Concussion in children and young people

What is a concussion?

Concussion is a type of brain injury that can alter the way a child’s brain functions. It can be
caused by either:

a blow to the head
something that causes the head and brain to quickly move back and forth or in different directions.

Effects of a concussion are usually short-term and are often described as a mild brain injury.

With the appropriate care and rest, most children should recover within about four to six weeks.

However, concussions can sometimes require emergency treatment and some people can have long-lasting difficulties after a brain injury.

My son collided with another boy during a football match. We all ran onto the field as it didn’t look good. He was out for a minute or so but it felt much longer and was very scary.”

Are children more prone to concussion than adults?

Evidence suggests that children, and in particular teenagers, are more likely to suffer a concussion than adults. Younger children are also at risk of concussion because their heads are disproportionately larger compared to the rest of their bodies.

Children’s brains are still developing and important connections between cells are still being strengthened. This process is known as myelination. Myelin is a protective coating around part of the nerve cells. Myelin in the brain is a bit like a coating of electrical wires with plastic to protect the electrical signal as it travels along a circuit. And because children have less myelinated brains than adults, they may be more susceptible to concussion.

What happens to the brain during and after a concussion?

The brain is surrounded by fluid and protective tissue which cushions the brain from light bumps and knocks to the head. But during a more severe blow to the head, or something that makes the brain move rapidly, this cushioning may not be enough to protect the brain.

Concussions generally do not show up on CT or MRI scans as they can’t detect the microscopic injury including chemical changes in the brain and damage to nerve cell function.

Symptoms of concussion in children and young people

The symptoms of a concussion can be very subtle and not always immediate. This means that a parent, teacher or sports coach could easily overlook the signs that a child or young person has had a concussion.

The symptoms listed below are signs that a person may be concussed but not all of these symptoms may apply. If a child or young person is showing even one of these symptoms, it may indicate a concussion. And sometimes symptoms don’t occur until a later stage.

It is important to remember that a person doesn’t have to lose consciousness for them to have had a concussion. They may remain conscious, but feel dazed or have other symptoms. Recent research suggests that a loss of consciousness is found to be a symptom in less than 14% of cases."

It’s not always easy to grade symptoms and categorise them from mild to severe. The below bullet points are meant to act as a guide if you are concerned that a child in your care has suffered a concussion. If in doubt, and the symptoms don’t fit into the ‘call an ambulance’ category, call 111.

For the following symptoms, call for an ambulance:

cannot be wakened, unconscious
difficulty staying awake
extremely confused state
problems in speaking, walking or balance
numbness or weakness in part of their body
vision problems with nausea or dizziness
clear fluid coming from ears or nose
bleeding from ears or bruising from behind the ears
a black eye that wasn’t the result of a blow to that area
a seizure or convulsion
neck pain.

For the following symptoms, visit your nearest A&E department:

woken up after being knocked out
has memory problems
a headache that doesn’t go away
been vomiting since the injury
significant changes in behaviour.

For the following symptoms, seek medical advice by phoning 111:

headache
feeling sick
slight dizziness
difficulty in concentrating
double vision.

Symptoms associated with neck injury can be quite similar to those of concussion. These include headaches, dizziness and vision problems."

Subtle or delayed symptoms of concussion

Sometimes there are no immediate signs of concussion. However, symptoms can sometimes appear after a few hours or even days after the injury. It is therefore important to ensure that teachers, parents and anyone who cares for the child is aware of any recent bumps or accidents so that they can look out for warning signs in the following days.

What you should do if you think a child or young person may have suffered a concussion

Remove them from play: As long as they haven't passed out and seem well enough to move, sit the child down, removing them from any sport or activity that they have been involved in.
Talk to them: If they are at an age where they can hold a conversation, now is a good time to ask the child or young person a couple of questions about how they are feeling. The way in which they answer might help you determine if they have had a concussion. For instance, if they slur their words or seem confused, this would be a good indication that they are concussed.
Get medical advice: While the NHS recommends that mild symptoms don’t require medical advice, it’s sometimes difficult to decide what might be mild. So, if there is even the smallest indication that they have suffered a concussion, it is a good idea to have them assessed by a GP or medic. Or you could call 111 for further advice on next steps.
Rest: If a child or young person has had a concussion it is important that they get some rest (both mental and physical) and don’t do anything that might worsen symptoms.

Tips on preventing concussion in children and young people

Understanding concussion and its effects

It is important that parents, teachers and sports coaches know what to look for if a child has suffered a blow to the head. It is also equally important for children and young people to be aware of concussion. You can order a printed booklet of this information to help explain the symptoms to help them better understand the condition and the importance of the recovery process.

