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 #41: Child abuse recognition and prevention

April is child abuse prevention month, so we are going to discuss this always challenging but critical topic in our field. We owe gratitude to the SCAN and CPS teams who work so hard to help evaluate and keep children safe. Our role in primary care encompasses strategies to build resilience, promote strong relationships/bonds, link families to resources, and screen and refer for concerns. The Protection, Advocacy and Outreach team at SCH has 3 prevention programs including Period of PURPLE crying, Medical-Legal Partnership and Positive Parenting (which provides funding for our Promoting First Relationships (PFR) training for residents).

Materials for this week:

Take-home points for child abuse recognition:

  1. We are mandated reporters for suspected child abuse and neglect and any allegations of sexual abuse. We are likely to encounter child maltreatment in our practices: 1 in 8 children between 0-18 years in the U.S. have some form of substantiated maltreatment. A meta-analysis of 22 US studies suggested that 30 – 40% of girls and 13% of boys experience sexual abuse during childhood.
  2. Neglect is the most common form of child maltreatment, accounting for ~60% of cases. Neglect is failure to meet the basic emotional, physical, medical or educational needs of a child. It includes lack of adequate nutrition, hygiene, shelter, and safety.
  3. Corporal punishment is not recommended in any form by the AAP. Spanking (i.e., using “an open hand on the buttocks or extremities with the intention of modifying behavior without causing physical injury”) is the least objectionable, but is considered maltreatment if it is done so hard as to leave a bruise.
  4. Children of all SES levels are at risk for child abuse. In ~80% of cases, parents are perpetrators of child maltreatment. Some specific parent-level risk factors for child abuse include parent poverty, parent of multiple children under 5, history of substance use or mental illness (including current depression), teenage parents, cognitive deficits, single parents, history of child maltreatment or intimate partner violence, failure to empathize with children, or inappropriate expectations for child development. Child-level risk factors include physical, emotional, or behavioral disability; result of undesired pregnancy; or multiple gestation pregnancy.
  5. Bruising is the most overlooked form of abuse. The TEN-4 rule is a helpful guide to remember patterns of bruising more associated with child abuse. TEN = Torso, Ears, Neck bruising and 4 = any bruise on a 4 month old or younger – those bruises should prompt more work-up and a referral to CPS. It's important for us to be aware of the bruising: before getting a diagnosis of child abuse, 25% to 30% of abused infants have “sentinel” injuries, such as facial bruising, which can be a harbinger of worse injury. 

TOW #7: Water safety

Summer is a great time to review water safety, especially in Seattle where we have access to so much beautiful open water and sunshine to enjoy it. Safety around water is critical, as drowning is actually a leading cause of injury death for children. Seattle Children's has partnered with community organizations through programs like Everyone Swims to develop materials and advocate for policy changes to prevent drowning, including contributions from our own residents: http://www.seattlechildrens.org/dp

Check out this week's teaching resources here:

Take-home points for understanding drowning and promoting water safety:

  1. Epidemiology: Death from drowning is a top 3 cause of injury death in childhood. It is the leading cause of injury death for 1-4 year olds and the 2nd leading cause for 5-14 year olds. Unfortunately, it disproportionately affects minority children. Children can drown in only 1-2 inches of water. Adolescent males have a 10-fold increased risk of drowning compared to females. They have higher risk exposure, more risky behaviors (e.g., swimming alone and at night), and are more likely to drink alcohol in aquatic settings.
  2. Definition: Drowning is no longer defined as death from submersion. The WHO defines it as “a process of experiencing respiratory impairment from submersion/immersion in liquid" and outcomes are classified as death, morbidity, or no morbidity.
  3. Risk reduction: Drowning can be prevented by many strategies including 1) adult supervision within arm's reach, 2) life jackets, 3) pool fencing that encloses the pool and is at least 4 feet high, 4) swimming at lifeguarded areas, and 5) swimming lessons. The American Academy of Pediatrics (AAP) recommends children begin to learn to swim by age 4. In one study, taking formal swimming lessons was associated with an 88% reduction in drowning risk (Brenner et al. Arch Ped Adol Med 2009).
  4. Pediatricians have a role in drowning prevention. Screen for swimming ability at age 4-5 and refer to swim lessons (see pool info handouts on Everyone Swims tab on the SCH drowning prevention page). Remind families about water safety and where to get information, including handouts here: http://www.safekids.org/watersafety

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.

TOW #4: Injury Prevention

Next up in TOW-land is reviewing injury prevention, a timely topic for summer months, which are known as "trauma season" to all those at Harborview. Please offer appreciation to your colleagues who are spending their time taking care of the high volume of injured children. We also owe gratitude to our amazing team of injury prevention experts including Drs. Beth Ebel, Brian Johnston, and Fred Rivara, who dedicate their time to making kids safer across our nation/globe.

