an informational website of the American Academy of Pediatrics.

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October 25, 2013

When Kids Get Headaches

Almost everyone gets the occasional headache, even children. Almost always, they’re insignificant in the grand scheme of health.

As described on KevinMD.com by Dr. Roy Benaroch, a pediatrician and author of “A Guide to Getting the Best Health Care for Your Child,” so-called “primary” headaches are those without a specific cause or association to a specific medical condition.

Often, he writes, headaches in children are are caused by a minor infection, dehydration, hunger or stress. “If they’re recurrent,” Benaroch says, “they’re likely to be one of the common primary headaches, like tension headaches or migraine or chronic daily headache. Headaches that are progressive (worsening), or associated with other prominent or worsening symptoms, need an urgent medical evaluation, but those are fortunately rare. More typically, headaches just need to be treated like, well, headaches.”

And what does that mean? As is often the case, it’s simple: a kiss to make it better, rest, a cool compress, something to help the kid relax. “In the long run,” Benaroch says, “those are probably better headache remed[ies] for children than any medication.”

Benaroch’s primer on primary headaches:

Migraine. This might be the most common of the more severe headaches. In children it’s often bilateral (not limited to one side of the head, as is common with adult migraines), and fairly brief. Sometimes it’s accompanied by vomiting, and gets worse with light or sound. Often the best treatment is to go to sleep. Migraines often run in families.

Tension. This creates a constricted feeling in the head, and isn’t usually severe. Kids of all ages get tense.

Chronic daily headache. This often occurs in addition to occasional more severe headaches, like migraines.

To treat chronic daily headache:

  • Avoid daily Advil or Tylenol. Using them more than three days a week perpetuates the headaches.

  • Follow a healthful lifestyle—good, regular sleep, sound diet without a lot of preservatives and chemicals, regular exercise.

  • Try not to miss school; it makes headaches worse.

  • Consider massage/yoga/relaxation therapy.

  • Address any depression/anxiety/mood issues. They often have a psychological component, either contributing to the headaches, or being caused by the headaches and missing school and activities.

  • Consider a daily medicine to control the headaches. Not painkillers, but meds that prevent headaches, which require a physician’s guidance.

CT scans are almost never necessary for chronic, ongoing, stable headaches, which come and go in a stable pattern. Imaging is useful only for acute, worse-in-a-lifetime headaches, those associated with other symptoms, such as seizures, or progressively worse headaches. CTs (or MRIs) are completely unnecessary in the workup of most children with headaches, and will sometimes give misleading results that lead to overtesting and misery. (See our blog, “CT Scans for All Kids with Head Injuries?”)

Most people who believe they have sinus headaches don’t. Truly recurrent sinus headaches are uncommon. When they do occur, they’re associated with persistent nasal congestion and cough that precede the headache. Migraines, which are far more common than recurrent headaches from sinusitis, can cause nasal or sinus symptoms that begin about the same time as the headache.

Another uncommon association with recurrent headaches in kids is vision problems. Some nearsighted people squint, and by the end of the day might develop pain from contracting the muscles of their face and scalp, but that, too, is uncommon.

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August 16, 2013

Anesthesia Drug May Cause Brain Damage in Kids Undergoing Surgery

Drugs that fall under the category of “anesthesia” are powerful in their ability to separate you from the sensation of pain, and when you’re on the operating room table you wouldn’t want it any other way. But a recent study suggests that for youngsters, at least one of these drugs can have ominous effects.

As reported by AboutLawsuits.com, the drug ketamine can have a toxic effect on developing neurons that can cause learning and memory disorders as well as behavioral problems.

The association was described in a study published in the journal Neural Regeneration Research. It found that children younger than 3 who underwent surgery for an extended period or repeatedly got ketamine for multiple surgeries, exhibited learning and memory disorders and behavioral abnormalities when they reached school age.

The research, which was conducted on rats, not kids, found signs of neural toxicity and neuron death caused by the drug. In case there’s any doubt of ketamine’s power, it has been implicated as a “date rape” drug that leaves victims unable to move or remember what happened. It’s in the same class of drugs as PCP (phencyclidine), a dangerous “recreational” drug, and propofol, the drug that killed Michael Jackson.