Following the rules

Knowing how to play a sport or game safely and by the rules is an important factor in preventing concussion.

Wearing and using recommended equipment

Ensure that the correct equipment and suggested protective accessories are used when taking part in sports and games.

Helmets: Compelling evidence shows that wearing a cycle helmet can reduce the risk of serious head injury by almost 70%. But cycling helmets and sport helmets are not concussion-proof. So it is important that children practice road safety and play by the rules in sports and games."

Road safety and car safety

Encourage positive road safety habits in children from a young age and explain the importance of wearing a seatbelt.

Recovery

Research suggests that children and young people can take three times longer to recover from a concussion than adults. Here are a few things that can speed up the recovery process:

When the doctor said our daughter had suffered a concussion, we were sent home with the advice of keeping an eye on her. We weren’t too worried, to be honest. Everyone has heard of concussion and we didn’t think it was too serious. But she really struggled to get back to her normal self, playing with her brothers and doing homework. She couldn’t concentrate and got tired very easily. It was then that we realised the full impact the concussion had on her. It took a lot of rest and several calls and visits to the GP for support and advice for her to fully recover.”

Rest

Some time off school can be a huge benefit to a child or young person who has suffered a concussion. Contact sport and excessive physical activity should also be avoided for at least 24-48 hours.

Children should avoid activity that may result in a second injury before the brain has recovered from the first and should avoid too much physical exertion – but not be totally sedentary (Giza, 2018). Research has found that those who had no activity had longer post-concussion symptoms.

Observation

Look out for any changes in behaviour or difficulty in concentrating following a brain injury in the first few days. If changes do occur you should seek medical advice. Ensure that people around the child or young person are aware of the injury so that they can seek help if necessary.

Medication

A GP may advise that a child should have paracetamol for pain or headache. Avoid aspirin or anti-inflammatory medication as this could cause bleeding. If a child is in pain, seek advice from a GP.

Gradual return to school and activities

It is advised that children do not need to be completely symptom-free to start the process of going back to school but that modifications should be made to suit their needs following the concussion. This might mean longer breaks or shorter days. If school and activities bring on new symptoms or make current ones worse, activities should be decreased.

Research suggests that a brief rest should be followed by the gentle re-introduction of cognitive and physical activity (cognitive activity involves thinking and could include drawing, card games or problem-solving). Early aerobic exercise, such as brisk walking, has been found to improve the time to recover after sports-related concussion compared with stretching exercises (Leddy 2019).

Trust your instincts

Don’t be afraid or embarrassed about getting more help, even if a GP or doctor has given the ‘all clear’. If you feel that something isn’t quite right with a child following a concussion or possible concussion, get further help from the GP or call 111 to explain your concerns. It’s often people closest to the child who realise that they are acting differently or suffering from the effects of concussion, and need further support in their recovery.

Returning to school

Experts have developed recommendations for the return to school and activity following a concussion.

The following guides are based on these recommendations by Canchild and can be used when a child’s GP or doctor is happy that they can gradually return to school, activity and sports.

An initial period of 24-48 hours of rest for the body and mind is recommended before starting the step-by-step guides.

It is important that everyone involved understands the process – including parents, teachers, sports coaches and the child or young person.

If activity brings on or worsens symptoms, go back to the previous stage until symptom-free for 24 hours. If new symptoms occur, or if symptoms are persistent, seek advice from a GP."

A gradual progression is very important. If signs of concussion return or worsen during activity, it is an indication that the brain has not healed.

When I went back to school, everything on the blackboard seemed blurry. And I couldn’t read anything as my headache would start. So after that, I stayed at home for a few days to get better.”

Step 1: Rest

24-48 hours off school. Rest and only do activity that doesn’t worsen symptoms. Activities such as watching television, texting or using a computer might make symptoms worse, so try to limit this as much as possible.

Step 2: Preparing for going back to school

Some reading, homework or other activities at home that involve some level of concentration. A short walk to the shops is a good opportunity to gradually increase physical activity at this stage.

Step 3: Return to school part-time

This could involve a half day or with longer breaks during the day.

Step 4: Return to school full-time

Gradually taking part in more school activities until a full day is possible.

Step 5: Full return to school and day-to-day activities

If no symptoms are present, the child should be able to return to normality at school and take part in everyday activities.

*There should be a minimum of 24 hours between each step. For full details of these steps please refer to CanChild’s Return to School Guidelines for Children and Youth.

