8 Concussion Myths

Concussions are relatively common. Fortunately there have been campaigns to increase awareness, so more kids are being properly identified. There are still many myths related to concussion that need to be clarified.

signs of concussion
Source: CDC’s Head’s Up

Common myths and misinformation about concussions:

Concussion myths are common. Learn to recognize a concussion and what the experts recommend.
There are many myths about concussions. Learn the facts.

1. A normal head CT means no concussion and a full return to play is okay.

Concussions are not diagnosed by CT. Brain bleeds and masses can be seen on CT, but the damage done to the brain during a concussion is not seen on a CT.

Concussions are diagnosed based on symptoms, such as headache, confusion, lack of coordination, memory loss, nausea, vomiting, dizziness, ringing in the ears, sleepiness, and excessive fatigue. Not all symptoms need to be present to make the diagnosis. Some symptoms develop over time and are not present at the time of injury.

A CT scan is usually not needed with head injuries. They involve radiation so are not without risk themselves. Unless there are signs of a possible bleed in the brain, skull fracture, or the type of injury suggests the need for a CT, a CT scan is not needed in the evaluation for concussion.

2. A minor hit to the head never causes concussions.

The force of a hit does not determine the severity of the injury.

It’s actually the force of the head moving back and forth, not an actual hit, that leads to changes in brain cells and chemical changes in the brain. A jolt to the body can also cause a concussion if the impact is strong enough to cause the head to forcefully move.

Some people with more significant problems initially also seem to heal more quickly than others with more mild injury.

It is very hard to predict how long it will be until all symptoms are resolved.

The most important thing is that if you have symptoms of a concussion, your brain needs rest and you should be seen by a doctor who is up to date on current treatment protocols for concussions.

3. After two weeks you can return to play without further testing.

Sadly I’ve had more than one patient who was given this advice from a medical professional, whether on the sideline at a game or in an emergency room or urgent care.

Although most concussions resolve within 2 weeks, not all do and returning to play before the brain is healed can lead to a more serious condition called “second impact syndrome.” Second impact syndrome is a very rare condition in which a second concussion occurs before a first concussion has properly healed, causing rapid and severe brain swelling and often catastrophic results, including death.

After a concussion clearance to return to play should only happen when the child, teen, or adult is re-examined and found to be symptom free.

Returning to play is done in a stepwise fashion, with each step lasting at least one day and only progressing to the next step if symptoms don’t resume. This starts with light exercise when there are no symptoms at rest, then progresses to moderate activity followed by heavy activity without contact, then full practice with contact (if the sport is a contact sport) and finally full competitive play if each step can be done without return of symptoms. If symptoms return, you back up to lighter activity.

Returning to play too quickly can prolong healing time and even lead to long term consequences.

Do not return to any activity that causes symptoms to worsen!

4. If a coach doesn’t recognize the concussion, it’s minor enough to return to play.

Coaches cannot see everything that happens on a field. If you had a head injury, tell your coach.

Even if you’re the star player.

Really.

You will do your team a favor if you take time to heal and can play again versus stay in the game and get more severely injured and are then out for good.

See these real stories of concussion survivors.

Someone who is trained in concussion evaluation should do a sideline evaluation.

If there is any chance of concussion, you should not return to play at all that day or until you are cleared by a doctor who understands concussions.

5. IMPACT testing is necessary.

IMPACT testing is a computerized test that measures neurocognitive functioning.

Neurocognitive testing can be done with other testing methods, but IMPACT testing is a specific computerized program.

If a neurocognitive baseline is done at least every 2 years, it can be compared to the same test after a concussion to check on status. Testing should only be done by a professional trained to perform and interpret the test.

Neurocognitive testing is one tool to help manage concussions and determine when it is safe to return to play, but at this time concussions are diagnosed based on symptoms and physical exam, not this testing.

6. Complete bed rest until all symptoms are gone is best.

Bed rest for the first day or two can help enforce brain rest and allow healing, but may not be required and prolonged bed rest is specifically not recommended.

Prolonged bed rest can increase stress in children who miss substantial amounts of school. This stress is thought to possibly prolong healing.

Depression is more common if bed rest is enforced beyond 48 hours. Socialization with friends and family can help provide emotional benefits that aid in healing.

This does not mean that people should participate in all social settings. They will likely need relative quiet, so even going to a sporting event to watch can lead to return of symptoms.

7. Concussions only impact sports.

Concussions take kids out of play, but other activities should also be limited until they are tolerated.

Lights, sounds and even smells can trigger symptoms after a concussion.

Things that take focus or a lot of brain work may cause symptoms to worsen. These include reading, watching television, or playing video games.

If anything leads to worsening of symptoms, it should be avoided.

Initially a child might need total restriction from these activities, and then can slowly add them back in small increments as tolerated.

