Ask the Doctor: Need to know information regarding kids and concussions

It’s kids and family week here at OnMilwaukee.com and, more than ever, we’ll feature articles and blogs about children’s health, education, travel, fun and more. Kids and family week is brought to you by Aurora Health Care.

There are few hotter topics in sports than concussions and the effects they have on children, but while brain trauma is serious there are measures that can be taken to not only keep your child healthy, but keep them in the sports they love.

Being that it is Kids & Family Week here at OnMilwaukee.com, we decided to tackle some of the questions facing parents and coaches today regarding concussion awareness and management.

Participating in our question and answer format are Dr. Kevin Walter, program director of Pediatric & Adolescent Sports Medicine at the Children’s Hospital of Wisconsin, as well as an Associate Professor of Orthopedics at the Medical College of Wisconsin; and Dr. Kevin Dahlman of Aurora Health Care – sponsor of Kids & Family Week – who is a pediatrician and often the first stop of children who come in for sport physicals or for parents who feel their child has suffered a concussion.

“A couple things have happened. Number one, we’re diagnosing them more because we’re recognizing the symptoms more,” Dahlman said. “The other realistic factor is that we’re seeing more concussions, I think because kids are participating at a level of competitiveness that wasn’t seen a generation ago.

“But, we don’t want the parents to be saying, no, you’re never allowed to play football or play basketball or play soccer. We’ve got to allow that brain injury to heal. I think the biggest challenge for us in the health care business is to really educate coaches and parents and students themselves in the signs and symptoms of concussions.

“There is always going to be a risk of injury and we want to play safe and we want to recognize that there are signs and symptoms of concussions but it shouldn’t prevent you from playing. We want kids to be out there on the sports field playing as hard as they can.”

OnMilwaukee.com: What is one of the first things parents need to think about, or be aware of, when it comes to concussions in youth sports?

Dr. Kevin Walter: One of the huge problems we have with concussions is self-reporting. We know athletes don’t necessarily want to say that they’re injured or they have a concussion because they know that they’re out. So, what I always encourage is for athletes to immediately report their symptoms and get off the field of play. There’s actually research evidence that shows the sooner you identify the injury and begin appropriate treatment, even if it means coming off immediately and staying on the sideline instead of playing five more minutes, the people that do the right thing earlier get better faster.

It’s all about awareness, recognizing they may have an injury – not oh my gosh, I have one, or I’m not sure, maybe I’ll play with it a little while – if you think you may have an injury report it right away and get evaluated on the sidelines. Or by the doc in the ER or wherever.

The other thing that I push to parents is know your coaches education level. It’s OK to question the coaches in the preseason – what do you do when there’s a concussion?  What do you know about concussions? How have you been educated? If you’re not comfortable with their response, that should be a big red flag. Everyone thinks football because of the NFL, but even soccer, sports like basketball, baseball and softball – those are ones where I find that families don’t really connect it together. They don’t think they’re big concussion sports. They happen in volleyball and track.

Dr. Kevin Dahlman: If we treat these appropriately, get in to the doctor and they can manage this correctly, then there’s no reason to believe that there is not 100 percent recovery from these concussions. But of course it has to be dealt with professionally.

OMC: At what age do you need to be more aware of the possibility of injury?

KW: I don’t worry quite as much at the five, six, seven-year-old level for concussions because those kids don’t get them at the same rate as the middle schools and high schools. Eight to 10 is when you start seeing an upswing in concussions because the kids are getting bigger, but they still don’t have great body control, and they still don’t have great technique, so that eight to 10 is when I tell parents to watch and if you see your child acting funny, you hope that education of awareness and reporting kicks in and they come over to the sideline. Then if they’re not acting like themselves or not playing like themselves, that’s a red flag and you need to get them over (to the sideline).

OMC: Not every parent is going to do a baseline test of their kid – what should they look for at home?

