6 do’s and don’ts of concussion

If your child experiences a concussion, it can be scary to think about the effects on their developing brain. The good news is, more than 85% of concussions heal well if managed properly early on.

“Early, appropriate treatment prevents kids from having to come see me as a neurologist,” says Dr. Sharief Taraman, pediatric neurologist and director of the CHOC Children’s Concussion Program. “It’s important to do as much as we can to prevent kids from getting a concussion, prevent reinjury, and treat them as aggressively and appropriately as possible in the early intervention stages.”

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Dr. Sharief Taraman, a pediatric neurologist at CHOC Children’s.

Follow these do’s and don’ts for proper prevention and treatment of concussion. If your child does sustain a concussion, be sure to see your pediatrician as soon as possible.

  1. Do protect a young brain

Athletes should be taught safe playing techniques, equipment maintenance and to follow the rules of the game. Always wear a helmet while playing contact sports like football, hockey and lacrosse, and during activities like horse riding, biking, skateboarding or snowboarding. Helmets should fit correctly and be in good condition.

  1. Don’t miss the signs

A concussion isn’t always obvious. Watch for these signs in your child or teen, especially while they are participating in sports. Symptoms may take up to a day to appear after an incident.

  • Headache
  • Nausea or vomiting
  • Balance problems
  • Dizziness
  • Visual problems
  • Fatigue or drowsiness
  • Sensitivity to light or noise
  • Numbness or tingling
  • Dazed or stunned
  • Irritability
  • Sadness
  • More emotional
  • Nervousness
  • Trouble falling asleep
  • Feeling mentally “foggy”
  • Feeling slowed down
  • Confused about recent events
  • Sleeping less or more than usual
  • Difficulty concentrating or remembering
  • Forgetful of recent information or conversations
  • Answers questions slowly or repeats questions

Seek emergency care immediately if your child or teen has experienced unconsciousness for any amount of time or has changes in alertness, convulsions or seizures, muscle weakness, persistent confusion, repeated vomiting, unequal pupils, unusual eye movements or walking problems.

  1. Do sit on the sidelines

The most important thing your child should do if they are injured during a sports activity is to immediately stop playing. It’s crucial that they avoid more hits, jolts, shakes or bumps to the head or spine. Getting back in the game is not worth the risk. Remember, the signs of concussion aren’t always clear, so when in doubt, sit it out.

Athletes may not want to tell their coach if they had a concussion. Encourage them to come forward if they have an injury, or if they notice a teammate is injured. Young athletes should never ignore a head injury or impact to the head.

  1. Don’t skip treatment

Even a mild concussion should be evaluated by a doctor. Get in to see your child’s pediatrician as soon as possible.

When a concussion is severe or symptoms won’t go away, talk to your doctor about a referral to the CHOC Children’s Concussion Program, which includes pediatric sports medicine specialists, neurologists, neurosurgeons, neuropsychologists and rehabilitation therapists who are all trained in concussion management.

  1. Don’t rush recovery

Rest is important immediately following a concussion. For 24-48 hours, your child should stay home from school and get plenty of quiet time and mental rest. This includes limiting activities like:

  • Television
  • Texting
  • Social media
  • Reading
  • Driving
  • Doing homework
  • Social interaction
  • Attending loud events

After the first 24-48 hours, light activities may help speed up recovery. Most children should be able to tolerate some school after a few days. If they need to miss more school than that, contact the school and your doctor to help intervene with short-term adjustments. Before returning to sports, be sure that symptoms have resolved and get medical clearance from your child’s doctor.

  1. Do prevent future injury

Parents, coaches and athletes should be extra cautious to prevent future concussions. One concussion is rough enough, but additional injury is even worse. Research has shown that repeated jars to the head can have long-lasting effects on the brain. And, if a child or teen suffers a second concussion before the first concussion heals, they are at risk for Second Impact Syndrome, a life-threatening condition.

“The CDC has called concussions an epidemic in the United States,” Dr. Taraman says. “Kids really do get into trouble if a concussion is not recognized, and if we don’t take the proper steps to get them better and avoid those second injuries, which can be catastrophic.”

Download 5 questions to ask an injured athlete

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Sudden unexpected death in epilepsy: What parents should know

By Dr. Lily Tran, pediatric neurologist and epileptologist and medical director of CHOC’s comprehensive epilepsy center

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Sudden unexpected death in epilepsy (SUDEP) occurs when someone with epilepsy suddenly dies unexpectedly and the cause is not related to an accident or seizure emergency. A seizure emergency could include status epilepticus, where someone has a seizure lasting more than five minutes, or two or more seizures within a short period of time without the person returning to normal in between. Aside from epilepsy, this person is otherwise considered healthy, and no other cause of death can be found. Each year, one in 1,000 people in the U.S. die from SUDEP.

