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New Concussion Recommendations for Kids

Sport-related concussion is a “hot topic” in the media and in medicine. It is a common injury that is likely underreported by pediatric and adolescent athletes.

Mark Halstead, MD, SLCH’s leading expert on concussions, discusses the AAP’s updated concussion recommendations to support children and teens engaging in light physical activity and returning to school as they recover. The report, revised for the first time in eight years, also advises against complete removal of electronic devices. Dr. Halstead, an associate professor of pediatrics and of orthopedic surgery at Washington University School of Medicine, is the lead author of the AAP report.
New Concussion Recommendations for Kids
Featured Speaker:
Mark Halstead, MD
Mark Halstead, MD's areas of research interest include the education of medical students and physicians-in-training, concussion management, running injuries in the high school athlete and  injury prevention

Melanie Cole (Host): Sport related concussion is a hot topic in the media and in medicine. It’s a common injury that’s likely under-reported by pediatric and adolescent athletes. Here to tell us about that today is Dr. Mark Halstead. He’s an Associate Professor of Pediatrics and Orthopedic Surgery at the Washington University School of Medicine and he’s the lead author of the AAP Report on Concussions. Dr. Halstead, I’d like to start by asking you to tell us a little bit about yourself and how you came to be St. Louis Children’s Hospital’s leading expert on concussions.

Mark Halstead, MD (Guest): Yeah, well when I came out of training from residency, one of the biggest problems that we had at that time, and this is back in the early 2000s, is there really was not great recommendations for pediatricians on how to manage concussions, whether it’s from sports or not from sports. So, I got involved with the American Academy of Pediatrics on their Council on Sports Medicine and Fitness and back in 2010, we wrote the first report helping giving guidance to pediatricians on how to manage sport-related concussions. Then we just came out with a revision this past year. So, part of my interest in that area has been going back for over a decade now and part because of writing that article got me where I am with the concussion world today.

Host: Then tell us about what’s going on with concussion today. Are you seeing more awareness? Are you seeing a rise or a decrease in the prevalence? Tell us what’s going on.

Dr. Halstead: Yeah, I certainly think there’s an increase in awareness. One of the things that I’ve been a little concerned about lately is I’ve noticed that it seems like there is probably a little bit of less urgency of taking care of the injury than there had been and I think some of that may be just from – I don’t know, maybe overexposure to it where people are just kind of getting back into their old habits and unfortunately, I’m seeing a lot more kids that are being allowed to return to play when they really shouldn’t be early on in the process after they have had their concussion. Which that can be a bad thing because if someone goes back into play right away afterwards, that we know that that actually puts them at risk for much worse symptoms and also can actually double their recovery time.

Host: Tell us about the research that prompted the AAP and the need to update the recommendations.

Dr. Halstead: Yeah, well there’s been a huge amount of increased research that’s been done over the last almost decade since we wrote the original report. One of the biggest changes, there has been a big shift or at least we are trying to get the big shift to happen, it’s still a little bit slow to take it up is shifting away from the extreme of what was referred to as complete cognitive and physical rest; where the thought process there is that if we just don’t let the brain work at all; we don’t let the person be physically active at all that that’s going to help facilitate the recovery quicker. Unfortunately, we found out that that really is not the case and it should have been something that would have been common sense for us in the world of medicine because we’ve learned for a lot of other conditions that that doesn’t really work of trying to shut someone down completely.

So, one of the biggest things that has come out of research over the last decade or so has been that it is okay to actually do a little bit of active exercise earlier in the process. That doesn’t mean for athletes returning them back to their normal sports participation but getting them active sooner rather than later which is actually shown to help reduce their symptoms and help to improve their recovery at a quicker pace.

Host: Expound on that a little bit, because we understand the need to take an immediate break from play after a concussion. But during the recovery process as you said; encouraging a reasonable amount of activity, such as brisk walking. What does that mean and also, they were kept out of school and electronic devices. So, really what does that mean for a parent or for a pediatrician following up on this particular patient?

Dr. Halstead: Yeah, well it’s being reasonable. So, what we oftentimes will suggest for the patients we see in our office is that early on in the process, they could start with – we usually suggest up to about 20 minutes of either some brisk walking and I describe it to the patient as kind of like you are late for class sort of walking speed or if they have access to an exercise bike, we get them on an exercise bike, just to get the legs moving, not to try and win any bike races or anything like that on the exercise bike. But we put some rules on that. So, the rule is, that they can do that exercise up to 20 minutes, but if their symptoms start to worsen, meaning they have more headaches or they have more dizziness, they are not feeling right; then we stop them for that day and then we try again the next day. When we talk about taking an athlete completely out of activity; we can get into deconditioning pretty quick. We can get kids fairly depressed fairly quick but then that kind of confuses some of the concussion symptoms that go on and then we don’t know which one of those is still the contributing factors.