Ketamine is a common anesthetic used in combination with a sedative. Apart from pediatric uses, it’s also common in veterinary medicine. Short term side effects sometimes include hallucinations and elevated blood pressure.

The Neural Regeneration Research scientists replicated results found in other studies. They expressed concern that ketamine might cause long-term neurological damage in children, prompting disabled learning and memory function. Dyslexia, hyperactivity and attention deficit hyperactivity disorder (ADHD) were mentioned specifically.

“Researchers,” said AboutLawsuits, “urge health-care providers and parents to weigh the risks with the benefits when considering using ketamine during surgery.”

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June 21, 2013

Bicycle Helmets Save Lives and Brains

Riding a bicycle without a proper helmet is a no brainer—that is, you risk losing your brain if you fall off a bike with an unprotected head.

Now, a new study published in the Journal of Pediatrics confirms the common sense of always wearing a helmet. It says that bike helmet laws seem to prevent more head injuries and deaths than formerly believed, a conclusion that contradicts another study questioning the safety value of bicycle helmet legislation.

As interpreted on AboutLawsuits.com, the Pediatrics research analyzed data from the Fatality Analysis Reporting System (FARS) of bicyclists younger than 16 who died between 1999 and 2010. FARS is a nationwide census providing the National Highway Traffic Safety Administration (NHTSA), Congress and the public with yearly data about fatal injuries suffered in motor vehicle traffic crashes.

Those data indicated that states with mandatory bike helmet laws had a 20% lower fatality rate than those that didn’t.

But a study published in the British Medical Journal (BMJ) that analyzed Canadian laws between 1994 and 2003 found no effect of bike helmet laws on child fatalities. (It defined young people as those younger than 18.)

Although that study concluded that injury rates declined in provinces that had bike helmet requirements, researchers said the decrease wasn’t the result of helmet laws because injury rates had begun to decline when the legislation was enacted, and they didn’t continue to decline after the laws were in place.

The BMJ researchers attributed the lower injury numbers to improved public education about bike safety, safe-riding media campaigns and wider availability of subsidized helmets.

But let’s look at that conclusion with a critical eye: Doesn’t it logically follow that if you are a better informed cyclist you understand the necessity of wearing a helmet? Why would authorities subsidize helmets if they weren’t clearly protective, if there wasn’t a clear benefit?

More than 900 people die each year from bicycle collisions, according to AboutLawsuits, and about 3 in 4 of those fatalities were caused by a head injury.

Every bicyclist, young or old, should wear a helmet. Parents should set the right example by wearing a helmet when they ride, and they should require their kids to wear one from the first time they get on a trike.

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March 29, 2013

Getting Back Into the Game After Suffering a Concussion

When we wrote about kids and concussions a while ago, the discussion concerned the rising awareness of how getting your head banged during an athletic competition can lead to traumatic brain injury, and that sports equipment manufacturers were responding by designing more protective gear.

How quaint. As of last week, the guidelines for treating kids who suffer a head injury on the field of play have become more stringent. At least that’s what the American Academy of Neurology advises.

As reported by the Associated Press, when athletes are suspected of having a concussion, they should be taken out of action immediately and shouldn't resume playing until they've been fully evaluated and cleared by a doctor or other professional with concussion expertise.

The academy’s recommendations support a position paper it issued in 2010, but the new guidelines are a more complete document for evaluating and managing a head injury based on a comprehensive review of scientific research.

The guidelines replace those published 15 years ago that advised grading the severity of a concussion at the time of injury as a way to measure when the player could return to the game. The new recommendations emphasize individual player assessment and management of the injury when it occurs, and are not flexible about returning to play: Don’t do it.

Athletes should not be allowed back into the game if they show any symptoms, such as dizziness, muddled thinking, blurry vision, headaches or nausea. The guidelines also say players of high school age or younger with a diagnosed concussion should wait much longer to return to action than older athletes.

AP pointed out that the research showed that the grading system didn't provide useful information about outcomes, and that recovery from concussion is not predictable—some people recover faster than others. But the first 10 days after a concussion, according to the guidelines, are when a player is at the highest risk of getting a second concussion

And getting that concussion before the first one is healed can lead to longer periods of disabling symptoms. Sometimes the damage, including mental impairment, memory loss, headaches and mood disorders, can be permanent.

