Today we’re chatting with Dr Elizabeth Sandel about concussion in young children. What causes it. What we need to look for and how we can help during the recovery process. There are free posters, helpful links and a video for you to use when you approach this topic with your kids. In the classroom we talk about personal safety and behaving well towards others, so why not expand that to talk about the very real possibility of concussion?
Please note: some of the graphics used in this post were created BY THE CDC.
Who is Dr Sandel?
Dr Sandel has specialized in caring for patients with brain injuries for more than 30 years and is board-certified in physical medicine, rehabilitation and brain injury medicine (BIM).
She has worked with patients of all ages injured in falls and motor vehicle accidents, as well as athletes, veterans, injured workers, and victims of violent crime. She is currently a medical director for Paradigm Management Services, which provides case management to those with concussions and severe brain injuries.
You can find Dr Sandel’s website HERE. Plus you can connect on:
Reasons to scroll down this post
Make sure you look out for:
- Free posters to explain concussion and its symptoms to young children.
- 1 minute video to explain concussion to young children
- Links to parent guides and other resources
- Links to websites discussed by Dr Sandel regarding nursery safety, preventing falls and where to check for crib and furniture recalls.
- Link to a free app for 6-8 year olds
Dr. Sandel, thanks so much for being on the Early Childhood Research podcast this morning.
I really appreciate the opportunity, thank you so much.
What is a concussion?
How can we recognise the signs of concussion, especially when the children are younger and they can’t express what they’re feeling? Sometimes we don’t know whether we should be panicking or not.
A concussion is what we call a mild brain injury. It’s caused by a blow or a bump or a jolt to the head, but the most important thing is you can have a blow, a bump or a jolt to the head and not have a concussion. It has to be a disruption of brain functioning.
How do we know a concussion has occurred?
Well if the person, child or adult loses consciousness, we know they had a brain injury. That doesn’t mean they have lasting problems, but they had a brain injury if they got knocked out or lost consciousness.
The other thing to remember is that the symptoms are not necessarily immediate, they can develop in the first 24-48 hours after the incident, but back to your question about children, I think we have to group them into the preverbal and the verbal children – children who have enough language to begin to express themselves.
In the pre-verbal category, I think it’s up to the parents to notice changes in the behaviour or habits that suggest something’s not right:
- Changes in sleep habits which happen across the board for adults and children with concussion.
- They might read facial expressions or gestures that would suggest that they had not just had a bump or a jolt or a blow to the head, but they had a concussion.
For verbal children, I think talking to them about
- Pain in their head (using language that is appropriate for the age)
- Nausea (do you feel sick in your stomach?)
- Sometimes, there’ll be worry
- A lot of crying
- Sensitive to light or sound
- Some trouble walking or some balance problems
Those are the things to think about in this particular age group.
Download this poster (and others) at the bottom of this blog post.
What about checking pupils?
Well, certainly, but if you have a situation where the pupils are not reactive, there’s a serious problem. The other thing to remember about pupils is about 10% of people have unequal pupils. It’s called anisocoria and so you can’t always go by that.
That’s interesting! That’s my new fact for the day.
So that’s not really something that would be helpful for a parent to do. I think it’s more:
- the behaviour of the child
- looking at facial expression and gestures
- if the child is obtunded, that is hard to arouse, then this is “Call 911”, call the emergency folks in.
Changes in sleeping habits
You said that people with concussion have changes to their sleeping patterns? What sort of changes are you talking about?
Well, that could be anything.
- Sometimes they sleep more than usual
- sometimes they have trouble going to sleep or staying asleep
- In other words, insomnia, they really have trouble sleeping at all
The most characteristic is an increased need for sleep, which is something those of us in the field of brain injury medicine have observed for a very long time. And I’ve always told patients, sleep, it’s good for you and you need more sleep now that you’ve had the concussion or serious brain injury.
Now sleep research is showing the restorative powers of sleep. Another whole topic that’s quite interesting is the glymphatic system, a system like the lymphatic system that actually cleanses the brain and it’s turned on while we’re sleeping.
