Concussion In Adolescents

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     There is increasing recognition of how frequent and how serious concussion can be in adolescents. Almost 10% of all high school sports injuries are concussions. It is estimated that almost 4 million brain injuries a year occur as a result of sports trauma. Females seem to have a higher rate of concussion than males and children are more susceptible to concussion than adults. The reported rate of concussion is probably smaller than the actual rate because coaches, trainers and physicians sometimes don’t recognize the subtle signs of concussion and because athletes who want to play will often underreport their symptoms.

     A simple definition of concussion is impaired brain function caused by trauma. You cannot see a concussion on an X-ray or CT scan. Those studies show swelling, bleeding and other forms of brain damage, but a concussion is defined by how it affects the brain. Even loss of consciousness does not correlate directly with the severity of the concussion or the duration of the concussion symptoms.

     The sport having the greatest risk of concussion is football with hockey, lacrosse, basketball and soccer as runners-up. Bicycle accidents are another common cause. Helmets and other protective gear are effective in preventing facial, eye, dental and severe brain injuries, but it is not statistically clear that they decrease the risk of concussion. However, elimination of body checking in hockey, helmet to helmet contact in football and heading the ball in soccer have been shown to decrease the risk of concussion (allowing players to head the ball increases the risk of head-to-head collision).

     The symptoms of concussion are headache (often made worse with activity), confusion, disorientation, memory loss (for events before or after the accident), dizziness and vomiting. Longer-term symptoms are depression, poor concentration, and behavior changes. If the symptoms last for more than two weeks, it is called post-concussion syndrome. If the symptoms are getting progressively worse, more serious brain injury is possible and the child needs to be evaluated (or re-evaluated) by his caregiver.

     The treatment for concussion is rest. It is not recommended to take non-aspirin pain medications immediately after an injury because of the risk of bleeding in the brain. Any activity (video gaming, listening to loud music, etc) that makes the headache worse should be avoided. If activity makes the headache worse, PE should be avoided. The athlete may be sensitive to light and need to wear dark glasses.

     If a concussion is suspected, an athlete should not return to play for the rest of the game - "if in doubt, sit it out". The athlete needs to be assessed by his caregiver before returning to further activity. Headache and nausea need to be totally gone before returning to the sport and the athlete needs to be back to the level of mental performance he was at before the injury. This can be tested with on-line evaluation tools that measure ability to concentrate but no single test should be used to determine whether an athlete can return to play. All symptoms must be taken into account. Once the symptoms have totally resolved, the athlete should slowly return to activity but should stop if symptoms return. Multiple concussions have been related to a permanent decrease in school performance and should be considered grounds for retiring from the sport.

     If an athlete gets another head trauma before the symptoms from the first concussion are resolved, there is a risk for something called “second impact syndrome”. This is a rapid, severe swelling of the brain that is rare, but is almost 50% fatal. Its cause is unknown.

Head Trauma in Young Children

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          Young children frequently hit their heads. Head trauma in this age group is usually minor and rarely results in serious brain injury. The most common cause of injury in very young children is falls. Over two years of age, motor vehicle accidents, bicycle accidents and sports accidents are common causes. Evaluation of children less than two year of age is more difficult because they cannot report symptoms such as headache and confusion. In this age group, a sign of more serious injury can be a large, soft swelling under the scalp called a hematoma. Parents should be concerned if a younger child has a fall from a significant height, if there is any loss of consciousness longer than a few seconds or if vomiting occurs after the trauma. Any change in a child’s behavior that occurs after head trauma should be investigated by the child's care-giver.             
         Young children are at greater risk for concussion, so parents should never hesitate to have a child examined after significant head trauma. Irritability, lethargy, unsteady gait or increasing clumsiness are symptoms which should prompt the parent to seek medical care. For the older child, there are some rules of thumb parents can use to evaluate the degree of trauma the child sustained:

                  1.   Loss of consciousness: The longer loss of consciousness, the more concern.    

                  2.     Loss of memory: The child can’t remember the details of the accident or, even more worrisome, the child can’t remember what occurred before or after the accident.

                  3.     Prolonged symptoms: If headache, confusion or other symptoms continue to persist after the accident, there is greater concern.

                  4.     Increasing symptoms: If vomiting, headache or other symptoms are gradually increasing, there is real concern. The child needs to be examined immediately.
        Any older child who has had head trauma from sports needs to be taken from the game and not allowed to play until the parent gets an O.K. from the child's care-giver.

      CT scan of the head is ordered if bleeding inside the head is suspected. CT scan does not show concussion. Because of the risk of radiation, CT scans must only be done when necessary and, if done, they must be done carefully. There are clear guidelines for how much radiation to use when doing these procedures on children, but they often are not followed, especially in hospitals that are not pediatric specialty hospitals. Regular X-ray studies are usually not necessary.

     If a child had a low-risk injury, did not lose consciousness, has no vomiting, no headache, no large scalp swelling and has no change in their normal mental status, it is usually safe to observe the child. Allow the child to do normal activity but refrain from activity which could cause another head injury. You don’t need to wake the child from sleep to monitor them, however, if the child wakes up spontaneously with pain, he needs to be examined.

Little White Bumps - A Common Rash

     A common rash in young children and adolescents is called molluscum contagiousum.  The name is unfortunate – they are minimally contagious. A sibling might catch them from another sibling, but they don’t spread through the daycare.

     They are little raised bumps that are white and have a mucous-like substance in them. If you lift off the thin membrane covering the bump, a white wad of mucous comes out. They can occur in a group or on different areas on the body. They do not have any redness or irritation around them and they do not hurt or itch (although if they are picked at or rubbed, they can get inflamed or infected). If you look closely, you will see a small “belly-button-like” dimple directly in the center of the bump. They are usually all about the same size but sometimes can vary in size.