Because of research that has been shown that it’s not harmful for their recovery; that’s why we are trying to encourage that. Same thing with school. We don’t need to stop everything. We just need to reduce and allow for a little lessened load on the brain but not eliminating everything altogether.

Host: And electronic devices too? So, they can sit on their phone or you don’t – you want it minimized, because that I think for parents, would be the hardest thing to keep your kids away from.

Dr. Halstead: Yes, but you know we can have a whole other discussion of whether or not how much should they be spending on their electronic devices to begin with right? So, but in general, yes, there is nothing inherently wrongful with using an electronic device. One thing that we do tend to see a lot of troubles with is because some of the devices have that blue light to them; that can irritate them a little bit more than others, especially with the newer type screens. So, if someone is having more troubles where the light really bothers them on the screen, they can either adjust the brightness. The nice thing about the new iPhones is they actually have the night mode now, so that actually is meant to change the lighting level on them so it’s not that irritating blue light as much. So, that can be helpful.

But if someone is really having a lot of troubles with sensitivity to light; we tell them don’t use those electronic devices in a dark room, because then that becomes a very bright thing and that oftentimes is more likely to irritate them. But we can also use their electronic devices to help. Some kids have a lot of struggles with reading small print and so I can take an electronic device and increase the font size and reduce the strain on their eyes. So, I can actually use it to my advantage in their recovery as well as far as not making things feel worse.

Host: Dr. Halstead, do you have any trends you’d like to address? What do we know about middle school versus high school versus collegiate sports in regards to the prevalence of concussion in boys and girls?

Dr. Halstead: Yeah, so even a decade ago, we still didn’t have great information on middle schoolers then and unfortunately, there’s not a lot more research on middle schoolers and so that’s the hard part is capturing that age group as far as what symptoms they have and things like that. There have been some tools that have been developed over the last decade since we wrote the original report that are geared towards the five to twelve year old aged patient that has better assessment tools looking at them that are more appropriate for their age and development level than what we were using in the high school and college athletes. We do always talk about concussions it’s the exact opposite of what we think about in sports medicine. Most injuries in kids will recover quicker than adults for their bones and joints and what have you. The problem is the concussion is always the opposite. Kids do tend to take longer and that’s partly because of the developing brain and it is something that takes a little bit longer for it to heal than we would think about in our older kids and certainly in the collegiate and adult patients with concussion.

Host: What else did the AAP report conclude? Tell us about any of the other aspects of this report that you think are important for other providers to know.

Dr. Halstead: Yeah, I think it’s important to try and stay as current as possible. I mean it’s overwhelming with the amount of research that’s coming out there and that was the purpose of the updated report is to kind of synthesize some of the newer things that are out there just in assessment tools and kind of come up with maybe a more efficient way for pediatricians to be able to evaluate patients and hopefully that got reflected in the report. But the biggest emphasis I think that really needs to be taken away from this is we really want to try and get away from the complete shutting everything down, don’t let them do any physical activity, don’t let them do any schoolwork at all kind of thing. And that needs to kind of go out the window and we need to be making sure that people are pushing towards the more active approach.

Other things that have come out is there has been some – certainly some evidence to show that doing more active rehabilitation and that may be for kids may get injuries to their vestibular system after their concussion and that may respond very well to physical therapy. We see a lot of associated neck strains from the whiplash effect from most concussions that those can actively be rehabilitated too and those can contribute a little bit to some of the symptoms that people experience and that may cause things to linger unnecessarily. So, we want to try and identify those and address those sooner rather than later to help facilitate recovery.

Host: And when should a patient be referred to a specialist and what else as we wrap up would you like referring pediatricians to know about concussion?

Dr. Halstead: Yeah so, I think it’s really a comfort level. Working with a lot of the pediatricians here in St. Louis with kids with their concussions; I have some that would rather us see them right off the bat and get them going and some feel very comfortable doing the initial evaluation. I tend to say if someone is getting closer to the four week point which is most kids, 80-90% of kids by most research will suggest that by four weeks most kids are fully recovered; but that’s not everybody. So, if you are having kids that are lingering with their symptoms beyond a month or so; then I think it’s probably worthwhile to start looking at referring to a specialist. I think that’s probably the most important point of that. But again, it’s a comfort factor. There are some that are much more experienced and more comfortable dealing with them in the longer term than others.

Host: Thank you so much Dr. Halstead for coming on and explaining the updated guidelines from the American Academy of Pediatrics and your report. Thank you again for joining us. A physician can refer a patient by calling Children’s Direct Physician Access line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to, that’s This is Melanie Cole. Thanks so much for tuning in.