There are several risk factors for SUDEP. These include:

  • Poorly controlled seizures, especially tonic-clonic seizures, characterized by a loss of consciousness and violent muscle contractions
  • Seizures, especially tonic-clonic seizures, that tend to occur in sleep or at night
  • Not taking medications regularly or as prescribed
  • Stopping or changing medications suddenly
  • Young adult age

The exact cause of SUDEP is unknown. More research is needed to understand its cause. Some research suggests that seizures lead to changes in the brain and/or heart’s ability to function, and related breathing difficulties may lead to SUDEP.

For anyone with epilepsy, the ultimate goal is always to minimize seizures as much as possible and strive to become seizure-free. There are several other things people with epilepsy can do to help prevent SUDEP, including:

  • Take your anti-epileptic medications as prescribed. Do not stop medications abruptly without talking to your doctor.
  • Stay healthy by eating a well-balanced diet and getting regular exercise.
  • Avoid potential seizure triggers.
  • Make sure your family members and/or caretakers understand seizure first-aid

Although seizure-alert devices are on the market, there is no scientific data to support the idea that these devices help prevent SUDEP. More evidence is needed to show they can accurately detect seizures and prevent SUDEP.

VIDEO: A CHOC neurologist explains epilepsy vs. seizures

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CHOC recognized as one of nation’s best children’s hospitals

CHOC Children’s is one of only 50 pediatric facilities in the nation to earn recognition as a best children’s hospital by U.S. News & World Report. The following CHOC specialties are honored in the 2019-20 Best Children’s Hospitals rankings: diabetes/endocrinology, cancer, neonatology, neurology/neurosurgery, pulmonology and urology. Cancer ranked in the “top 20.”

“The national recognition for CHOC’s cancer program is well-deserved. There’s nowhere else I’d rather have gone through treatment than CHOC,” says 17-year-old Sydney Sigafus, CHOC patient and cancer survivor. “Everyone who works at CHOC cares about you as a person, not just a patient. I was included in every decision and conversation about my care.”

The Best Children’s Hospitals rankings were introduced by U.S. News in 2007 to help families of children with rare or life-threatening diseases find the best medical care available. Only the nation’s top 50 pediatric facilities are distinguished in 10 pediatric specialties, based on survival rates, nurse staffing, procedure and patient volumes, reputation and additional outcomes data. The availability of clinical resources, infection rates and compliance with best practices are also factored into the rankings.

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“We understand how scary it can be for parents whose children are dealing with life-threatening illnesses or injuries. That’s why we are committed to the highest standards of care, safety and service,” says Dr. James Cappon, CHOC’s chief quality officer. “While we are proud of our accolades, including being named a best children’s hospital, we remain focused on preserving the magic of childhood for all kids, whether they are seriously ill or healthy, or somewhere in between.”

Learn more about the Best Children’s Hospitals rankings.

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Can children outgrow autism?

A study recently published in the Journal of Child Neurology suggests that children may outgrow autism. We spoke to Dr. J. Thomas Megerian, pediatric neurologist and clinical director of the Thompson Autism Center at CHOC Children’s, about what parents should know about these findings.

What does this study’s findings mean for parents?

Many parents ask me, “Will my child outgrow autism?” and I always tell them that what we hope for is that with services and growth, the child will improve so much that after as little as a few years, they no longer meet the criteria for Autism Spectrum Disorder (ASD). Outgrowing the label may mean they have learned to compensate or overcome some challenges like socialization or repetitive movements. They may have little features left of ASD, and what symptoms they do have, may cease to interfere with their development or daily lives. When they have progressed to the point where they have outgrown the label, any remaining traits may be so small that only a parent would notice, but a new person who has just met the child wouldn’t pick up on anything.

However, I advise my patients’ parents that if and when their child outgrows the label of autism, they may still have other co-occurring issues like anxiety, attention deficit hyperactivity disorder (ADHD) or learning disabilities that require ongoing care.

So yes, indeed this study should give parents hope surrounding a child’s ability to outgrow the autism label, despite their other potential ongoing issues.

In some instances, schools may suggest a decrease in services because a child has improved and outgrown the label of autism. That same child may still be struggling with organization or learning certain subjects. Parents may be in a position to say that just because their child has outgrown the autism label doesn’t mean they do not have a need for additional support.

What does life look like for a child previously diagnosed with autism who is no longer on the spectrum?

Learning disabilities, obsessive compulsive disorder, and attention deficit disorder are common among children with ASD. Rates of other disorders are common among children with autism, including: gastrointestinal disorders, ear infections, seizures and anxiety. They may clear up later in life or become better managed, but they don’t necessarily go away at the same time as their autism label.

