7 Concussion Myths

As the country is focusing more on concussions, I've seen a lot more kids come in after head injuries, many of which are concussions. Even some kids who went to an ER after a head injury get incorrect information about return to play sometimes.

Source: CDC Heads Up

Common myths and misinformation about concussions:

1. A normal head CT means no concussion and a full return to play is okay.

Concussions are not diagnosed by CT. Brain bleeds and masses can be seen on CT, but the damage done to the brain during a concussion is not seen on a CT. Concussions are diagnosed based on symptoms, such as headache, confusion, lack of coordination, memory loss, nausea, vomiting, dizziness, ringing in the ears, sleepiness, and excessive fatigue. Not all symptoms need to be present to make the diagnosis. Some symptoms develop over time and are not present at the time of injury.

A CT scan is usually not needed with head injuries. They involve radiation so are not without risk themselves. Unless there are signs of a possible bleed in the brain, skull fracture, or the type of injury suggests the need for a CT, a CT scan is not needed in the evaluation for concussion.

2. A minor hit to the head never causes concussions.

The force of a hit does not determine the severity of the injury. Some people with more significant problems initially also seem to heal more quickly than others with more mild injury. It is very hard to predict how long it will be until all symptoms are resolved. The most important thing is that if you have symptoms of a concussion, your brain needs rest.

3. After two weeks you can return to play without further testing.

Sadly I've had more than one patient who was given this advice from a medical professional, whether on the sideline at a game or in an emergency room or urgent care. Although most concussions resolve within 2 weeks, not all do and returning to play before the brain is healed can lead to a more serious condition called "second impact syndrome." Second impact syndrome is a very rare condition in which a second concussion occurs before a first concussion has properly healed, causing rapid and severe brain swelling and often catastrophic results, including death.

After a concussion clearance to return to play should only happen when the child, teen, or adult is re-examined and found to be symptom free. Returning to play is done in a stepwise fashion, with each step lasting at least one day and only progressing to the next step if symptoms don't resume. This starts with light exercise when there are no symptoms at rest, then progresses to moderate activity followed by heavy activity without contact, then full practice with contact (if the sport is a contact sport) and finally full competitive play if each step can be done without return of symptoms. If symptoms return, you back up to lighter activity.

Returning to play too quickly can prolong healing time and even lead to long term consequences. Do not return to any activity that causes symptoms to worsen!

4. If a coach doesn't recognize the concussion, it's minor enough to return to play.

Coaches cannot see everything that happens on a field. If you had a head injury, tell your coach. Even if you are the star player. Really. You will do your team a favor if you take time to heal and can play again versus stay in the game and get more severely injured and are out for good. See these real stories of concussion survivors.

Someone who is trained in concussion evaluation should do a sideline evaluation. If there is any chance of concussion, you should not return to play at all that day or until you are cleared by a doctor who understands concussions.

5. IMPACT testing is necessary.

IMPACT testing is a computerized test that measures neurocognitive functioning. Ideally a baseline is done prior to the season (or at least every 2 years) and then testing is repeated if a concussion is suspected. The results of the current test are compared to the person's baseline and can be repeated at intervals until the person is back to baseline and able to be cleared to return to play. It is one tool to help manage concussions and determine when it is safe to return to play, but at this time concussions are diagnosed based on symptoms and physical exam.

6. Complete bed rest until all symptoms are gone is best.

Bed rest for the first day or two can help enforce brain rest and allow healing, but may not be required and prolonged bed rest is specifically not recommended. Prolonged bed rest can increase stress in children who miss substantial amounts of school. This stress is thought to possibly prolong healing. Depression is more common if bed rest is enforced beyond 48 hours. Socialization with friends and family can help provide emotional benefits that aid in healing. This does not mean that people should participate in all social settings. They will likely need relative quiet, so even going to a sporting event to watch can lead to return of symptoms.