So, parents, coaches and trainers, if a child of yours bangs his or her head in the course of the game and is seeing stars, having trouble with balance, unable to focus or complaining of headache, that child does not belong in the contest that day and for days to come. At least.

If your child’s coach (or any other authority) encourages him or her to just shake it off and get back into the game, it’s time to find another place to play.

To learn more about concussions, link here on website of the American Academy of Neurology.

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February 28, 2012

CT Scans for All Kids with Head Injuries?

From high-profile former NFL players to soldiers returning from Afghanistan, the emerging picture of head trauma is not pretty. And of course the lingering, often-delayed effects of traumatic brain injury (TBI) aren’t limited to adults.

We’ve talked about children at risk of concussion when they play sports, and how manufacturers are developing “anti-concussion” athletic equipment.

Writing on KevinMD.com, malpractice attorney Maxwell S. Kennerly suggested that some practitioners still aren’t taking head injuries to children seriously enough.

Last year, he noted, the Centers for Disease Control and Prevention (CDC) reported “a growing awareness among parents and coaches, and the public as a whole, about the need for individuals with a suspected TBI to be seen by a health-care professional.” He pointed to the CDC’s Heads Up initiative as exemplary of efforts to raise consciousness that seeing stars isn’t a badge of athletic honor, it’s a reason to seek medical care.

What remains questionable, Kennerly wrote, is how prepared emergency and primary care physicians are to handle the increased number of head trauma cases they’ll see as a result of greater awareness of the problem.

“Viewed through a narrow lens, the solution to a suspected brain injury is obvious,” he wrote. “[I] f a kid complains about anything relating to their head, give them a CT scan. But CT scans come with their own costs and risks, not least exposing a developing brain to a year’s worth of background radiation.”

Too often medicine overtreats patients because technology enables it, insurance pays for it and/or doctors are worried about being challenged if they fail to perform every test within reach. Often a more conservative approach is better for the patient.

But when it comes to kids and head injuries, in deciding whether to order a CT scan for a kid with new head trauma, Kennerly says the conservative treatment approach is wrong.

“I’m not here to tell you where the CT / no-CT line should be drawn,” Kennerly claimed. “I can tell you, however, how I would draw that line as a medical malpractice lawyer when a parent comes in and tells me their doctor didn’t order a CT scan after a minor head trauma and their child later developed serious sequelae [i.e., a brain injury]."

In the world of medical malpractice, such a circumstance is known as “failure to diagnose.” As Kennerly explained, laypeople—like jurors—might well respond to the concept of incremental risk a witness might offer to defend against the charge of failure to diagnose. “One head CT scan,” the witness might say, “has more radiation than 20,000 trips through the TSA scanner at the airport.”

That sounds scary. But is it scarier than risking chronic, lifelong problems with the ability to think, loss of memory, headaches, attention deficit, mood swings and the other markers of brain injury?

Kennerly cited an article published in the January issue of Critical Decisions in Emergency Medicine, “Evaluation of Minor Head Trauma in Pediatric Patients," that argues for CT scans for children who present with any evidence of brain trauma.

If you’re the parent of a child who has fallen from a great height, who has emerged woozy from a collision in soccer, who claims his or her vision is blurred from a bang on the noggin, take him or her to your physician or emergency room immediately. And if the child doesn't show full recovery of normal consciousness very quickly, without any symptoms of brain trouble, a CT scan could be in order.

A British website offers guidelines for CT scans for anyone younger than 16 with a head injury, and the CDC's Heads-Up site helps observers spot the signs of concussion. They are:

  • loss of consciousness;

  • loss of memory;

  • abnormal drowsiness or sluggishness;

  • nausea or vomiting;

  • bruise, swelling or laceration on the head, behind the ears;

  • bruising around the eyes ("panda" eyes);

  • fluid leakage from ears or nose;

  • confused, dazed or stunned appearance;

  • personality changes;

  • headache;

  • problems balancing or abnormal clumsiness;

  • double or blurry vision; or

  • abnormal sensitivity to light or noise.
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