2018-19 TOW #7: Concussions

In addition to summer recreational activities, youth around our area are doing camps and early practices for the fall sports season. This is an opportune time to review concussions, a very timely topic in pediatrics (and society-at-large). We as pediatricians are called upon to address these injuries in clinic and clear youth for return to activities, as mandated by the Lystedt law in Washington.

Links for this week’s materials:

Key take-home points for concussions:

  1. What is a concussion? A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces with 5 common features:1) induced by traumatic forces to the head, either directly or indirectly, 2) rapid onset of short-lived neurologic impairment that resolves spontaneously, 3) may have neuropathological changes but these are functional more than structural, 4) a graded set of clinical symptoms which resolve following a sequential course, however, symptoms may be prolonged, and 5) no structural abnormality on standard neuroimaging.
  2. What’s the epidemiology of concussions? Concussion accounts for an estimated 8.9% of high school athletic injuries, and this is likely a low estimate due to underreporting. Football has the highest incidence of concussion, followed by girls’ soccer. Girls have higher concussion rates than boys do in similar sports (possibly due to both physiologic reasons and higher reporting). Loss of consciousness occurs in about 10% of concussions, but may signal a more severe injury.
  3. What work-up should be done when concussion is suspected? Workup should include history of event including loss of consciousness, amnesia, prior injuries, and current symptoms. Assess 4 broad categories of symptoms–physical, cognitive, emotional, and sleep. Be sure to ask parents, not just patients. Review any assessments done at the time of injury (e.g. on-field SCAT5, etc). Physical exam should include GCS scoring, and examinations of the head, neck, pupils, and a full neurologic exam including gait, balance, coordination, and orientation. Consider using standardized tools to complete the evaluation, such as the SCAT5 and Child SCAT5 for ages 5-12.
  4. When should imaging be done? CT scans are not routinely indicated unless there are significant symptoms including severe headache, vomiting, worsening symptoms, or neuro changes suggestive of more serious injury. See the HMC algorithm for determining need for CT after head injury, based on the national Pediatric Emergency Care and Research Network (PECARN) criteria. This helps avoid unnecessary imaging, while covering those who still need it.
  5. How should we treat? Fortunately, most people recover from concussions within 7-10 days, but youth may take longer than adults. After concussion diagnosis, we recommend moderate cognitive rest and a gradual return to play with 24 hours at each stage (e.g., rest, walking, light aerobic activity, higher exertion, practice, scrimmage, games); this generally means about a week before full return. Do not progress if there are symptoms at any stage. Here’s a handout that reviews symptoms and return to play. We should also recommend gradual return to learning, and youth may need accommodations before returning to full cognitive performance, such as test-taking. Check out sports concussion resources from our sports medicine experts here.

TOW #42: Sleep disorders

This week we broaden the topic for sleep problems beyond the newborn period. There are plenty of sleep-challenged toddlers through teens out there!

Materials:

Take-home points for pediatric sleep problems:

  1. Epidemiology: In community surveys, 25% to 50% of preschoolers and up to 40% of adolescents experience sleep-related problems. These are common problems so it pays to know them well!
  2. Sleep duration varies by age and by person: There is individual variation in need for sleep, but generally, newborns sleep 16-20 hours and most can sleep longer stretches (4-6+ hour stretches) by 3-6 months. Infants sleep 13 to 15 hours, 2 to 5 year olds sleep 11 to 12 hours, school-age kids sleep 10 to 11 hours, and adolescents ideally 9 hours. Most children drop their naps before age 4 (give or take). Remember, sleep duration includes both daytime and nighttime sleep added together. After babies are about 6 months old, the natural rhythm of sleep follows a 70-100 minute cycle through deep sleep/REM/arousal.
  3. What are common sleep problems at different ages? One of the most common for toddlers is nighttime waking. For many young children, transitioning between sleep stages leads to a fully awake state. Combined with the developmental phase of separation anxiety and fear of the dark, this can increase nighttime demand for the parent. Gradual removal of the parent role in returning to sleep will lead to improved sleep habits. For teenagers, their circadian rhythm shifts and can shift their natural bedtime, often about 2 hours later –  a common problem is disrupting sleep drive with light stimulus from phones and devices. Sometimes teens compensate with long afternoon naps that diminish their sleep drive at night. Strategies include removing devices an hour before bed, not taking naps, avoiding caffeine in afternoon/evening, and trying to stick to a regular bedtime and wake-up within an hour of usual time.
  4. Sleep routines and sleep environment help with regular sleep: A consistent schedule is one of the most important parts of sleep routine. Dr. Canapari recommends keeping it simple enough that one parent can do alone. Use the 3 or 4 “Bs for bedtime”: (Bath), Brush, Book, Bed. (In our house, we added “Ballads” and include nighttime songs.) Environment: quiet, low nightlight, cool, and definitely no TV or other devices. Consider a fan or white noise machine, which can help with sounds in the house or outside (especially in our urban environment!).
  5. What are important issues we screen for? Ask about Bedtime “BEARS”: Bedtime problems, Excessive sleepiness, Awakenings at night, Regularity and duration, and Snoring. If you can only do one, ask about snoring to screen for obstructive sleep apnea (OSA). The articles above review diagnostic criteria of specific disorders. When concern for OSA, or other sleep disorder that is interfering with function, consult with a sleep specialist. Our own SCH sleep clinic experts provide handouts and info here.