Materials for review:

Take-homes points:

  1. Epidemiology: Injury is the leading cause of death among children and adolescents > 1yr in the US, and ~1 in 4 children has an unintentional injury that requires medical care each year. In the US, injuries cause 42% of deaths in children ages 1-4 and 65% of deaths ages 4-18.  Injury peaks during the toddler years (ages 1 to 4) and again during adolescence and young adulthood (ages 15 to 24). The problem is even more profound in developing countries.
  2. Improvements in injury rates due to multiple public health and health care efforts: Between 2000 to 2009, the unintentional injury death rate for American children <19 declined by 29%. This decline is attributed to seat belts and child safety seats, reduced drunk driving, increased use of child-resistant packaging, better safety awareness, and improved medical care. The highest death rates remain from motor vehicle accidents, so we will cover that more in-depth in another topic. 
  3. Injury prevention is most effective with 4 components: Mace and colleagues describe the “four E’s of injury prevention”-education, engineering (modifying environmental or product design), enforcement (mandating appropriate laws), and economics (creating financial incentives and disincentives). In general passive interventions that don't require someone to act (like air bags, road design) work better than active ones that require users to choose them (like seatbelts, helmets).
  4. Our role in education (and advocacy): In the primary care setting, education is the primary method of providing anticipatory guidance, and the AAP recommends that every well-child visit include age-appropriate injury prevention counseling. However, only approximately 50% of pediatric residents and practitioners provide injury prevention counseling at well-child visits. We have to be strategic because we can't cover every topic every time. Bright Futures helps guide which injury prevention topics are most appropriate at each age. We also have to extend our role to advocacy to address the other "E's."
  5. Teachable moments after injury: There may be more opportunity for a “teachable moment” soon after an injury, when injury-specific information can be distributed (e.g., bicycle safety info for an unhelmeted cyclist with a head injury). Due to the lack of data, there is some controversy that the “teachable moment” has an added effect, but disseminating information in general can be effective.

TOW #40: Child abuse recognition & management

April is child abuse prevention month, so we are going to discuss this always challenging but critical topic in our field. We owe gratitude to the SCAN and CPS teams who work so hard to help evaluate and keep children safe. Our role in primary care encompasses strategies to build resilience, promote strong relationships/bonds, link families to resources, and screen and refer for concerns.

Materials for this week:

Take-home points for child abuse recognition:

  1. We are mandated reporters for suspected child abuse and neglect and any allegations of sexual abuse. We are likely to encounter child maltreatment in our practices: a recent study found 1 in 8 children between 0-18 years in the U.S. have some form of substantiated maltreatment. A meta-analysis of 22 US studies suggested that 30 – 40% of girls and 13% of boys experience sexual abuse during childhood.
  2. Neglect is the most common form of child maltreatment, accounting for ~60% of cases. Neglect is failure to meet the basic emotional, physical, medical or educational needs of a child. It includes lack of adequate nutrition, hygiene, shelter, and safety.
  3. Corporal punishment is not recommended in any form by the AAP. Spanking (i.e., using “an open hand on the buttocks or extremities with the intention of modifying behavior without causing physical injury”) is the least objectionable, but is considered maltreatment if it is done so hard as to leave a bruise.
  4. Children of all SES levels are at risk for child abuse. In ~80% of cases, parents are perpetrators of child maltreatment. Some specific parent-level risk factors for child abuse include parent poverty, parent of multiple children under 5, history of substance use or mental illness (including current depression), teenage parents, cognitive deficits, single parents, history of child maltreatment or intimate partner violence, failure to empathize with children, or inappropriate expectations for child development. Child-level risk factors include physical, emotional, or behavioral disability; result of undesired pregnancy; or multiple gestation pregnancy.
  5. Bruising is the most overlooked form of abuse. The TEN-4 rule is a helpful guide to remember patterns of bruising more associated with child abuse. TEN = Torso, Ears, Neck bruising and 4 = any bruise on a 4 month old or younger – those bruises should prompt more work-up and a referral to CPS.

Thanks for your work to help protect children.

TOW #6: Concussions

Unfortunately, summer is known as "trauma season" at Harborview when we see a peak of youth injuries, especially head trauma. In addition to summer recreational activities, youth around our area are starting camps and early practices for the fall sports season. So, this is an opportune time to review concussions, a very hot topic in pediatrics (and society-at-large, for that matter). We as pediatricians are increasingly called upon to address these injuries in clinic and clear youth for return to activities. Below are teaching materials for this week. Also check out R3 Emilie Weigel's great RCP review on concussion which she presented this month.

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

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 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 resources from our sports medicine experts here.

Have a great week!

Mollie