Concussions: Parents Critical Participants in Recognition, Treatment, Recovery

Along with teachers and other school personnel such as coaches, school nurses and administrators, a child's parent play a crucial role in a child's treatment and recovery from a suspected concussion, including decisions about return to school, return to sports/recreation and return to everyday social and home activity:

• Active involvement of the parent is standard practice in pediatrics;

• The student athlete's everyday environments at home and at school serve as important venues for observing post-concussion symptoms; and

• Parents and teachers possess a wealth of information about the child's behavior and functional status in these settings that is directly relevant to an assessment of their post-concussion symptoms.

Parent checklist

1.  Regularly and closely monitor athlete for first 24 to 48 hours.²

• Most sport-related concussions are mild, but the potential always exists for a more serious, life-threatening head injury, such as an epidural hematoma (bleeding between the skull and the brain), subdural hematoma, subarachnoid hematoma, or second-impact syndrome. 

• Because delayed onset of symptoms during the first 24 to 48 hours is possible (and more likely in children), parents - or another responsible adult - should closely monitor the athlete during this time. 

  • The traditional rule has been to wake up a concussed athlete every 3 to 4 hours during the night to evaluate changes in symptoms and rule out the possibility of an intracranial bleed, such as a subdural hematoma.

  • The new thinking is that there may be more benefit from uninterrupted sleep than frequent wakening, which may make symptoms worse, so that waking up your child during the night to check for signs of deteriorating mental status (see #2) is now recommended only if your child  experienced a loss of consciousness or prolonged amnesia after the injury, or was still experiencing other significant post-concussion signs or symptoms at bedtime. There is no need to check his eyes with a flashlight or test his reflexes. 

2. Immediate hospitalization if condition deteriorates.²  If your child experiences any of the following signs of deteriorating mental status, take her to the hospital immediately:

• Has a headache that gets worse

• Is very drowsy or can't be awakened (woken up)

• Can't recognize people or places

• Is vomiting repeatedly

• Behaves unusually, seems confused or very irritable

• Experiences seizures (arms and legs jerk uncontrollably)

• Has weak or numb arms or legs

• Is unsteady on his feet or has slurred speech.

3.  Use acetaminophen (e.g. Tylenol®) or codeine for headache. Do not give aspirin or non-steroidal anti-inflammatory medicine(NSAIDs)(e.g. Ibuprofen/Advil®). An ice pack on the head and neck is okay as needed for comfort.  [Note: a 2010 clinical report from the American Academy of Pediatrics' Council on Sports Medicine and Fitness³says that, because no studies have documented any harm from use of NSAIDS after a sport-related concussion, the common recommendation against their use remains more of a theoretical risk].

4.  No drugs, alcohol: Warn your child about the dangers of ingesting alcohol, illicit drugs, or other substances that might interfere with cognitive function and neurologic recovery.  Do not give sleeping tablets.

5. No driving until medical cleared.

6.  Normal diet: Limited information is available regarding the recommended diet for the management of concussion. A normal well-balanced diet that is nutritious in both quality and quantity should be maintained to provide the needed nutrients to aid in the recovery process. Avoid spicy foods.

7.  Physical and "cognitive" rest:

• Treating young athletes is uniquely challenging, because their brains are still developing. The cornerstone of concussion management is physical and cognitive rest until symptoms clear and then a 5-step graduated exercise program prior to medical clearance and return to play.¹  

  • Avoid strenuous activity until the athlete has no post-concussion symptoms at rest because physical activity may make symptoms worse and has the potential to prolong recovery.  Broad restrictions of physical activity are recommended, including:

    • the sport or activity that resulted in the concussion

    • weight training

    • cardiovascular training

    • physical education classes

    • sexual activity

    • leisure activities such as bike riding, street hockey, and skateboarding that risk additional head injury or make symptoms worse.³

  • limit their day-to-day and school-related activities until symptom free. 

    • This means no homework, video games, text messaging and staying home from school while still experiencing concussion symptoms.

    • A temporary leave of absence from school, shortening of the athlete's school day, reduction of workloads in school, and allowance of more time for the athlete to complete assignments or take tests may be necessary.³

    • Taking standardized tests while recovering from a concussion should be discouraged, because lower-than-expected test scores may occur and are likely not representative of true ability.³

• No further treatment is required during the recovery period apart from limiting physical and cognitive activities (and other risk-taking opportunities for re-injury) while concussion symptoms are still present,  and the athlete typically resumes sport without futher problem.

8.  Graduated,, individualized, conservative return-to-play. The Zurich Consensus Statement on Concussion in Sport¹ and the American Academy of Pediatrics³ recommend that athletes NOT be allowed to return to play on the day of injury under any circumstances, or while still experiencing symptoms at rest or during exercise.  When returning athletes to play, they should follow a 5 step, symptom limited exercise program with each stage taking 24 hours or longer to complete, and the athlete returning to stage 1 if symptoms recur with exertion or at rest.  Return to play should follow an individualized course, because each athlete will recover at different rate. Because a number of studies have shown that younger athletes take longer to fully recover cognitive function than college-aged or professional athletes, a more conservative approach should be taken in deciding when pediatric and adolescent athlete can return to play, even when they show no symptoms of concussion.³

9.  Further testing/management. The Zurich consensus statement abandons the simple versus complex classification in favor of a list of "modifying factors," the presence of which may suggest the need for more sophisticated concussion management strategies,  such as examination by a specialist and more testing.  These factors include:

• Symptoms persist. His post-concussion signs or symptoms  last more than 7-10 days or recur with exercise;

• Extensive LOC or amnesia.  He experienced concussive convulsions or prolonged loss of consciousness (LOC) (one minute or more) or amnesia at the time of injury;

• Multiple concussion history.  He has suffered one or more concussive events in the past, especially where they appear to be recurring with progressively less impact force (e.g. a minor blow) or takes longer to recover after each successive concussion; or

• Other neurological disorders present.  He has learning disorders and/or attention deficit hyperactivity (ADHD).

10.  Trust your instincts. Be as involved in the management of your child's concussion as your instincts tell you to be. Don't be afraid to ask your child how he is feeling, or take him to his pediatrician or a specialist if you suspect something is wrong.

1. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.  Br. J. Sports Med. 20090: 43:i76-i84.

2. Sport Concussion Assessment Tool 2, Br. J. Sports Med. 2009; 43; i85-i88

3. Halstead, M, Walter, K. "Clinical Report - Sport-Related Concussion in Children and Adolescents"  Pediatrics. 2010;126(3): 597-615.