The weather has begun to warm again and the kids are really itching to get outside. With increased outdoor time comes increased participation in athletic events. Frequently, our young athletes will suffer some kind of head injury and the question always arises as to what to do with these kids.
There are two significant consequences of head injury, concussion and intracranial bleeding. Intracranial bleeding is relatively infrequent. These patients usually (but not always) have a significant head injury. They develop headache, nausea, vomiting and/or irritability that gradually worsens, usually prompting medical attention. We saw this recently with a famous model/actress who'd been skiing, hit her head and over the next 24-48 hours had headaches that came and went, gradually worsening. Unfortunately, she perished due to lack of nearby facilities, lack of recognition of a problem, and patient resistance to admitting her symptoms were getting worse. Anytime that there is a head injury, be very aware of symptoms that are getting worse and have worsening symptoms evaluated quickly.
The second significant consequence is far more common and usually considerably more subtle. A concussion is defined as ANY head injury, no matter how minor, that leads to neurologic symptoms. These symptoms can be as mild as several moments of dysorientation or as severe as "blacking out" for many minutes. Clearly, the more severe the injury or the symptoms, the more seriously physicians take the injury, but studies have shown that even minor injuries can lead to long term changes. These chronic changes include persistant headaches (especially with exercise), persistant trouble concentrating (including one patient I had who developed ADD like symptoms for years after the injury), irritability and other personality changes. These symptoms generally resolve spontaneously, but can persist for weeks, months and potentially even years. The symptoms are treated accordingly, but there is no treatment for the underlying cause, that is, the concussion.
While these symptoms are a serious problem for those who suffer from them, the bigger issue is the risk of secondary concussions and, more importantly, second impact syndrome. The research is very clear that individuals who have had a first concussion are at several fold higher risk of having more concussions in the future. All activities with risk for a head injury most be approached with this risk in mind. Any protection that can be afforded to these individuals to prevent a head injury is appropriate. Second impact syndrome is a rare, but potentially fatal complication of having a second head injury while the symptoms of the first concussion are still present.
With these risks in mind, there are certain guidelines for returning to a risky activity after a concussion. Most experts believe that a very mild concussion (head injury with a little dizziness lasting a minute or so) can return to play once COMPLETELY symptom free for more than five minutes. Any persistent symptoms are a reason to remain out of play. Any loss of consciousness should probably result in an athlete being pulled for the duration of the game. Return to play is determined by persistence of symptoms. There is a very gradual return to full activity. Athletes start with usual activities of daily living (walking, going to school). If there are headaches, difficulty concentrating, trouble with short term memory, or irritability, the athlete doesn't move to the next step. The next step includes basic, gentle exercise. Jogging, biking and swimming would fall in this category. Once these activities can be done completely without symptoms, then the athlete may return to sport specific activities including drills. At this point, weight lifting may be resumed. Only when extensive sport specific skills can be done without any return of symptoms may the athlete be returned to competitive play.
Head injury is a serious injury in any child. Athletes are at much higher risk of complication if they return to play too quickly. The key issue is if there are ANY symptoms that you as a parent can see, don't take any chances. Consult with your pediatrician, trainer or sports medicine specialist on how to proceed.
Monday, April 12, 2010
Friday, April 9, 2010
What IS that white stuff?
Another absolutely beautiful day in St. Louis. We don't get that many, so I hope you're out there enjoying it.
At least once a week, I get a visit or a phone call about white stuff in a baby's mouth. In spite of many warnings from grandparents about "thrash," not all that's white in the mouth is thrush. Thrush is a yeast infection in the mouth. Usually, we find it in babies whose immune system hasn't developed to the point of being able to fight it off. Breaset and bottle fed kids both get it. I seem to see it more often in breast fed kids, but I don't think that's generally true in all communities. The yeast comes off of the breast or bottle nipples. Sometimes, Mom will get the infection on her breasts and develop soreness and cracking.
Other kids will get thrush after a round of antibiotics. Thrush is also one of the primary side effects of inhaled steroids.
The best way to tell if a baby has thrush is to look for white patches on the insides of the cheeks. If these patches can not be scraped off, then it is likely thrush. Often, these same patches will appear on the gums. They usually do not appear on the tongue. There are several different treatments for thrush, all of which are reasonably effective. Preventing thrush involves boiling bottle nipples after use (or sending them through the dishwasher). Sometimes, we recommend mother be treated if it appears she is carrying the yeast and giving it to the baby.
Other white rashes in the mouth are also common. The most common misperception is that a white tongue is thrush. Again, if there are no white patches on the cheeks, there probably isn't thrush. The white tongue is usually caused by the environment in the mouth. Mild dehydration will dry the tongue a little and make it white. A recent meal can become somewhat adherent and look like a white coating on the tongue. Geographic tongue describes a tongue that develops serpentine patterns under certain conditions and these patterns are sometimes whitish, but sometimes reddish.
A big cause of white in the mouth is often confused for teeth coming through. The gums of newborns can develop little white cysts. These cysts are entirely developmental in nature. They seem to come and go over the course of the first several months of life. Unfortunately, they do not usually indicate teeth coming in and they are never an indication of thrush.
So next time it looks like there's white stuff in an infants mouth, think of the wide variety of things that turn the mouth white. Consider what part of the mouth has the white spots. Then, when all the information is in place, give your pediatrician a call.
At least once a week, I get a visit or a phone call about white stuff in a baby's mouth. In spite of many warnings from grandparents about "thrash," not all that's white in the mouth is thrush. Thrush is a yeast infection in the mouth. Usually, we find it in babies whose immune system hasn't developed to the point of being able to fight it off. Breaset and bottle fed kids both get it. I seem to see it more often in breast fed kids, but I don't think that's generally true in all communities. The yeast comes off of the breast or bottle nipples. Sometimes, Mom will get the infection on her breasts and develop soreness and cracking.
Other kids will get thrush after a round of antibiotics. Thrush is also one of the primary side effects of inhaled steroids.
The best way to tell if a baby has thrush is to look for white patches on the insides of the cheeks. If these patches can not be scraped off, then it is likely thrush. Often, these same patches will appear on the gums. They usually do not appear on the tongue. There are several different treatments for thrush, all of which are reasonably effective. Preventing thrush involves boiling bottle nipples after use (or sending them through the dishwasher). Sometimes, we recommend mother be treated if it appears she is carrying the yeast and giving it to the baby.
Other white rashes in the mouth are also common. The most common misperception is that a white tongue is thrush. Again, if there are no white patches on the cheeks, there probably isn't thrush. The white tongue is usually caused by the environment in the mouth. Mild dehydration will dry the tongue a little and make it white. A recent meal can become somewhat adherent and look like a white coating on the tongue. Geographic tongue describes a tongue that develops serpentine patterns under certain conditions and these patterns are sometimes whitish, but sometimes reddish.
A big cause of white in the mouth is often confused for teeth coming through. The gums of newborns can develop little white cysts. These cysts are entirely developmental in nature. They seem to come and go over the course of the first several months of life. Unfortunately, they do not usually indicate teeth coming in and they are never an indication of thrush.
So next time it looks like there's white stuff in an infants mouth, think of the wide variety of things that turn the mouth white. Consider what part of the mouth has the white spots. Then, when all the information is in place, give your pediatrician a call.
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