Why sleep is super important
One of my theories is that the reason there’s this increased sleep demand, in the literature, it’s called excessive daytime sleepiness, mostly studied in adults, but it’s because it’s a way the brain is healing.
I don’t have research evidence for that yet, but they’re making all kinds of connections with the neurodegenerative disorders like Alzheimer’s disease.
Some mild activity is OK, too
There is a lot of suggestion that we should initially encourage rest and allow extra sleep for this brain recovery, but not put people at total rest, I think that’s really important too.
Gradual resumption of activities on a guided basis by a paediatrician or if you’re going to a concussion clinic, but initially that rest is very important.
What are the greatest causes of concussion in young children?
I’d like to focus on a couple that I think are really important in terms of what can be done as far as prevention, which is a key issue. Most households in the United States with infants or young children use nursery products. I have a grandson who is 11 months old and he has all the nursery equipment we will talk about, so I’m pretty familiar from that personal experience.
The other area I want to talk about is playground injuries, because for the older children, that’s a key area where there’s certainly causes of concussion as well as opportunities for prevention.
The equipment, of course, is an issue because there are unsafe products, and actually, I discovered in doing a little research that nursery products are the leading category of children’s products that are recalled in the United States, and there are millions of these products in US households, so I really encourage people to go to:
- THE CONSUMER PRODUCT SAFETY COMMISSION WEBSITE – They can find about safety issues with these products. (PS When I [Liz] checked on July 9, 2017 there were recalls of some chests of drawers that tended to fall forward if not bolted to the wall – they could certainly lead to concussions – especially if the kids were trying to climb the furniture)!
The other causes are children and their parents!
There are a lot of opportunities there for safety too. Let me spell out a little bit about which products.
I tend to think of recall as being related to choking issues rather than concussion issues.
Oh no, there are other reasons, and actually, one of the recalls involved baby walkers. Those are those pieces of equipment that allow the baby to walk around when they’re really not capable of walking otherwise, and they could be at the top of the stairs and tumble down the stairs.
There’s been a lot of injuries. There’s an interesting study that came out just recently. The research group is the Center for Injury Research and Policy at Nationwide Children’s Hospital in Columbus, Ohio, and I would direct the listeners to their website because there’s a lot of good information including:
So these baby walkers, there has been a campaign against them, and what these researchers showed is that there has been a dramatic decrease in the first period of their study which was 1991 through 2003, I believe it was, a decrease in the number of injuries from these baby walkers because of the campaign, but actually an increase overall in the later period up to 2011.
This was a huge database that they researched, an average of about 66,000 injuries a year, but now they’re from falls that involve the head and neck. About 80% were from falls involving these products, and kids were brought in the emergency room.
These are only emergency room visits, there could be many more injuries, it’s just the ones that are going into emergency rooms, but half of them involve the head or neck.
Drop side cribs banned
So the kids are rolling out of a baby carrier or a stroller or a crib, and they’re falling on their heads. So, dramatic injuries to the head and neck. There have been attempts to improve some of this equipment. For example, the cribs that have moving parts, what are called drop-side cribs, were banned in the United States in 2011 because of the high rate of injury because the drop side could come down and the child could fall out or jump out, so they’re banned.
Using safety straps
And as you mentioned, suffocation, so bumpers in cribs are now considered ill-advised: beddings, pillow, blankets and stuffed animals shouldn’t be in the crib. But a lot of the issues here have to do with parents not using buckles to buckle their child into the carrier or the stroller, safety straps improperly used, they’re not locking the wheels, or they’re putting a bag on the handle so the stroller tips over.
Ah, yes, I hadn’t thought of that, the weight shift.
High versus low surfaces
Right, exactly, and then infants being placed on high surfaces, like a changing table instead of on the floor, and once they get more active, and it can change from one day to the next, there’s never a dull moment as we say as parents or grandparents.
Are we distracted?