7. Concussions only impact sports.

Concussions take kids out of play, but other activities should also be limited until they are tolerated. Lights, sounds and even smells can trigger symptoms after a concussion. If anything leads to worsening of symptoms, it should be avoided. Things that take focus or a lot of brain work may cause symptoms to worsen. These include reading, watching television, or playing video games. Initially a child might need total restriction from these activities, and then can slowly add them back in small increments as tolerated. Many kids need to have breaks during school, a decreased work load, and shouldn't take standardized tests until they can focus for a prolonged time. If computers are used for school, it might be necessary to use paper books and worksheets and to limit computer use until it can be tolerated.

For more information:

• Heads Up is a free resource for parents, athletes, coaches, and medical professionals
• Acute Concussion Evaluation (ACE) Care Plan has all the typical symptoms of a concussion, general guidelines to healing, plus return to school and sport templates
• Dr. Mike Evans has two great concussion videos:

• Concussion 101

• Concussion management and return to learn

Updated Sinusitis Guidelines

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This month the American Academy of Pediatrics updated the guidelines for management of sinus infections in children (1-18 years of age) in the June edition of Pediatrics, available online.

Many parents bring kids in to the doctor for green or yellow runny noses because they're worried about bacterial sinusitis. Sinuses can be infected with viruses or produce mucus from allergies, so not all sinus infections are bacterial. Most of these kids do not need antibiotics to get better, but the guidelines help determine who might benefit from them and when to change an antibiotic if not improving. The guidelines are based on duration of symptoms and severity, not the color of the drainage, how much drainage there is, or fancy testing. Only infections caused by bacteria need antibiotics. Overuse of antibiotics can lead to resistance (so when there is a severe infection it becomes more difficult to treat), side effects (such as diarrhea), or allergic responses.

Unfortunately, a physical exam is not helpful in distinguishing a simple viral cold and cough from a bacterial sinus infection, but is needed to identify other problems that might complicate the picture, such as pneumonia or an ear infection. The inside of the nose can be swollen and various shades of pink, red or blue in sinus infections from bacteria or other causes. How often have I palpated those sinuses to see if tender, yet I know from personal experience that mine hurt when my allergies flare-- certainly not a reason for antibiotics!

I wish there was a simple test, but nose swabs for culture have not been found to be accurate in predicting bacterial cause of the infection. Imaging studies are not needed to help diagnose sinusitis because the inflammation seen in pictures can be from other causes, not just bacterial.

Most cases of runny nose, fever, and/or cough are due to a viral illness. The nasal discharge usually starts clear, but can become thick and discolor over time for several days. It often goes back to a thinner, clear color before resolving without antibiotics. Fever in a typical viral illness tends to be the first several days, and may precede the other symptoms. Fever usually resolves by day 3, when the nasal discharge and cough tend to worsen.  Symptoms tend to peak between the 3rd and 6th day, then resolve after about 10 days. (Though some studies show longer.) Back to back infections are common in kids, especially during the winter months, which can be confused with one prolonged sinus infection.

Guidelines to diagnose and treat acute bacterial sinusitis in a nutshell:

• Symptoms in a child with upper respiratory infection suggest acute bacterial sinusitis if: 

• there is persistent illness (nasal discharge or daytime cough) of 10 days without improvement. This persistence can be difficult to distinguish from back to back viral illnesses, so a careful review of symptoms is important.

 or

• there are worsening symptoms (nasal discharge, cough, fever) after initial improvement. (New in the 2013 guidelines.)

or

• there is severe onset (fever over 102.2F and discolored nasal discharge for at least 3 consecutive days). Several viral infections, notably influenza, can cause severe onset of symptoms, but a clue to the bacterial nature is the combination of fever with mucus in the initial days, since the fever usually comes before the mucus in many viral illnesses. 