TOW #30: Headache

Next week’s topic is headaches. Evaluating them in our patients can sometimes feel like they result in our own, so I am hoping a review of this topic can result in fewer for all involved. Our own local expert neurologist, Dr. Heidi Blume, wrote the Pediatrics in Review article, which is really comprehensive.

Materials for this week:

Take-home points for pediatric headaches:

  1. How many children report headaches? Depending on the study definition and time period, 17% to 90% of children report headaches, with an overall prevalence of 58% reporting some form of headache in the past year. By adolescence, girls report headaches more often than boys.
  2. What are the main types of headaches? Classifying the headache into one of 4 basic patterns helps with evaluation and diagnosis of the cause: 1) acute; 2) acute recurrent (or episodic); 3) chronic progressive; and 4) chronic nonprogressive. Most primary headache disorders are of an acute recurrent or chronic non-progressive type. Most concerning for something serious is the chronic progressive pattern.
  3. What are the red-flags for secondary headache from space-occupying lesions? Progressive pattern of severity or frequency; sleep-related headache, absence of family history of migraine, headache <6 months’ duration, change in headache type, confusion, abnormal neurologic findings, lack of visual aura symptoms, and vomiting.
  4. What work-up should be done? Neuroimaging should be considered in children who have abnormal results on neurologic examination, seizures, or red-flags by history. It should not be used routinely when there’s a normal neuro exam and recurrent headaches that are non-progressive. Some recommend using imaging for chronic headaches as a tool to reassure the patient and family, which may be therapeutic in and of itself.
  5. How should we manage headaches? Use SMART  as an acronym for headache management: regular S=sleep, M=meals, A=activity, R=relaxation & stress management, T=trigger avoidance. (See our expert Dr. Blume’s thorough review!) I really like Dr. Julie Bledsoe’s reminder to her patients when there are brain-related diagnoses: “we have to do the basics well” including sleep routine, nutrition, and physical activity. We can avoid triggers, and maybe even medications, through doing the basics well. When we do have to use medications for frequent headaches, it’s recommended to limit to one rescue and one prophylactic medicine, and to try to use rescue only 2-3 times per week to avoid medication rebound headaches. One option to consider for analgesia is Naproxen, which has longer duration and is not typically associated with rebound headaches.

TOW #6: Concussions

In addition to summer recreational activities, youth around our area are starting camps and early practices for the fall sports season. This is an opportune time to review concussions, a very hot topic in pediatrics (and society-at-large). We as pediatricians are called upon to address these injuries in clinic and clear youth for return to activities, as mandated by the Zachery Lystedt Law in Washington. Below are teaching materials for this week. Recent grad Emilie Weigel did a great RCP on concussions last year.

Links for this week's materials: Concussion Case and Discussion and AAP Statement on Concussion and powerpoint

Key take-home points for concussions:

  1. Epidemiology: Concussion accounts for an estimated 8.9% of high school athletic injuries, and this is likely a low estimate due to underreporting. Football has the highest incidence of concussion, but girls have higher concussion rates than boys do in similar sports (possibly due to higher reporting). Loss of consciousness occurs in about 10% of concussions-but may signal a more severe injury.
  2. Concussion definition: complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces with 5 common features:1) induced by traumatic forces to the head, either directly or indirectly, 2) rapid onset of short-lived neurologic impairment that resolves spontaneously, 3) may have neuropathological changes but these are functional more than structural, 4) a graded set of clinical symptoms which resolve following a sequential course, however, symptoms may be prolonged, and 5) no structural abnormality on standard neuroimaging.
  3. Work-up should include history of event including loss of consciousness, amnesia, prior injuries, and current symptoms. Assess 4 broad categories of symptoms–physical, cognitive, emotional, and sleep. Be sure to ask parents, not just patients. Also review any assessments done at the time of injury (e.g. SCAT3, etc). You can also complete these in the office, such as the SCAT3 version used at HMC. Physical exam should include GCS scoring, and examinations of the head, neck, pupils, and a full neurologic exam including gait, balance, coordination, and orientation.
  4. Imaging: CT scans are not routinely indicated unless there are significant symptoms including severe headache, vomiting, worsening symptoms, or neuro changes suggestive of more serious injury. See HMC algorithm for determining need for CT after head injury. This HMC algorithm is based on the national Pediatric Emergency Care and Research Network (PECARN) criteria. This helps avoid unnecessary imaging, while covering those who still need it.
  5. Treatment: Fortunately, most people recover from concussions within 7-10 days, but youth may take longer than adults. After concussion diagnosis, we recommend a gradual return to play with 24 hours at each stage (e.g., rest, walking, light aerobic activity, higher exertion, practice, scrimmage, games)-this generally means about a week before full return. Do not progress if there are symptoms at any stage. Here's a handout to use that reviews return to play. We should also recommend gradual return to learning, and youth may need accommodations before returning to full cognitive performance, such as test-taking.

Check out sports concussion resources from our sports medicine experts here.