Residual symptoms of these co-occurring diagnoses may last into adulthood. For example, a child may outgrow their ASD label but still have anxiety that can be managed by cognitive behavioral therapy.

Why is early detection and early intervention of autism so important?

Early detection and intervention help many kids outgrow the autism label in the future due to improvements with socialization and repetitive behavior. It’s important for people to remember that just because they have lost the autism label, doesn’t mean they don’t have other diagnoses or disorders that may require ongoing treatment.

There’s no question that early intervention makes a big difference in helping kids with the potential to outgrow their ASD diagnoses achieve that milestone even sooner. The trajectory has changed for many of those kids.

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Living with polymicrogyria: Angelina’s story

Johanna and her husband Graham were expecting a healthy baby.  Already parents to one little girl, they were looking forward to expanding their family.

At Johanna’s 33-week anatomy scan, she and Graham were thrilled to learn they were expecting a girl, but shocked to learn she might have club foot, a birth defect where the foot is twisted out of shape or position. They learned there was a chance it could be due to a neurological defect since everything else was showing up as normal.

“We started mentally preparing ourselves for our baby to have a club foot,” Johanna said. “We had another anatomy scan, but they couldn’t say for certain what was going on.”

On January 26, 2018 Johanna delivered a baby girl named Angelina via c-section. A neonatologist was in the delivery room in case Angelina needed immediate medical attention after birth. She was having trouble swallowing and was monitored in that hospital’s neonatal intensive care unit (NICU).

Three days later, a CHOC neonatologist rounding at the delivery hospital recognized that Angelina needed a higher level of care and a bigger team of specialists. He suggested that she might need an MRI to give doctors a better look at her brain, and determine if her condition was neurological.

“Even though I’d never been to there, I knew that when it was an option to go to CHOC, you go to CHOC,” Johanna said.

Their older daughter Genevieve had been born at St. Joseph Hospital in Orange, next door to CHOC Children’s Hospital.

“I was so freaked out before I had my first child, because of all the things that can go wrong during childbirth. I delivered Genevieve at St. Joseph because I liked knowing that CHOC as right next door if we needed them” Johanna said. “When they gave us the option to send Angelina to CHOC, there was no question—we just immediately went.”

angelina-baby-choc-childrens-nicu
Angelina during her stay in CHOC Children’s NICU.

Angelina was admitted to CHOC’s NICU and evaluated by neonatologist Dr. John Tran, of CHOC’s neurocritical NICU. Special rooms of CHOC’s NICU are designated for the neurocritical NICU, where neonatologists and neurologists have the expertise and equipment to carefully treat babies with neurological issues.

An MRI showed that Angelina had polymicrogyria, a condition characterized by abnormal brain development. Johanna and Graham had never heard of this condition and had a hard time processing the diagnosis. Then they met with Dr. Donald Phillips, a pediatric neurologist at CHOC.

He explained to the family that typically, the surface of the brain has many ridges and folds, called gyri. In babies born with polymicrogyria, their brain surface has too many folds that are too small to process information received, which leads to problems with body functioning, similar to the effect a stroke can have on the brain.

Dr. Tran explained the spectrum of care for polymicrogyria. Some patients are nonverbal, some go to school, and some even live with this condition and never know. It was too soon to tell where on that spectrum Angelina would fall.

“Caring for babies with neurological conditions can be difficult. Not only are you medically treating a newborn baby, but you are also counseling a family and giving them an uncertain prognosis,” says Dr. Tran. “In the neurocritical NICU, our first goal it to treat the baby’s underlying condition. The second goal is to educate the most important members of our care team― the parents. We know that the NICU is not a part of the birth plan, but our job is to help alleviate some of the anxiety that comes with uncertainty. We strive to optimize the potential of our patients, whatever it might be, as they go home.”

The diagnosis was a lot for her parents to take in.

“We knew we were getting the best care for our daughter, but it was such heavy news,” Johanna said. “Even with a typical kid, we don’t really know what their life will be like. Every life is a gift. Once I started going towards that mentality, I realized that nothing is certain, even with typical kids.”

At her delivery hospital, one of the red flags that Angelina needed a higher level of care was that she kept crashing when she was breastfeeding.

“It made me freaked out to feed my daughter,” Johanna said.

Soon after coming to CHOC, Angelina began swallowing therapy. When someone experiences swallowing difficulty, they are at risk for food or liquid entering their lungs, called aspiration, which may lead to pneumonia. Karin Mitchell, a speech and language pathologist who specializes in the NICU setting, worked with Angelina on swallowing safety. Karin guided baby Angelina through exercises for her mouth and tongue to learn how to properly swallow saliva. Then, they could work on breastfeeding support and syringe feeding.