• Observation without antibiotic is acceptable with a persistent infection over 10 days for another 3 days if there was not a severe onset or worsening of symptoms. (This differs from the 2001 guidelines to use an antibiotic for symptoms of 10 days.)
• Imaging is not recommended to diagnose routine sinusitis. Plain x-rays, computed tomography (CT), magnetic imaging (MRI), and ultrasounds (US) cannot distinguish between viral, bacterial, or allergic nature of the inflammation. 
• If there is a suspicion of extension of the infection outside of the sinus cavities, such as into the eye orbit or central nervous system, a contrast-enhanced CT scan is indicated. These might be suspected if the eyelid is swollen and the mobility of the eye is decreased, sensitivity to light, severe headache, seizures, or other neurologic changes. 
• When antibiotics are indicated, amoxicillin or amoxicillin with clavulanate (Augmentin) is the first line choice unless there are documented allergies to penicillins. If there are allergies or failure to respond to the amoxicillin, a cephalosporin may be used. There are other good choices, but studies do not show that azithromycin (Zithromax) or trimethoprim sulfamethoxazole (Bactrim) are good choices because they aren't effective against the most common bacteria of bacterial sinus infections. The duration to take an antibiotic is not well identified. Recommendations vary from 10 to 28 days, or 7 days from the time symptoms go away. This will vary by prescriber's preference and experience.
• If there are worsening of symptoms or failure to improve within 72 hours of initial visit, a repeat evaluation is recommended. If no other source of symptoms is found on physical exam, adding an antibiotic (if not previously initiated during the observation period) or changing the antibiotic is recommended. 
• There was not enough evidence to support other treatments, such as decongestants, antihistamines, nasal corticosteroids, or saline rinses. More studies in children are needed to validate whether these are effective or not. There's always more to learn!

Know Your Insurance Formulary

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When kids with a chronic illness (migraines, asthma, ADHD, acne) need a first-time prescription, I often ask the parents to look at their formulary first. This upsets some parents because they want to start something today, but I refuse to play the phone tag game for the next week.

What do I mean?

Most diseases have more than one medication that can be used to treat the condition. Many of these medicines are very expensive, and insurance companies put them in various tiers depending on how much they pay for the medicine.  The more they are contracted to pay, the higher the tier, resulting in a higher copay for the consumer. This varies from company to company, so what someone with a prescription plan from Company A has different costs than someone with a plan from Company B.  Even different plans within company A vary.  High deductible plans add in even more confusion because your cost depends on how much you've already spent.

I saw a formulary for one company recently that the medicine was generic tier for those under 18 years, but over 19 years it needs a prior authorization. Huh? The condition doesn't change with the birthday. The medicine is approved for both age groups. Why they have that prior authorization requirement is a puzzle to me.

I simply can't keep all the plans straight. Ideally electronic records would link to each insurance plan's formulary and let us know immediately how much a prescription will cost, but they don't.  Even pharmacies can't give the cost until they "run it through".  There are simply too many insurance plans.

So if you think you will need a long term prescription for a long term problem, I simply ask that you do your homework first. The insurance company won't tell me what your plan says. You must ask.  When we know the formulary, we can discuss the best option to begin treatment.  When 2 medicines have equal risks and benefits for a condition, we will choose the least expensive. If the lesser expensive options don't work, we may end up on a higher cost medicine. At that point other things have been tried and the cost is more acceptable.

Without the formulary, what tends to happen is I write for Drug A. When the parent goes to the pharmacy to pick it up, it is too much money, so they call use to change. Of course they don't know what to change to, so I change to Drug B.  Same story.  Turns out, it will be Drug E that is the lowest tier. Parents are frustrated with me for not giving the "right" one, but I am blind. Drug A was cheapest on the last plan I wrote a script for. Who knew yours is different?  This leads to too many trips to the pharmacy and phone calls back and forth. Everyone is frustrated and time is lost. It is faster to spend some time in advance finding out what to try first!  Please.

Believe me, this is frustrating for all of us. I wrote about my personal experience with formularies in Health Insurance Woes.  As an update to that, we are now using a mail order pharmacy. It is still much more than our last plan, but better than local pharmacies.

Spring Forward... Lose sleep...

As we move our clocks forward to increase the number of daylight hours, we all lose one hour of sleep.  In the whole scheme of things, this isn't much. Most people (kids and adults) lose needed sleep every night.  Only 8% of teens get the recommended amount of sleep.  Eight percent!  No wonder they have increasing rates of so many problems.