And I do think that parents are more distracted now, so the main advice I have is don’t lose sight of that child especially an infant or a child that’s a toddler for that matter. We have to be vigilant. When my kids were growing up, I always said that my peripheral vision was really getting a whole lot better than it had before I became a mother.
High chairs and booster seats
The other area of course with the head injuries and concussions is high chairs and booster seats, and THERE’S ANOTHER STUDY from the Children’s Hospital in Columbus that has provided some data on that, and that’s interesting because two-thirds of the children injured in that study were climbing or standing in the chair, so they’re not being restrained. And they’re agile enough to get up there and might be even playing on the chair. So the important advice there is to make sure that they understand that’s where they eat, it’s not a place to play. And of course, the chair has to be stable.
Kids are so quick though, aren’t they? You turn your back and they’re somewhere else. So the issue that you are talking about is we’re using these products, but we need to be using them with the safety issue in mind.
Can the high chair be kicked over?
Right, exactly. You know one other thing that was mentioned by the researchers of that study is that if the highchair is put close enough to a wall where they can kick it, especially if the chair isn’t stable, they can kick it over. So, make sure that the chair is not in a position where they can use the wall to kick it over.
Because I suppose too, they could be close to the table in that way. We tend to put them close to the dining table where we’re eating.
The tray table is not a safety device!
Exactly. And then of course you know, a lot of people, and I think that I had some lack of knowledge in this regard as a mother, when I look back. We think that the tray table is good enough, but the tray is not a protective device. It’s there for you to put the food on, right? It’s not secure for the kid.
And then the playground injuries I can talk about briefly, because that’s another area where there can be a lot of injuries, including concussions.
There’s been some recent research too showing it’s swings, climbing structures, and slides. We all remember on playing on those, and of course, when I think back, I climbed up the slide, instead of taking the stairs.
There were all these things that can be the cause of injury, especially for very young children in this age group that you’re talking about, and of course, teaching the kids playground safety rules, but also, surveying the playground for hazards and making sure that your child is age-appropriate, and I think checking with the child’s paediatrician is really the way to go if you have any questions about age-appropriate playground use.
It’s difficult, isn’t it, because sometimes I feel like the safety issues are real, but if we try and protect everyone, then there are no more slides and there are no more swings, and you’ve got the helicopter parenting thing and you’re all just like, “Oh my gosh, my child can’t do that!”
You’re absolutely right, and I think in regard to the helicopter parenting issue – knowledge is power. If you get all the information and you read the instructions on this equipment, you look for signs in the playground that say what categories of equipment are age-appropriate and so forth.
There’s great information on the web:
- Centers for Disease Control
- American Academy of Pediatrics – type ‘concussion’ into their search bar and lots of articles will pop up.
- Nationwide Children’s Hospital in Columbus
- Ontario Brain Injury Association – including THIS EXCELLENT RESOURCE.
Chat with other parents
It’s really about talking to other parents too, and of course you can do that at the playground. As long as you’re not distracted and you’re not watching your child!
Yes, that’s an interesting point because you’re saying we’re more distracted and people are so often on their phone, and you think, “We’ll if you’re doing that in the middle of changing the baby, it is easy to be distracted just for those few seconds too long.”
Yes, absolutely. Let me just say the one thing about the incidents of concussion increasing. Every age group, we see an increase in concussion, and that’s probably not necessarily only incidents. It may be because people are more aware. Maybe somebody whose toddler fell and hit his head would be more likely present to an emergency room now than ten years ago, or even five years ago.
I agree. People understand the ramifications a bit better than they used to, or they used to just say “We’ll just shake it off or sleep it off”.
Shaken baby syndrome
I also have a question about issues such as shaking with young children?
Well, what we used to call ‘shaken baby syndrome’ is now called ‘paediatric abusive head trauma’, and that takes more than just some movement that we would call simple shaking.
I will also say that’s a whole other topic, there’s a lot of controversy about shaken baby syndrome, or what is now called something a little more academic, shall we say? But:
- It takes a very strong force to cause a severe injury
- and there’s a certain pattern that’s seen on imaging studies and so forth in the retina, in the back of the eye and so forth, but I think that could be another interesting topic to cover.