KD: Let me give you a scenario, typically what I see. What will generally happen is a kid is on some kind of sports field – it doesn’t have to be football – or could be in a car accident. There was no loss of consciousness. And most concussions, 90 percent of concussions do not have any kind of loss of consciousness – so, that’s the first rumor I try to dispel. The big thing I’m looking for is any kind of headaches, does the kid say they have a dull headache that just won’t go away. You could have nausea, a little dizziness or unsteadiness. Sensitivity to light or noise. Some kind of mental fogginess. And usually parents can pick up on this. They’ll say if I ask them a question, she seems to be a little bit slower in answering that. Those are the things I really look for and ask the patient if they’re experiencing any of those symptoms. So, by definition, if you’ve had a hit to the head and you experience any of those symptoms, that’s a concussion. It’ll be really key to pull a child out of sports at this time so there is adequate healing and then follow the evidence-based guidelines in a step-wise fashion slowly return the student-athlete to sports and activities as tolerated up until full clearance.

OnMilwaukee.com: In youth sports, parents don’t often pay attention – you’ve got other kids to manage, maybe you’re on your phone or tablet. How important is to really watch your kid, because they may knock heads, or catch an elbow, or fall?

Dr. Kevin Walter: It is. The more eyes you have watching the better. If they move up to high school, officials can send players off if they suspect a concussion. There’s a little bit of a ruckus about that because, oh my gosh that can change the dynamic (of the game) but the truth is it’s just more eyes. We naturally tend to follow the ball. A lot of injuries happen off the ball. The more people you have watching, the better it is.

And having the parents come down from the stands, I know the kids don’t like it, parents feel uncomfortable and coaches sometimes feel encroached upon, but it’s player safety and if it’s your child, you should go down there and do it.

And when those big contact episodes or hits or falls happen, I usually push all the coaches I educate to pull the kid over real quick and just interact real quick, ask them a couple questions, see what they’re like, and if they seem OK, just keep a close eye on them for a while. If they seem off or different, pull them out and give me a call. But if you don’t ask, most athletes aren’t going to tell.

Dr. Kevin Dahlman: That comes from a coaching and officiating standpoint, the people out on the field looking at these kids. If they’re noticing that this kid is a little slow to get up, kind of clumsy on the next play, not realizing what’s going on, go ‘hm, maybe that hit to the head was more significant than we thought.’ Helmets are not going to prevent concussions. They certainly will reduce the risk a little bit and certainly prevent things we really worry about like cranial fractures, so that knowledge that you can still have a concussion and to be aware on the sports field is going to be key to pulling the kids out of activity when you do see those signs.

OMC: A lot of attention, as it is across many levels, is paid attention to boys sports and especially football. But girls are just as at risk, too, as well as athletes in other contact sports.

KD: Soccer and basketball carry twice the risk for concussions in girls than boys. People kind of expect it from football, and that’s understandable, but we’ve really got to be attentive to what’s going on in these other sports. If you have people running around in a field, there’s going to be concussions happening. We see this in quite a few sports. We have a list – ‘concussions happen most frequently in these sports, in this order: football, boys and girls ice hockey, girls lacrosse, girls soccer, boys lacrosse, wrestling, girls basketball, girls field hockey, boys soccer, softball and boys basketball.’ So, it really encompasses all sports. There are concussions occurring in track. If you fall and hit your head, you’re at risk at having a concussion.

OMC: What’s going on with former pro football players is scary, but there’s a big gap between that and you’re 10-year-old – how have you balanced the new fear level of parents with, hey, you’re kid can remain active as long as a concussion is treated properly right way.

KW: Right now there is a lot of fear because you hear about these terrible stories from the old NFL players, and so families think, oh my God my kid has a concussion or two concussions and they’re going to end up like Dave Duerson or Junior Seau or John Mackey, which isn’t the case. Those guys have had multiple, multiple concussions, probably many of them undiagnosed or mismanaged, and then repetitive, non-concussion impacts over years and years and years and years. So, they’re a whole different animal than even your high school athlete where if you identify your injury right away an d you’re off the field of play, if you treat it effectively, you’re going to get back to normal and you’re going to be fine. It’s not going to give you brain damage. It’s not going to make you dumb or lower your IQ. It’s not going to change your personality.

