Guest post from Carrie R. Muh, MD, MS
Assistant Professor of Neurosurgery and Pediatrics at Duke University Medical Center
September means the end of summer, and for those of us with kids, it’s back to school time! That also means it’s back to school sports. Sports are great for kids to help them keep in shape, learn to deal with competition, develop self-confidence and leadership skills, and, at times, learn how to lose gracefully. Along with the myriad benefits of sports, however, come the inevitable injuries. As a pediatric neurosurgeon, I have seen my share of concussions, skull fractures, hemorrhages and other forms of traumatic brain injury (TBI) from sports — a line drive to the skull during a baseball game, head to head collisions during football games, and a child who headed the goal post in a soccer match.
Some TBIs are obvious — if a child has a skull fracture or needs surgery, clearly he or she will not be returning to the game very soon. But concussions, also referred to as mild TBI (mTBI), may not leave visible signs. Even a CT or MRI may look normal, as there may not be any structural damage to the brain. But the metabolism and physiology within the individual neurons — the basic cells of the brain — may not be working correctly, and no current imaging study can show us that. Those cells must be given time to heal before the child goes back to play.
It is estimated that 1.6 to 3.8 million sports and recreation-related TBIs occur in the United States each year, including 200,000-300,000 sports-related concussions annually., This number is not known for certain, as most of these are mTBIs that are not treated in a hospital. Concussions represent 9-13 percent of all high school athletic injuries. , The most commons sports leading to concussions and mTBI are bicycling, football, both girls’ and boys’ soccer, wrestling and girls’ basketball.
A concussion can be hard to diagnose, as the symptoms can vary. Recovery time varies widely as well, with some kids feeling better almost immediately and others suffering post-concussive symptoms for months or even years. The most common complaints are headache, dizziness, difficulty concentrating, confusion, sensitivity to light and nausea. Symptoms fall into four categories: physical, cognitive, emotional, and sleep. Symptoms can include vomiting, balance difficulties, amnesia, forgetfulness, feeling “foggy,” sadness, being more emotional than usual, drowsiness, difficulty sleeping, sensitivity to noise and answering questions more slowly than usual. , Loss of consciousness occurs in less than 10 percent of concussions. Any child with loss of consciousness of more than a few seconds, seizure, focal weakness, significant neck pain, persistent vomiting, slurred speech, or a declining neurologic exam should be brought to an emergency room.
In releasing a new policy statement this summer, the American Medical Association (AMA) stated that a recent study of high school athletes with concussions found that 15 percent returned to play before they should have, and almost 16 percent of football players who suffered a concussion with loss of consciousness returned to play in less than one day. 
Another recent study looked at the age at which former NFL players’ first started playing football and their risk for cognitive impairment. They found that players who started playing under age 12 performed significantly worse on tests of memory and verbal IQ than did players who began playing at age 12 or older.  They concluded that “sustaining [repeated head impacts] during critical periods of brain maturation could alter neurodevelopmental trajectories, leading to later-life cognitive impairments.” While no definite conclusions can be drawn about the safety of pee wee football from one retrospective study, and most kids who play school sports will never be exposed to the repetitive collisions inherent in the NFL, numerous studies have shown us that we need to be cautious with mTBI in children. Young athletes whose brains are still developing may be more susceptible to the effects of a concussion, and recovery time may be longer than for adults. ,
There are several current initiatives aimed at keeping our kids safer. Safer Soccer is a campaign to eliminate heading the ball in kids’ soccer before age 14. More than 30 percent of concussions sustained in soccer are from heading the ball or colliding while attempting to head the ball. For the past decade, the Centers for Disease Control and Prevention (CDC) has been promoting the Heads Up program to “create a culture of safety for young athletes.” They offer free online concussion training and have specific information available for coaches, athletes, sports officials, parents, teachers, school nurses and even physicians. Furthermore, AMA’s newly released concussion policy recommends that kids who are suspected of having had a concussion be removed immediately from the activity and not return until being evaluated and cleared by a physician, using evidence-based, age-specific guidelines for return to play.
The CDC, AMA, and multiple sports organizations have made clear that kids who suffer a concussion should not return to sports, PE or high-speed activities while concussive symptoms are present. They should not return to play that same day. Only once all symptoms have resolved, and the child is acting like himself, may he gradually return to his normal activities. Kids may want to play in an important game, so it is up to parents and coaches to enforce this.
We can’t protect our children from everything, but we can do a few things to try to make them safer. We should insist that they wear a seat belt every time they are in a car, wear a helmet every time they ride a bike or play football, and keep them out of the game after a concussion until all of their symptoms have resolved.
 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Heads Up: Facts for physicians about mild traumatic brain injury (MTBI). Accessed at: http://www.cdc.gov/headsup/pdfs/providers/facts_for_physicians_booklet-a.pdf on 8/05/2015.
 Centers for Disease Control and Prevention. Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged ≤19 years–United States, 2001-2009. MMWR Morb Mortal Wkly Rep. 2011 Oct 7;60(39):1337-42.
 Gessel LM1, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athl Train. 2007 Oct-Dec;42(4):495-503.
 Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. American Journal of Sports Medicine. 2012 Apr;40(4):747-55.
 Halstead ME, Walter KD; Council on Sports Medicine and Fitness. American Academy of Pediatrics. Clinical report–sport-related concussion in children and adolescents. Pediatrics. 2010 Sep;126(3):597-615.
 New AMA Policy Aims to Reduce Risk of Concussion in Youth Sports. June 9, 2015. http://www.ama-assn.org/ama/pub/news/news/2015/2015-06-09-ama-policy-reduce-youth-concussion-risk.page Accessed 8/5/2015.
 Stamm JM, Bourlas AP, Baugh CM, Fritts NG, Daneshvar DH, Martin BM, McClean MD, Tripodis Y, Stern RA. Age of first exposure to football and later-life cognitive impairment in former NFL players. Neurology 2015 Mar 17;84(11):1114-20.