Many kids need to have breaks during school and a decreased workload.

They shouldn’t take standardized tests until they can focus for a prolonged time.

If computers are used for school, it might be necessary to use paper books and worksheets and to limit computer use until it can be tolerated.

Concussion Symptoms:

 

  • headache (most common)
  • nausea
  • balance problems/dizziness
  • double or blurry vision
  • sensitivity to light and noise
  • fatigue or drowsiness
  • changes in sleep patterns
  • trouble comprehending and/or concentrating
  • depression
  • irritability, nervousness, or sadness
  • feelings of being “just not right” or in a “fog”

Danger signs that deserve immediate evaluation:

  • seizures
  • not knowing people or places
  • unusual behavior
I thought I added #8 above, but edited this to add it after it was posted earlier today…

8. Wake a child with a concussion often to be sure they seem normal.

This is a common misconception. And a scary thing to do.

No child wakes easily from sleep.

It used to be thought that we should wake people up after a concussion to be sure they could arouse well, but studies show that isn’t necessary.

Most people with a concussion want to sleep, and that’s okay. Brain rest is actually what’s recommended.

After a concussion, if a person is awake and able to hold a conversation and there are no other symptoms, such as dilated pupils or trouble walking, it is okay to allow sleep.

For more information:

  • Heads Up is a free resource for parents, athletes, coaches, and medical professionals
  • Acute Concussion Evaluation (ACE) Care Plan has all the typical symptoms of a concussion, general guidelines to healing, plus return to school and sport templates
  • Dr. Mike Evans has two great concussion videos:

Lip Licker’s Dermatitis

As the leaves fall and the wind blows, I know that I will start seeing kids with smiles bigger than life due to red swollen chapped lips. Parents frequently bring kids in year after year with this “recurrent rash” that comes every dry season and goes away (or at least improves) in the Spring. Licking your lips is the most common way to get drier lips!

Licking your lips leads to dryness

dry lips, cracked lips

Dry lips are a problem that tends to worsen with the treatment that comes most naturally: licking your lips.

Saliva contains enzymes that break down food you eat — or the lips you are licking.

It also damages regular skin, so the skin around the lips dries if licked, the skin on the neck and chest are affected in droolers,  and thumbs or fingers can get really chapped if they are sucked this time of year.

The same theories discussed below can be used to treat other dry skin worsened by saliva.

What can help?

First, stop licking your lips!

I know that’s easier said than done, especially for kids with a strong licking habit.

If you catch them licking, offer a lip balm or suggest that they drink some water.

Remember to praise them if they make a choice to do anything other than lick!

Licking lips leads to more dryness and irritation.

Add water to the air

Adding humidity to the air helps and doesn’t require child participation (since they resist so much of what we do).

Even if you have a whole-home humidifier, add a vaporizer or humidifier to the bedrooms each night.

Be sure to keep it clean and out of reach of little hands.

Drink more water

Everyone should drink plenty of water throughout the day.

Lip balms or ointment

Seal in moisture with a lip balm or ointment.

Ingredients such as shea butter, lanolin, petrolatum, sunflower seed oil, squalane, and vitamin E are common.

Products with glycerin, hyaluronic acid, or sodium PCA also have been shown to help.

The more often they are applied, the better they work, so try to keep them available throughout the day. (This might require talking to teachers to allow it to be freely available at school.)

Waxes are good to avoid dry lips, but don’t help as much as a moisturizing product once the lips are already dry.

Avoid some balms

Avoid products with eucalyptus, menthol, or camphor because they can increase dryness and irritation.

Since flavored lip products might encourage licking lips, I suggest you avoid them.

More lip balm tips:

Use one with sunscreen when outdoors.

Keep the balm handy throughout the day and be sure to apply after brushing teeth before bed.

To avoid sharing germs, everyone should have his own, and I prefer sticks versus anything you dip your fingers into.

It is okay to apply the balm or ointment to the skin surrounding the lips if needed– for those kids who have a wide area they lick around the lips!

Many parents ask if their kids will become addicted to the lip balm. Simple answer: No. They might use it more frequently as they get used to the idea of using it instead of licking their lips when they feel dry, but that is a good habit, not an addictive behavior.

As soon as the weather warms up, we don’t feel our lips being as dry, so we use the balm less often.

Avoid evaporation.

Mouth breathing dries the lips, so try to get kids to breathe through their nose.

Keep the wind off the lips with a scarf. The wind increases the evaporation of water from the skin, drying it out.

7 Vitamin K Myths Busted

Social media has allowed the sharing of misinformation about many things, especially medically related things. When the specifics of something are unknown to a person, pretty much anything that’s said can sound reasonable, so people believe what they hear. This happens with many things, such as vaccine risks, chelation, and vitamin K. I want to tackle 7 Vitamin K Myths.