Angelina couldn’t move her legs when she was born, and her parents weren’t sure if she ever would. Thanks to physical therapy, today she can bend her legs more than 90 degrees.

Throughout their stay in the NICU, Johanna and Graham were thankful to have the ability to sleep overnight in their daughter’s private room. Because Angelina was born during flu season, her 3-year-old sister couldn’t visit the NICU. Her parents would stay at CHOC all day, go home to do their older daughter’s bedtime routine, and then one parent return to CHOC to sleep alongside their new baby.

“We had the privacy we needed, and I felt comfortable doing kangaroo (skin to skin) care,” Johanna said. “I hadn’t planned on my baby staying in the hospital, and at least having our own room, and even something as small as being able to watch TV gave me a small sense of normalcy.”

Johanna and Graham also appreciated the sense of normalcy provided by a Super Bowl party thrown for parents on the unit. An infant CPR class offered on the unit helped them feel more prepared to eventually take their baby girl home.

For big sister Genevieve, CHOC offers an innovative webcam system so family members can be together and bond with their newborns when they can’t be at the bedside. The system allows families to see real-time, live video of their infant remotely, from anywhere they can securely log onto the internet.

“CHOC had a lot of things in place, like the secure camera in Angelina’s room, to make things easier on us as a family,” Johanna said.

A month after she was born, Angelina got to go home for the first time.

angelina-first-halloween
Angelina dressed as a pumpkin on her fist Halloween.

“We were so ready to take her home, and finally be together as a family,” Johanna said. “But it was still a little nerve-wracking. We bought four different types of baby monitors; we were used to seeing her surrounded by machines.”

A few weeks later, Angelina began swallowing therapy twice per week and physical therapy three times per week. Now 15 months old, the amount of progress she has made has made her parents proud.

She couldn’t move her legs at birth, but a year later she is rolling and reaching. Her parents credit her CHOC physical therapist Lauren Bojorquez.

“Lauren didn’t just think of what Angelina was doing now; she was always thinking ahead about what would benefit her in the future,” Johanna said.

For example, Lauren and Angelina worked on rolling because it would eventually help her learn to sit. When babies roll, it helps develops muscles that will later help them sit.

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Angelina with her speech and language pathologist Annie.

Meanwhile, Angelina was working with CHOC speech and language pathologist Annie Tsai to learn how to cough, swallow, and accept food by mouth. Swallowing therapy focused not on quantity of food consumed but on quality of how the child feeds or swallows safely. Angelina’s work with Annie focuses on movement, strength and coordination within the mouth to prepare for eventually swallowing food.

Angelina still receives most of her nourishment through a feeding tube, also called a g-tube. The tube can stay in a patient’s stomach for months or years and allows the child to receive fluids, medicines and nutrition when they can’t take in enough nutrition by mouth. Every few months, Angelina sees gastroenterologist Dr. Jeffrey Ho for follow-up appointments for nutrition, feedings and g-tube care. Dr. Ho remains in close contact with Annie, her speech and language pathologist.

“Being able to eat in a typical manner is always the goal,” says Dr. Ho. “Every baby and child are different. Right now, we are focusing on what we can do to better optimize her potential to orally feed.”

Now, Angelina can sit in a highchair, bring her hands to her mouth, accept small tastes by mouth and better clear her congestion especially when she’s sick.

“Something I hadn’t realized before Angelina was how big a part food plays in our culture. As people get older, going out to eat or meeting for coffee is a social activity. I was sad that she wouldn’t get to have those same experiences,” Johanna said. “When she started to accept tastes by mouth, it made me think of her in the future, and being able to go out with friends and at least taste something, and still participate socially.”

To further practice feeding therapy at home, Angelina has a mesh pacifier typically used to soothe teething babies. Her parents often put the same foods in her pacifier as the rest of the family is eating. So far, there hasn’t been a food she’s tried that she hasn’t liked.

Angelina’s paternal grandma was an adult speech and language pathologist by training. When Angelina started speech therapy, she updated her license and certification to help her granddaughter at home. She comes to some of her sessions at CHOC and learns from Angelina’s care team.

Also participating in therapy is big sister Genevieve, who helps hold the pacifier and can even spoon-feed her baby sister, with a little bit of help.

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Angelina with her family at Disneyland.

“I am super grateful for CHOC,” Johanna said. “That’s why our family started participating in CHOC Walk when Angelina was born.”

These days, Angelina likes playing with toys, playing with her big sister, and listening to all types of music.

“I had a lot of preconceptions about disabilities and special needs,” Johanna said. “Having a child with special needs is not what I thought it would be. It’s better than that.”

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