Angela Lumba-Brown, MD, co-director of the Stanford Concussion and Brain Performance Center, is the lead author of the newly published CDC Guidelines on the Management of Mild Traumatic Brain Injury in Children. In a recent interview, she explained what families should know about concussions.
September 4, 2018 - By Erin Digitale
Angela Lumba-Brown, MD, first learned about concussions from personal experience.
“I had two concussions playing high school basketball,” said Lumba-Brown, a clinical assistant professor of emergency medicine and of pediatrics at the Stanford School of Medicine. “I had great doctors who were able to explain to me what I was feeling, which added to my rapidly developing interest in how the brain works.”
Knowledge of brain injuries has advanced significantly since those conversations, in part thanks to Lumba-Brown’s work. She conducts research on brain injury at the Stanford Concussion and Brain Performance Center, which she co-directs, and treats patients at Stanford Health Care’s pediatric emergency department. She is also the lead author of a new set of guidelines from the U.S. Centers for Disease Control and Prevention advising clinicians on the diagnosis and treatment of mild traumatic brain injuries, including concussion, in children and teenagers. Published Sept. 4 in JAMA Pediatrics, the new guidelines are based on evidence from over 35,000 scientific studies of brain injury that came out between 1990 and 2015. Specific resources for patients and families also are highlighted in the guidelines. Lumba-Brown spoke with science writer Erin Digitale about what families should know about concussions.
1. What are the warning signs that a child who has bumped their head should be taken to the emergency department or their pediatrician?
Lumba-Brown: There are many important warning signs of mild traumatic brain injury that can be difficult to discern from more severe types of brain injuries. These warning signs require evaluation by a clinician right away and include: the child not acting like their usual self, worsening symptoms following injury, headache that becomes severe, unsteadiness or difficulty walking, changes in their speech, seizures, “black-outs” and any excessive sleepiness, dizziness or confusion.
If the mechanism of injury was severe — a car accident or fall from a height, for example — they should also be examined by a clinician. In general, families should exercise caution and come to the emergency department or their doctor if they feel something is not right with their child.
2. The new CDC guidelines recommend changing the terminology we use for concussions. Why?
Lumba-Brown: Traditionally, concussion has been considered a type of mild traumatic brain injury in which there is no evidence of hemorrhage on standard neuroimaging. However, other “mild” brain injuries, including those with small amounts of bleeding or bruising of the brain, are treated exactly the same way as concussion. Studies have also shown that there is a different perception about the terms “concussion” and “mild traumatic brain injury” among patients, families and coaches. We want to ensure that we are describing the most medically correct process possible when advising our patients, and hence we are now talking about “mild traumatic brain injury.”
3. What should parents expect if their child is being evaluated for a mild traumatic brain injury?
Lumba-Brown: The main test we use to evaluate a child for this type of injury is our physical exam, which includes assessment of neurologic function. This exam includes assessing the child’s speech and flow of thoughts and emotions, how they move and walk, their coordination, their strength and muscle tone, and the action of facial muscles that can reflect potential problems with cranial nerves, as well as neck injuries or other injuries. Families sometimes expect an imaging test, but the physical exam performed by the doctor is actually the most important test. The doctor may also want to monitor the child for a couple of hours for any change in symptoms that might reflect a more serious process, such as significant bleeding on the brain, which could take time to develop. The new guidelines do not recommend head CT imaging or X-rays for children suspected of having a concussion, since it’s important to avoid exposing them to unnecessary radiation.
Families should tell their doctor about any previous head injuries their child has had, as well as any bleeding disorders or other neurologic issues, such as seizure disorders, ventriculo-peritoneal shunts, brain surgeries or neck injuries. Other important medical history to share with the doctor include: history of attention deficit hyperactivity disorder, mood or anxiety disorders, prior issues with their balance, problems with their eyesight, sleep disorders, or a history of migraines. Children with these medical histories may have longer recoveries.
It’s important for families to know that many pediatricians or family medicine physicians will manage a child’s mild traumatic brain injury. However, in some instances, a doctor may recommend follow-up with specialists.
4. What should families know about the recovery from mild traumatic brain injuries?
Lumba-Brown: In most cases, physicians can discharge children from the emergency department after determining that they’ve suffered a concussion. But physicians need to tell families to return to an emergency department or clinic right away if they see any worsening symptoms. We advise families that their child should take it easy the day following the injury but re-integrate into physical activity as soon as possible. It is common for a child with mild traumatic brain injury to have a headache, nausea and dizziness in the days following their injury. They may not even remember the actual injury or even events surrounding the day of the injury. It is also common for children to have problems focusing and changes in sleep patterns over the next weeks. They could be more emotional or get headaches more easily. Specific symptoms will change as the child is recovering.
The brain needs some stimulation to get blood flow back to the injured areas, so we don’t want a child in a dark room, sleeping all day. It’s better to maintain the usual routine, maybe with some naps but also some walking, running and playing. Re-integrating into exercise is important for recovery and overall health. However, children should avoid activities that carry risk for re-injury — such as jumping off couches, playing soccer, riding a mountain bike downhill, or jumping on trampolines. Cognitive activities like reading, watching TV or playing on an iPad are OK if they aren’t worsening the child’s symptoms significantly.
Re-injury is the major risk for a child or teenager with a mild traumatic brain injury. Let’s take this example: An injured knee is weaker as it recovers, and a fall or misstep could much more easily re-injure it. The brain is similar: With another blow to the head, a second injury can occur at a lower threshold of impact. That’s why clinicians recommend no contact sports during recovery from a mild traumatic brain injury. This can be difficult advice for children who thrive on play; we need to ensure the child understands to the best of their ability why they can’t climb trees, head their soccer ball or participate in other activities that could result in re-injury.
Children should see their doctor for a second visit within a week of their injury to assess how they are improving. Their doctor can guide the family about a return to full activity, including contact activity. If a child is not recovering at the expected rate as the month progresses, a brain-imaging test, such as an MRI, may be warranted.
Mild traumatic brain injuries need time to heal, and children need emotional and physical support from their families, teachers and sports coaches to help their recovery and ensure that they aren’t overexerted or re-injured.
5. What are the big unanswered questions about concussion and other forms of mild traumatic brain injury?
Lumba-Brown: Most children’s symptoms begin to improve by about 10 days, but 20 to 30 percent recover much more slowly. The doctor’s clinical exam, including evaluation of the child’s medical history and current symptoms, flags who may be at risk for slower recovery: For example, more symptoms and more severe symptoms are warning signs. We’re now studying how to effectively treat these symptoms.
Research conducted at the Stanford Concussion and Brain Performance Center has identified five main groups of symptoms following concussion: headache or migraine; cognitive symptoms, such as slowed reaction time and difficulty processing information; anxiety and mood symptoms; ocular-motor symptoms, such as blurry vision and trouble with eye-tracking; and vestibular or balance symptoms. But we are just starting to understand how these different groups of symptoms may benefit from specific types of treatment.
Research on mild traumatic brain injury conducted by Lumba-Brown and others will be discussed April 27 during the first-ever Stanford Sports Concussion Summit at the Arrillaga Family Sports Center. The event will be open be open to the public.
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