Refusing Vitamin K

I am especially frustrated when parents refuse to give their newborns vitamin K after birth. Since 1961, the American Academy of Pediatrics has recommended giving every newborn a single shot of vitamin K given at birth. This is a life saving treatment to prevent bleeding.

Life saving.

Vitamin K works to help our blood clot. Insufficient levels can lead to bleeding in the brain or other vital organs. Vitamin K deficiency bleeding or VKDB, can occur any time in the first 6 months of life. There are three types of VKDB, based on the age of the baby when the bleeding problems start: early, classical and late. Unfortunately there are usually no warning signs that a baby will have significant bleeding, so when the bleeding happens, it’s too late to do anything about it. Why parents don’t want to give this preventative life saving treatment is usually based on incorrect information.

This is a matter of a fairly low risk of bleeding if you don’t give vitamin K: 250-1700 per 100,000 within the first week, and 4-7 per 100,000 between 2 and 12 weeks. You might notice that the number is variable – it’s hard to study since the large majority of babies have gotten vitamin K over the years and the risk is low even without vitamin K. However, when there is bleeding it has significant consequences: lifelong disability or death. And we also know that there’s very low risk from the vitamin K and it works very well to prevent bleeding. So why take the chance of not giving it?

Conspiracy Theories, Misunderstandings, and Science

This is not a governmental conspiracy to somehow kill children. It’s a world wide attempt to help children survive and thrive.

The World Health Organization (WHO) guidelines:

All newborns should be given 1 mg of vitamin K intramuscularly [IM] after birth [after the first hour during which the infant should be in skin-to-skin contact with the mother and breastfeeding should be initiated]. (Strong recommendation, moderate quality evidence)

Science is hard to understand

Most people look at scientific information and can’t make heads or tails of what it means.

Photo Source: Hemorrhagic Disease of the Newborn

That coupled with the fact that things we read that make us react emotionally (such as fear that something will harm our child) makes us remember and associate with the information that created the emotion, whether it is right or wrong. This can lead parents to make dangerous decisions for their children while trying to do the right thing.

Myth Busting

I’m going to attempt to de-bunk the most common concerns I’ve heard because the best way to combat misinformation is to help explain the facts as we know them.

1. If every baby’s born with too little vitamin K, that’s the way we’re supposed to be.

Babies are born with very little vitamin K in their body. If they don’t get it with a shot, they need to either eat it or make it. Breast milk has very little vitamin K and babies won’t be eating leafy greens for quite awhile. Formula does have it, but it takes several days for vitamin K to rise to protective levels with formula and the highest risk of bleeding is during that first week of life. (Of course if you’re using this argument because you want babies to be all natural, you probably won’t be giving formula at this point.)

Bacteria help us make vitamin K, but babies aren’t colonized at birth with these gut bacteria.

Just because they’re born that way doesn’t mean they’re supposed to stay that way. Inside the mother the baby is in a very different situation. They don’t breathe air. A fetus doesn’t eat. They don’t have gut bacteria. Their heart has a bypass tract to avoid pumping blood to the lungs. This all works well in utero, but must change once they leave the womb. Change takes time, and during this time they are at risk. Why not minimize the risk if we know a safe way to do it?

2. The package insert has a big warning at the top that it can kill.

There are many reasons why we should not use the package insert of a medicine or vaccine to make healthcare decisions. These have been discussed before so I won’t go into all the details but please see these great blogs on how to read and use package inserts:

It is true that there is a black box warning on the top of the vitamin K package insert. This has scared some parents from wanting to get the vitamin K shot for their newborn.

Screen Shot from Package Insert 

Reactions to IV (intravenous) vitamin K are much more common than IM (intramuscular) injections. The difference is anything given by IV goes directly into the bloodstream and back to the heart. But we don’t give vitamin K by IV to newborns.

IM injections go into the muscle, allowing very slow absorption of the medicine. This not only decreases reactions to the injected vitamin, but also helps the level of vitamin K stay elevated for a prolonged time after a single injection.

I only found one report of a newborn with a significant reaction to vitamin K. The authors of the paper did note that IM vitamin K has been given for many years to babies all over the world without significant reactions and could not explain why the one infant had such a significant reaction.

Since we must always look at risk vs benefit, the very, very low risk of a serious reaction from receiving vitamin K IM is preferable to the benefit of the prevention of VKDB.

Another great resource on this topic is Dr. Vincent Iannelli’s That Black Box Warning on Vitamin K Shots.

3. Vitamin K causes cancer.

Many years ago there was a small study that suggested vitamin K led to childhood cancers. This issue has been extensively studied since then and no link has been found.

Vitamin K does not cause cancer.

Rates of cancer have not increased in the years since vitamin K has been given to the large majority of newborns worldwide. This is reported in the Vitamin K Ad Hoc Task Force of the American Academy of Pediatrics report Controversies Concerning Vitamin K and the Newborn.