Returning to sport and activity

Note: contact sport refers to a sport where players come into bodily contact with each other, for example rugby and some martial arts.

Step 1: Limited activity

Daily activities that do not increase symptoms. For example, a short amount of time reading a book.

Step 2: Light activity and exercise

Walking or cycling at a slow to medium pace. Or something similar that raises the heart rate.

Step 3: Return to sport-related exercise

Running, for instance, is an example of an appropriate exercise at this stage. But not games or sport that might lead to a blow to the head, such as football.

Step 4: Practice with the team, no contact training

Something that requires more concentration such as passing a ball in training. No heading the ball, tackling or scrumming.

Step 5: Full contact practice

If agreed by the child's GP or doctor, a return to normal participation in training activities.

Step 6: Return to sport

Normal gameplay and matches.

There should be a minimum of 24 hours between stages.

If symptoms last for more than one month, the child should be referred back to their GP or specialist."

Post-concussion syndrome (persistent post-concussion symptoms)

There are a few things that are sometimes linked to a longer recovery time for some children and young people. These risk factors include:

if a child has been concussed before
children being of a younger age
previous diagnosis of attention deficit hyperactivity disorder (ADHD)
mental health issues
if a child has had a prolonged loss of consciousness.

Sometimes a child who has suffered a concussion will develop a collection of symptoms that last weeks, months or possibly longer. This is called post-concussion syndrome (or persistent post-concussion symptoms) and can lead to significant difficulties for a child.

If a child has suffered from a concussion and has been having some lasting difficulties or ongoing effects, they could possibly have post-concussion syndrome.

Symptoms include:

headaches
dizziness
fatigue/tiredness
insomnia; where the child finds it difficult to sleep
irritability
anxiety
loss of concentration or memory difficulties
noise and light sensitivity
tinnitus; a ringing in the ears.

If a child is diagnosed with post-concussion syndrome, options should be discussed with the child’s GP. They may be referred to a specialist or rehabilitation service to support them in dealing with some of the effects or difficulties they are having.

If you feel that your child is having ongoing difficulties, as mentioned above, The Children’s Trust Brain Injury Community Service may be able to provide support."

Concussion in babies and toddlers

A concussion can happen at any age. Accidents can happen and as babies and toddlers learn to crawl, walk, run and play a little more roughly with toys, it is quite common for them to have a few bumps to the head. And they are at an age where they don’t fully understand the concept of risk or danger.

Concussion can also happen to a baby or toddler through non-accidental causes.

Some common causes of concussion in infants and toddlers:

•   falls from beds
•   bumping into something or being hit by something
•   being dropped from a carer’s arms
•   car accidents
•   non-accidental causes (including forceful shaking).

It can be more difficult to spot signs of concussion in babies and younger children as they may not able to tell you how they feel.

Call 111 or visit A&E: If you think a baby or toddler has had a significant injury to the head or they are showing any symptoms listed above.

Call an ambulance: If the symptoms are more severe, for instance if they are unconscious or are having a seizure/fit.

Some things you should look out for:
•   persistent crying
•   loss of balance
•   poor coordination
•   possible headaches; persistent rubbing of the head
•   vomiting
•   change of usual mood, such as irritability or difficult to console
•   changes in sleeping pattern
•   unusually sleepy or listlessness
•   sensitivity to light and/or noise
•   will not eat or drink
•   seizures/fits
•   visible bruises/marks on the head
•   unusual fluid from nose, mouth or ears.

I just turned around to get a nappy and some wipes and when I turned back my baby was slipping off the bed. It happened so quickly, in slow motion, but I couldn’t do anything. Although he soon settled, I took him to A&E just to make sure. He was absolutely fine but I spent the rest of the day paranoid and inspecting him for injury."

Tips on preventing concussion in babies and toddlers

Floors free of clutter

If a child has just learnt to walk try to keep the floor free from toys or obstructions that can be tripped over.

Buckle up

Always use the straps in a pram, pushchair or highchair. And always ensure that car seats and booster seats are properly installed and age-appropriate.

Stair safety

Fit a safety gate at the top and bottom of your stairs.

Furniture safety

Anything that is at risk of being pulled down, such as heavy ornaments, should be out of reach. And furniture, such as bookcases, should be secured to the wall.

Never leave babies unattended on raised surfaces

This includes beds. Even if a baby has not started rolling yet, it is surprising how their natural kicking and fidgeting can lead to a fall. That one time you leave them on a bed, might be when they learn to roll for the first time. And never leave a baby’s car seat or bouncer on a table or other high surface.