People should not be shaking their children. I don’t mean to play this down, but it takes a lot of force for an injury to occur, and of course, with the infants, less force can be more dangerous.
So the risk gets less and less as the child gets older.
Ideally, parents should not be engaging in any of that behaviour, and certainly not on infants.
I just thought I’d touch base with that because it is something that goes in the back of your mind when you think about concussion in young children.
What should I do first?
We’re talking about the younger ones and maybe they’ve fallen over in their walker and they’ve given themselves a head injury. As a parent, what should I do in that moment when it happens?
Keep people nearby
I think the most important thing is if there are other people around, to have them stay with you until you can really determine whether there’s been an injury. You might be by yourself, hopefully you do have that distracting device, the cellphone, if you need it.
Don’t panic. Observe instead.
It’s also important not to panic, but on the other hand to be very observant. Parents know their children better than anyone else, so the powers of observation are really important. If there are signs of physical injury, for example, laceration or anything like that, the child needs to be seen anyway in an emergency room or urgent care. If they bump their head, and they seem to be fine, crying for a minute or so and then resuming many activities, then there’s no cause for worry. But again, it’s observation. I think it’s really the key thing.
What about recovery?
Let’s say my child has fallen over in the walker, he did get lethargic and I took him to the doctor, and they say “Yes, he has a concussion.” What kind of things do you do to help with recovery with young children? How long a process is this?
It varies. The typical time frame that’s talked about in young people, and I have to say here that in researching this over the years, and coming up to date more recently with some of the literature, there’s not a lot of research on the youngest children.
There’s so much research on sports injuries and adults with concussions, but very little on this with younger children.
You could probably assume, as with older children and adults, that headaches are probably part of it, because that’s the most common symptom, and then dizziness and balance problems can be a problem too, across the board. That’s fairly common as well.
Treat the symptoms
But after decades of work in Physical Medicine and Rehabilitation and Brain Injury Medicine, we’re still at the point where we don’t have enough research to have a magic pill.
Most of the treatment is symptomatic:
- If you have a headache, treat the headache.
- If they have dizziness and balance problems, you look for a source for that that’s treatable, and that could be some problems in the inner ear that require some maneuvers to get the little crystals in the ear back into place.
There are some specific things that we can do, but mostly it’s the tincture of time and making the person comfortable. So that would be still the same advice for children, and also because of the balance problems, protecting them against having another injury. So, in that recovery period it’s really important to be, in a sense, over protective.
Your child is probably not wanting to be over protected.
Right. Exactly. That’s just some general advice. Hopefully, the paediatrician would be helpful. The websites that I mentioned are also really helpful, and I think 7-10 days is said to be pretty typical for youth concussion. However, that’s on average.
You do see children with sports concussion, these are older children who have symptoms for much longer than that. That’s the other thing we’re not very good at, we’re not very good at prognosticating. Who’s going to be in that group that doesn’t recover for weeks or months?
Kids MUST be symptom free (as a bare minimum)
I suppose a lot of the issue with concussion is that the kids are wanting to go out and play again, and so, how early are you letting them play? Is it just a one-off event or is it that these kids seem to be hurting themselves on a regular basis?
Your risk for having a second, or third or fourth concussion goes up with each subsequent concussion after the first one. But also, very important that the child be symptom-free before they go into an at-risk activity. So for example, let’s just say, soccer. We’re talking about older kids, I guess-
They play pretty young here in Australia!
They can play pretty young, right? So, you want to make sure that they’re symptom-free before they’re going back if they’ve had a concussion.
Can they go to school?
They can go back to school with symptoms, if the symptoms are manageable, but they can’t go back to a collision sport until they are totally symptom-free. And even then, I think it takes a good examiner to make sure that their balance and reaction time are back to some sort of base line or adequate for them to go back because I think some of the second and third and fourth concussions are occurring because they might be symptom-free, but they haven’t completely physically recovered.