I tell people every time when you come into clinic and I see them, I say I expect you to make a full recovery and get back to normal. And it’s the people that lie about symptoms and try and get back too soon, where you get an injury on top of an injury, those are the ones that get more complicated. It’s the people that have had full blown, three, four, five injuries quickly together, those are the ones that raise the red flags. But even at the youth level, the vast, vast, vast majority of those kids do not go on to have long term – at least we don’t think go on to have long term function problems. When we test them most of the time the IQ is pretty similar, their functioning is pretty similar, their mood is pretty similar as well.

OMC: Some kids can be more prone to concussions, for whatever reason – just like a person may be more prone to muscle issues. There is a law of diminishing returns at some point though, even if they’re treated properly.

KW: The big international guidelines, like the Zurich guidelines that most of the Doc’s follow are really nice. But I don’t think they apply word for word to young athletes, and there’s a little thing if you read the big article, there’s a section on kids – hey we need more information and research on kids but you need to be a little more conservative with them. I’m not opposed to, if I see this bad trend to where you’re getting concussions quickly, saying hey, maybe we need to have an open discussion about what does basketball mean to your daughter? And do we need to stop this early because as good as we all are in high school, when we just look at the numbers, most of us are not going to college and playing, and certainly not playing professionally. So there comes a time when you have to realize that getting all these concussions and struggling to get back into the classroom and potentially getting lower grades to play a sport – I love sport and all the messages and positive impacts it has on life – there comes a point when you say our future is in academics and the workforce, and you don’t need anything to continue to happen that’s going to decrease your grades and negatively affect your future and getting into college and what you want to do when you grow up.

OMC: What are the challenges your profession faces in educating the parents of young athletes, since you probably only see them once a year, maybe twice?

KW: It’s exactly what you said – you’re dealing with a generally healthy population, so they’re coming in every one to two years, usually for their sports physical. So the way I look at it is the awareness and education is an ongoing, continuous effort, and it’s not just parent education. You can do education sessions at club sports, the XYZ soccer organization, and you come in and give preseason educational stuff on concussions and nutrition and injury prevention and stuff like that. You do interviews like this and media appearances. And then you educate the providers, too. As a sports medicine specialist, I see these people when they’re hurt, so it’s my job – or part of my job – to educate the pediatricians, primary care docs, on what’s going on in the world of sports medicine so they, who see the kids more frequently, will feel more comfortable talking with families about sport-related activity. It’s challenging to do all that because taking time out to go to a meeting there or do research there is not included.

OMC: A lot of attention is placed on the coaching staffs of youth sports, and their role in concussion awareness, but is the current culture of specialization and expensive travel programs and camps create problems with parents – where they don’t want to hear that their kid has to miss two to three weeks of something they spent thousands of dollars on?

KW: Absolutely. That is an absolutely, positively accurate statement. It’s hard. I’ve had in clinic, people with back injuries, and have said it is in your child’s short and long term best interests to take a break and rest and work on rehab and it’s going to take two months before they’re back to full speed in whatever sport. And I’ve had families say, well, that’s not going to happen because we’ve just spent $2,000 on this summer camp and my child is doing it. Well, that’s not what I recommend and when you want to get better come back and see me. So, families do really push it.

KD: The bottom line is when there’s an injury, you absolutely need to pull a kid out of sport, and I break kid’s hearts every day unfortunately and say, look, I’m sorry but we want to protect your brain. Typically what I do is educate – especially at those sports physicals – say ti’s not worth it. If you think you have a concussion you have to come in to see me. You cannot participate in any sports. Just like everything in my job, I try to view it as risks and benefits and certainly there are lot of benefits for a child to be on the  sports field and playing, but if the risk of having a second concussion when that first concussion is not fully healed, there can permanent, irreversible brain damage – and it’s just not worth the risk. I need my patients to have their brains for the rest of their lives. It’s their greatest and their best asset. That’s what I really try and emphasize in education.

The other thing I can finally say is there’s a state law now, since April of 2012 that is mandating that if an athletic coach or official sees any kind of symptoms or is suspicious of a player having a concussion, they are by law required to sit that player out, require that they are checked out by a health care provider and assigned clearance before going back. I think if we can just get the word out there, the WIAA web site has a lot good resources for coaches and parents to be educated about the seriousness of concussions.

They are traumatic brain injuries. When you phrase it like that I think parents kind of sit up a little bit more and go oh, this is really important. Yes, it is.