4. Bleeding from vitamin K deficiency is rare or mild.

In the US bleeding from vitamin K deficiency is rare because most babies get the vitamin K shot soon after birth. In countries where vitamin K is not used routinely, bleeding is not rare at all. Some communities of the US where vitamin K is being refused by parents are seeing an increase in newborn bleeding.

Early VKDB occurs within 24 hours of birth and is almost exclusively seen in infants of mothers taking drugs which inhibit vitamin K. These drugs include anticonvulsants, anti-tuberculosis drugs, some antibiotics (cephalosporins) and blood thinners to prevent clots. Early VKDB is typically severe bleeding in the brain or gut.

Classic VKDB typically occurs during the first week of life. The incidence of classic VKDB ranges from 0.25-1.7 cases per 100 births.

Late onset VKDB occurs between 2 and 12 weeks usually, but is possible up to 6 months after birth. Late VKDB has fallen from 4.4-7.2 cases per 100,000 births to 1.4-6.4 cases per 100,000 births in reports from Asia and Europe after routine prophylaxis was started.

One out of five babies with VKDB dies.

Of the infants who have late VKDB, about half have bleeding into their brains, which can lead to permanent brain damage if they survive. Others bleed in their stomach or intestines, or other vital organs. Many need blood transfusions or surgeries to help correct the problems from the bleeding.

5. It’s just as good to use oral vitamin K.

Early onset VKDB is prevented well with the oral vitamin K in countries that have oral vitamin K available, but late onset VKDB is an issue.

Children with liver or gall bladder problems will not absorb oral vitamin K well. These problems might be undiagnosed early in life, putting these kids at risk for VKDB if they are on an oral vitamin K regimen.

Getting the oral form isn’t easy

There is no liquid form of vitamin K that is proven to be effective for babies in the US.

That is a huge issue.

Some families will order vitamin K online, but it’s not guaranteed to be safe or even what it claims to be. This is an unregulated industry. It is possible to use the vitamin K solution that is typically given intramuscularly by mouth, but this requires a prescription and the taste is questionable, so baby might not take the full dose.

It would be an off-label use so physicians might not feel comfortable writing a prescription. The other issue that might worry physicians is with compliance in remembering to give the oral vitamin K as directed, since most studies include babies with late onset bleeding who had missed doses.

Vitamin K in food

Most of us get vitamin K from gut bacteria and eating leafy green vegetables.

Newborns don’t have the gut bacteria established yet so they won’t make any vitamin K themselves. They may get vitamin K through their diet, but breastmilk is very low in vitamin K. Unless baby is getting formula, they will not get enough vitamin K without a supplement.

It is possible for mothers who breastfeed to increase their vitamin K intake to increase the amount in breast milk, but not to sufficient levels to protect the baby without additional vitamin K.

What do other countries do?

Many countries that have used an oral vitamin K protocol, such as Denmark and Holland, have changed to an intramuscular regimen because the oral vitamin K that was previously used became no longer available.

There are various oral vitamin K dosing strategies that can be reviewed in the linked abstract.

  •  Australia and Germany: 3 oral doses of 1 mg vitamin K are less effective than a single IM vitamin K dose. (In 1994 Australia changed to a single IM dose and their rate went to zero after the change.)
  • Netherlands: A 1mg oral dose after birth followed by a daily oral dose of 25 mcg vitamin K1 may be as effective as parenteral vitamin K prophylaxis.
  • Sweden: (a later study) 2 mg of mixed micellar VK given orally at birth, 4 days, and 1 month has a failure rate of one case of early and four cases of late VKDB out of 458,184 babies. Of the failures, 4 had an undiagnosed liver issue, one baby’s parents forgot the last dose.
Oral Vitamin K vs injectable (IM) Vitamin K

When vitamin K is given IM, the chance of late VKDB is near zero.

Oral vitamin K simply doesn’t prevent both early and late bleeding as well. This is especially true if there is an unknown malabsorption disorder, regardless of which dosing regimen is used.

6. My baby’s birth was not traumatic, so he doesn’t need the vitamin K.

Birth trauma can certainly lead to bleeding, but the absence of trauma does not exclude it.

Late vitamin K deficient bleeding (VKDB) cannot be explained by any birth traumas since they can occur months later.

7. We’re delaying cord clamping to help prevent anemia and bleeding. Isn’t that enough?

Delayed cord clamping can have benefits, but decreasing the risk of bleeding is not one of them.

There is very little vitamin K in the placenta or newborn. Delaying the cord clamping cannot allow more vitamin K into the baby.

Still not convinced?

Read stories about babies whose parents chose to not give vitamin K:

For More Information:

Evidence on: The Vitamin K Shot in Newborns (Evidenced Based Birth)