Concussions and Children: What You Need to Know

What is a concussion?

A concussion, also called a mild traumatic brain injury, is a blow or jolt to the head, or a forceful hit to the body that causes the head and brain to move rapidly back and forth. The rapid movement of the brain (soft tissue) within the skull (hard bones) can cause bruising or injury to the brain and supporting structures. Concussions can also occur as a result of repeated or violent shaking of the upper body and head.

This injury kicks off a cascade of chemical and metabolic changes in the brain that makes the brain more susceptible to further injury and harm. The good news is that a “typical” concussion is considered a reversible, recoverable process when an individual receives appropriate care and follows treatment recommendations. Your child will recover from a concussion.

How do I know if my child has a concussion?

A concussion changes the way a person thinks, acts or feels, but it isn’t always easy to know if someone has a concussion. Some of the signs of a concussion may be subtle or may develop over a short period of time. Other symptoms may be immediate and clearly identified. The Centers for Disease Control and Prevention and American Academy of Pediatrics have information on the signs and symptoms of concussions.

It is important to note that a concussion may or may not result in a loss of consciousness. You do not have to blackout immediately after the injury for your injury to be classified as a concussion.

Infants or very young children can present with different symptoms than older children or adults. Persisting symptoms for infants and young children may include excessive crying, poor attention, changes in nursing or eating habits, changes in toilet habits, decreased coordination, being easily upset, tantrums, and a lack of interest in favorite toys or activities.  

The most important things to remember when it comes to concussions are:

• IMMEDIATELY remove your child from sporting activities if it appears that your child has sustained a strong jolt to the body or head and appears dazed, confused or to be exhibiting any signs of a concussion.
• When in doubt, sit them out! It is much better to remove a child from a game for evaluation than to miss a concussion and run the risk of a subsequent – and potentially more serious – injury to your child. No tournament, championship game or college scout is worth the risk of a long-term brain injury.
• Have your child evaluated by a medical professional to check for any urgent medical needs, such as a skull fracture or brain hemorrhage.
• Continue to follow up on a routine basis with your child’s primary care physician or specialty care provider to determine when it is safe to return to activities.

How often should I take my child to the doctor to be evaluated after a concussion?

An initial evaluation should occur within the first 24 to 48 hours of sustaining the injury. Oftentimes pediatricians have appointments saved in their schedules for urgent cases.  Urgent care or walk-in clinics are good alternatives. And, of course, the emergency department is always open and available.

Once the initial period following a concussion has passed, many physicians will have routine follow-up visits to monitor your child’s progress and symptoms. They may be every week or every other week – they vary depending on the physician. As your child’s symptoms decrease, your physician may give you specific instructions for completing graduated steps for returning to learn and play, and ask you to check back in when your child has reached a certain level and remains symptom-free.

Since cognitive symptoms can be harder to identify, your child may also undergo an assessment by a neuropsychologist. This assessment evaluates the way your child is currently thinking, learning and remembering information, as well as how quickly he or she is able to react and process information.  

It is important to note that if you’re concerned about rapid changes in thinking or other concussion symptoms, you should always seek medical consultation. These changes should be considered “red flags” and signal that your child needs immediate care:

• Neck pain
• One pupil is larger than the other
• Drowsiness/can’t wake up
• Worsening headache
• Weakness, numbness or decreased coordination
• Difficulty with recognizing people or places
• Repeated vomiting
• Slurred speech
• Increasing confusion, restlessness or agitation
• Unusual behavior
• Altered, changed or loss of consciousness (even brief) after the initial concussive period

What is "cognitive rest"?

When you sustain a concussion, the brain is in an active state of metabolic chaos. That chaos needs to stabilize and calm down for recovery to occur. The only way to do that is to decrease the demands on the brain to think and perform cognitive tasks.

Cognitive rest is the powering down of the brain. It means disengaging from anything that places a demand on the brain to think or problem solve. This is quite a bit more difficult than it sounds.

For full cognitive rest, there should be no school work, reading, television, tablets, e-readers, texting, video games, using smart phones or social media. Not unplugging from these types of activities can increase the chance of worsening headaches and other symptoms.

After a concussion, when can my child return to regular activities?

There is no specific timeline for recovery. With a single concussion, a majority of individuals will be fully recovered within 30 to 60 days of the injury. With multiple concussions, the recovery time can be longer.

Other risk factors that may make recovery longer include a history of headaches or migraines, developmental disorders (Attention deficit hyperactivity disorder, learning issues) or psychiatric factors (depression, anxiety, sleep disorders).  

Appropriate treatment for concussions involves full cognitive rest as well as physical rest in the acute stages of the recovery, followed by a gradual return to cognitive and physical activity in stages. These graduated plans are often referred to as “Return to Play” and “Return to Learn” plans.

A primary care physician or other specialists (such as a pediatric neurologist) will guide you and your child through these stages, which are tailored to your child’s rate of recovery, sporting activity and emotional state.

Are there special precautions to take when my child returns to school?

In the early stages of recovery, concussed students may need a temporary accommodation plan (a Section 504 plan) put in place when they return to school.

Accommodation plans allow for specialized instruction, temporary reductions of homework, and other assistance needed including, but not limited to:

• Time off from school
• Shortened school day
• Rest breaks during classes
• Permission to rest in the school’s health office
• Permission to wear a hat and/or sunglasses on the playground
• Extended time to complete assignments and tests
• No significant classroom or standardized testing during recovery

It will also be important for your child to be excused from physical activities until he or she is cleared for physical activity by your physician.

When can my child return to playing sports?

A Return to Play plan depends on the severity and duration of your child’s symptoms, and medical release from your child’s physician. All 50 states have legislation in place to protect children and student athletes from returning to sporting activities before recovering from concussive injuries. In California, updates to the concussion safety law (AB 2127) became effective in 2015 and introduced a mandatory graduated Return to Play protocol of at least seven days.

Your medical provider will guide your child through a graduated Return to Play plan in which your child will work on increasing heart rate and physical movement over a series of closely monitored steps, with the final goal being return to practice and sports.

Your child’s symptoms will be monitored at each step to ensure there is no return of concussive symptoms. The time spent at each of these steps depends on how your child feels and the symptom progression. With younger children, treatment and timelines are more conservative.

When your child returns to sports, make sure they always wear the appropriate protective gear for that sport. Be sure the equipment is fitted specifically for your child each season and worn appropriately.

Do you have any tips or recommendations to help my child recover from a concussion?

First and foremost, stay positive and be confident your child will recover. Reassure your child that he or she will recover.

Next, ensure complete rest! Disconnect from electronics and other taxing activities. Set a routine bedtime and limit sleepovers during recovery. AAP notes your child’s pediatrician may ask you to check on and wake your child every two to three hours. Don’t worry about waking your child up throughout the night when they are first concussed unless there was evidence of loss of consciousness or amnesia around the injury. It is more important that your child rests.

Follow the recommendations of your child’s physician. This guidance will ensure your child is back to learning and activities in the shortest timeframe possible. Often, when children progress through the stages of graduated return to learn or play without being fully stabilized at each stage, it takes longer to fully recover, or can cause a child to be more susceptible to a successive and more serious injury.

Lastly, always make sure your child is well protected from unexpected injury. This includes keeping their room free from tripping hazards and clutter, and making sure children always wear safety belts or restraints in a car.