Last night I watched "Race to Nowhere" a documentary of the pressures placed on our kids today.  Kids feel pressure to do well in school (many while taking an overload of AP classes), leading to many hours of homework each night.  They participate in sports, which takes up valuable time after school away from homework, but does help them exercise and do something they enjoy (until they burn out and don't like it anymore). They feel the need to do community service and join clubs to build their portfolio to get into a great college.

While I think the film was developed with an agenda and not every kid is suffering from overload, I certainly see enough teens (and preteens) who seem to suffer from sleep deprivation, depression, anxiety, stress, and more.  Are these kids simply not using time efficiently?  Even the documentary showed one of the troubled teens doing homework with her cell phone right there and texting interrupting her thought.

Maybe a quick break after school to play outside for 30 minutes will help release energy and allow the brain focus to study.  Then turn off the tv and put the phone in another room and get to work.  My question: Are these kids spending 6 hours doing 1 hour worth of work?  

Interesting point made in the film though: Studies show that as the amount of homework assigned decreases, test scores increase.

Are we setting our kids up for failure from the beginning? Research shows that kids under 3 years who watch tv have higher incidences of ADHD and aggression along with lower cognitive development.  Kids with ADHD take longer to do tasks because they do not focus and concentrate until the task is complete.  They often need to re-read or re-do work because they miss concepts.  They can suffer from poor self esteem and increased rates of depression because they feel like failures.  In the short video below Dr. Dimitri Christakis explains how researchers are learning about the influences of stimulations (too little and too much) on learning and development.  Take 16 minutes to watch it!

Past growth and development cannot be changed, but we can improve current growth and development.  Maximizing nutrition, healthy exercise, and sleep can help the body and brain be its best.

Kids and teens are staying up too late (sometimes all night) to finish homework.  They are tired during class so take caffeine or other stimulants (such as those used to treat ADHD without a prescription) to stay awake.  They are too tired to focus in class, so they perform below their knowledge on tests.  Between 7-12 years old, kids need 10-11 hours of sleep every night.  Teens need 8-9 hours, sometimes more during rapid growth spurts.

Kids who once enjoyed a favorite sport feel the pressure from coach to train more, but the demands of school put the kids in a quandry: they need to make grades to play, but they don't have time after practice to do the homework.  Often practice and game times are late in the evening, making it hard for kids to fall to sleep at a normal bedtime, since the body needs about 2 hours after exercise to fall to sleep.  I have blogged on this before here.

I see many kids and teens who have chronic headaches or other symptoms that are likely due to sleep deprivation, but they insist it is something else and they want the million dollar workup to find a cause and expensive medications to treat the symptoms.  Once symptoms have started, they might need more treatments, but beginning with healthy nutrition, exercise, and sleep might prevent many of these problems!

The fear of failure and pressure to succeed is leading to kids trying anything to succeed, not just staying up late and drinking too much caffeine.  Cheating in schools, such as copying homework, plagiarizing, or cheating on a test is becoming commonplace. The large majority of high school students admit to cheating.  What does this mean for our future society if kids learn to cheat the system to succeed?

Kids who are chronically sleep deprived are at risk of physically hurting themselves due to slowed reaction times, concentration and focus failures, and difficulty processing information (much like being under the influence of drugs or alcohol).  They are more likely to be injured while playing their sport. Drivers are more likely to be in a car accident.  Drivers 16-24 years of age are the most likely to report falling to sleep at the wheel in the past year according to a study by the AAA Foundation for Traffic Safety.  Also in this study, people who sleep 6-7 hours a night are twice as likely to be in an accident as those sleeping 8 hours or more.  People sleeping less than 5 hours increase their risk 4-5 times!

How can we all wake up rested and still get everything done each day?  What can we cut back on with our families?  There are initiatives to get schools to enforce less homework and to start later, but until then, what can YOU do to help your kids get the sleep they need?