That makes sense. I can kind of imagine the family situations because the kids will be wanting to go back into their activity, and even the little ones will be like, “I want to go back on the slide,” and they’ll nag, nag, whinge, whinge and it’s just like “Aaaaahhhhhhhhhh! I can’t stand it anymore”.
So, you’re saying “Be strong”.
Exactly. That’s why I say parenting is the hardest thing you can do.
How do we explain concussion to our kids
What’s the simplest way for parents and teachers to explain what concussions are to young children?
The brain moves inside the head. I think it’s important to let kids know that when they hit their head, what happens is the brain, and you can show them pictures of course, the brain is actually moving around inside the head.
And so it can be injured even if they can’t see that it’s injured and it can be injured even if the head isn’t injured.
If someone pushes them and they don’t completely fall and hit their head, but they’re jostled by that, they can have some movement of the brain within the head. Now I’m not saying automatically they have a concussion, because again, it requires that observation or symptoms that indicate that something’s happened to the brain, but to let them know that this is what we call an “invisible injury.” Even if they have a CAT scan in the emergency room, that might be normal, but they actually still had a brain injury based on the other things that we talked about.
Watch adult sport re-runs
One thing to do with young children is to have them watch sports on television because in these collision sports, it’s happening all the time. Whatever your sport is in your country, or your state or city, I think if they see these adults playing and getting injured. You’ll see them slump down sometimes, hold their head, I think it’s important to use that as a teaching tool.
Chat and make observations
“Did you see what happened? Another player slammed into them as they were trying to put the basketball in the basket” or whatever, and again remind them that the head doesn’t have to be struck for this to happen.
Explain the symptoms
I think it’s also important to explain to them what they could anticipate as symptoms. So, we talked about headaches, maybe they can’t think too clearly or they feel all dizzy or sick to their stomach, explain what might happen.
Really let them know that it’s serious because, although they’re more than likely going to heal from it, they don’t want to get another injury because then something really serious can happen.
When we’re talking about classroom safety, when we’re talking about how we behave to each other, when we talk about why you can’t push people over, it is often “you’ll hurt them”, but it’s usually talking about hurting themselves on the outside. But this is a good point to remind them that actually you can hurt someone on the inside as well.
Download this poster (and others) at the bottom of this blog post.
Right. I do think for the younger children, maybe having them get most of the information visually and talking to them as they’re getting that information, especially from sports.
I like the idea of talking to kids about the symptoms because we try to teach our kids to self-regulate, and even though they’re young, if they hear it from a young age and they themselves know, “If I’m feeling a bit queasy, or if a feel a bit dizzy, I need to tell someone.”
Girls report more than boys
Right, exactly. One of the reasons why girls seem to have a higher incidence of concussion in sports that are played by boys, is because they report their symptoms more than boys do. I do think that educating them before it happens is really good, so that they know what the symptoms are, but also they’re being encouraged indirectly to report, should they have anything happen.
Dr. Sandel, thank you so much for coming on and talking with us this morning. It’s been really fantastic having you here.
Well thank you so much, I really enjoyed it. I hope it’s helpful.
Dr Sandel’s book
Oh wait, I forgot. You’ve got a book coming out, don’t you? We need to mention that. Can you give us the name of your book?
The tentative name of my book is “Coming to Our Senses about Concussion, Why We Need to Wake up To the Facts”.
Is this going to cover all age groups?
It is, and all causes and all consequences. Of course, I won’t have everything to say about that because there’s on-going work and research and so forth, but it will be much more than sports concussion. And it certainly will include this age group that we’ve been talking about.
Excellent. I’m really glad you have the book coming out. It will be so helpful to people.
Well, thank you for advertising it, even though it’s not published yet! (Additional note: we’ll add a link to Dr Sandel’s book after publication).
We’ve got to have positive thinking, we’ve got to be ahead of the game.
That’s right. Exactly.
It was great talking to you this morning, thanks so much!
Thank you again. Take care.
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