     If your child has red, raised, itchy lesions, which are various sizes and seem to come and go, he probably has hives. Molluscum contagiosum comes on and stays – often for weeks.

     No treatment is necessary for molluscum contagiosum. If left alone, they finally go away just as mysteriously as they came. If they get infected, covering them with an antibacterial ointment and a band-aid usually heals them. However, any red, swollen, painful skin lesion needs to be seen by the child’s caregiver.

     There has always been a discrepancy between the way dermatologists and pediatricians deal with molluscum contagiosum. Dermatologists treat molluscum aggressively by picking each lesion off, burning them off or putting wart-removing chemicals on them. I found early in my career that after I picked off 25 or so molluscum, the child was bloody and crying, the mother and even the nurse were crying and, within 2 weeks, a hole new crop of molluscum would pop up. Dermatologists insist that by treating molluscum they go away faster, but I’ve never found that to be the case. I’ve also never found the minimal improvement that treatment affords to be worth the discomfort (and sometimes scarring) caused by the treatment.

Cow's milk - Too Much Of A Good Thing

     A question parents frequently ask is: “How do I know if my child is drinking enough milk?” The answer is that we should be more worried about our children drinking too much milk.

     Doctors have long known that too much cow’s milk can cause iron deficiency. Low iron can cause permanent problems with mental and neurologic development and those neurologic delays can occur even if the child is not anemic, so measuring the child’s blood may not show the iron deficiency. A study published in Pediatrics in December of 2012 looked at cow’s milk intake and clearly showed that the more cow’s milk the child drinks, the lower the iron will be.

     Drinking too much cow’s milk can result from a number of reasons. If a family is poor, the high cost of formula may cause them to substitute cow’s milk in an infant’s bottle. When a child turns one year old, it is common for parents to put cow’s milk in the bottle because they are told, “Get off the formula” but the child still wants something white in the bottle. Picky feeders are often encouraged to drink more milk during the day under the impression that it will “at least give them some nutrition”.  Parents may allow a toddler to carry around a bottle of milk to “snack on” during the day.

     The vitamin D in cow’s milk is essential to good bone development. The study showed that about 2 cups (16 ounces) of cow’s milk a day gives the right amount of vitamin D without lowering serum iron. Children with darker skin pigmentation needed 3 to 4 cups during the winter months.

     The best rule of thumb for parents to follow is that when an infant under a year of age is starting to practice with a cup, put cow’s milk or water in the cup but keep formula in the bottle until the first birthday. After one year of age, the only thing that goes in the bottle is water – never juice or milk – no matter whether the bottle is given in the day or at night. A child is allowed a glass of milk with each meal, but the only thing the toddler is allowed to drink between meals is water. This not only helps prevent iron deficiency but it also eliminates the most common cause of tooth decay in toddlers.

Colic

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      I have written about fussy babies before (see: “The baby’s crying” -  Dec 2012; Gas and reflux -  Jan 2012; Fussy 1 month-old  - Jan 2012). Nothing makes a parent feel more frustrated and helpless then when a baby is crying and the parent has “tried everything” to make him stop. Between birth and 3 months of age, babies cry a lot. Even when there is nothing wrong, they will make fussing, straining or crying noises when they are just “talking” to you. Feeling cold, hungry, tired and having their bowels move are things that never happened to them while they were in the uterus, so their response to normal living is often to cry. Eventually, they get used to being here, as we all did, but for a few months, it can be rough for babies and parents.

     There is no clear definition of colic. An infant with colic is simply one who cries a lot in the first months of life.

     The most common causes for an infant’s crying are hunger, a soiled diaper and being tired. Change your crying infant first, then feed him as much as he wants (don’t limit the amount – let him eat until he stops actively feeding) then gently hold or rock him. If he has been up for more than an hour or two and starts to drift off when you hold him, put him down in a quiet, dark room and let him fall asleep (even if he has to cry a little to do it). Infants need more sleep than most parents realize and an infant who has had lots of stimulation and little naptime is certain to be wildly fussy by 4 pm.

     Infants normally spit up a lot (some more than others), but “reflux” that needs “treatment” is actually rare – even though it is commonly diagnosed and often treated. Most spitty babies only require lots of laundry and a few months of growing. Medicines for infant reflux don’t usually cure fussiness any better than placebo.
     Too much carbohydrate in the diet can make a baby bloated and fussy, so, if you use powdered formula, be sure to prepare it correctly

     Pushing at hard stools can make a baby fussy and, if a baby seems to strain and push a lot, using a half of a baby glycerin suppository on a regular basis can keep the rectum dilated and make the stools easier to pass. If that doesn’t work after a week’s trial, switching from a milk-based formula to a soy-based formula is worth a try.  Lacto-free and other “gentle” formulas are primarily marketing gimmicks and, if the formula is actually making the infant fussy, the only change that makes medical sense is to a soy formula (breast-feeding mothers should stop drinking cow’s milk). If you change to a soy formula, the baby will need at least two weeks to get used to it, so don’t give up too soon.
      Studies show that giving probiotics to babies with colic decreases their symptoms. Discuss how to do this with your baby's care-giver.
      Another interesting theory is that babies with colic may be suffering from migraine headaches. Teenagers and adults with migraines are reported to have had colic as infants more than people who don't have migraines.

   If your infant is unusually fussy, especially if it is a change from his normal pattern, he needs to be examined by your care-giver. If he is found to be otherwise healthy, trying some of the things I’ve mentioned may help. If not, he’ll be older by then and colic rarely lasts much beyond three months.