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Decisions like the one Texas Longhorn Nolan Brewster recently made to quit playing football are tough. I am not one of the physician taking part of his care, so I do not know all the specifics. But having had similar conversations with my patients, I can understand the process he has gone through. The Sport becomes part of the athletes’ identity. In the case of a top college football player, it is also a potential source of future income for himself and his family. But when the safety of the athlete becomes a major concern, sometimes this tough decision is the right decision. This decision did not happen overnight. It involves the discussion of the whole family along with a multi-disciplinary approach with coaches, trainers, and medical professions. I always recommend consultation with a sports psychologist when concussions start affecting the normal routine for an athlete, and especially when decisions about quitting or changing a sport is involved. Depression is among the possible symptoms of concussions and cumulative head injury. For an athlete who needs to find a new identity, strong family support and a good sports psychologist are the most important things going forward. I wish Nolan Brewster much luck and success on the next chapter of his life.
Here are some pictures of the Nautica NYC Triathlon last weekend. I was there as a physician volunteer and was at the swim exit and then at the finish line. The NYC Triathlon is an Olympic distance event which covers a distance of 1.5K Swim, 40K Bike, and 10K Run. The swim is done on the Hudson River, the bike is along the West Side Highway, and then it finishes with a run through Central Park.
This got me thinking about triathlons for children. Currently, there are a number of triathlon events around the world geared toward children of all ages. In 2009, the New York Times did an article about this as well. In one triathlon, the youngest child to participate was 3 years-old. Before anyone becomes outraged at this, keep in mind that swimming, biking, and running are all things that children as young as 3 can do. Training for a triathlon may actually be better for overall development than many other popular sports like baseball and football since it incorporates various skill sets and utilizes the entire body. Triathlon events for children are great as long as everyone involved keeps some key points in mind:
1. Keep it fun: The emphasis should be on exposing the child to something enjoyable. While adults treat their own triathlon races as a competition between each other or trying to achieve a personal best, these events for children should not be timed or scored for record purposes.
2. Keep it age and individual-child appropriate: All events that I have seen have specified distances based on age. But parents must also be aware of what is appropriate for their child. Not all children have the same ability, and putting a child into a race just because he/she is within the “age category” is not always correct. Courses must also be designed for appropriate ages.
3. Keep it safe: Overall, the triathlon is a safe event. But there are no specific guidelines out there yet for safety. Accidents are more likely to happen in the swim and bike sections of the race. All events should have appropriate personnel and equipment at hand for emergencies.
4. Don’t Over-do it: The main concern for children are that they have open growth plates, and injury to them can have significant consequences on their development. There is limited data on the injury rates of these events. Studies from kids’ marathons have suggested that rates of injury on the day of the race are less than adults. There needs to be more studies in this regard, and there also needs to be studies on injuries during training for the events. As with all sports, overuse injuries can occur from improper training. Over-training can lead to injuries as well as mental burn-out. Consult with your pediatrician or a pediatric sports medicine specialist if you are planing to start your child on a training program.
Running, Biking, and Swimming are great for children. If your child loves to do all three, try a triathlon!
It has been an extremely hot summer so far in all parts of the United States. Record highs are being set all over the country. Today we will discuss exertional heat illness in children so you can be better prepared to identify and prevent this in our children as they continue to be active throughout the summer months.
Why is temperature regulation important?
Our bodies are made to function at an optimal core temperature of 98.6°F (37°C). The “thermal neutral” zone in which we operate is 36.5 – 37.5°C . When the temperature deviates too much from that, temperature sensitive structures such as body enzymes and other proteins begin to denature, and essential processes start to fail. Extreme cold slows down metabolic processes and at temperatures below 33°C we lose consciousness. In extreme heat, temperatures above 42°C are not compatible with life.
How do we temperature regulate?
Even without activity, our body is generating heat at a rate that would increase our core temperatures by over 1°C per hour. When we are exercising hard, that heat generation can increase 10-fold. Therefore our bodies are equipped under normal circumstances to dissipate the heat. The main methods of heat dissipation are: radiation, convection, conduction, and evaporation. Radiation is the primary way in which heat is dissipated when the skin temperature is greater than air, but when air temperature exceeds the skin temperature, evaporation becomes the primary method of cooling. This happens in the form of sweating (humans), and panting (dogs). When normal functions of heat dissipation are not working correctly, or when heat generation exceed heat loss, the body is in danger of a spectrum of heat-related illnesses from heat cramps, heat exhaustion, and heat stroke.
Why are children at greater risk than adults?
Children are more susceptible to heat illness because they have:
1. Greater surface area to body mass ratio
2. Lower rate of sweating
3. Higher temperature at initiation of sweating
4. Slower rate of acclimatization to heat
Tips on beating the heat?
1. Stay indoors or in a shaded area during the hottest part of the day. Schedule practices or events before 11am and after 6pm.
2. Pre-hydrate! Dehydration increases the risk of EHI.
3. Hydrate on a regular schedule during and after exercise. Thirst is a poor indication of hydration status, especially in children. A good starting point is 4 to 6 ounces of fluid every 15 minutes for a 90-lb child.
4. Check the weight! Checking your child’s weight before and after exercise will give you an idea if hydration was adequate. Weight loss of greater than 2.5% indicates dehydration.
5. Get acclimatized. The body can take 1-2 weeks to get adjusted to the heat, so avoid strenuous practices in the beginning. Start light and gradually increase.
6. Wear appropriate clothing. Keep it light on the hottest days.
7. Know the symptoms of heat exhaustion and heat stroke:
Heat exhaustion: Athletes can be sweaty, ashen in color and complaining of weakness, headache, dizziness, irritable, nauseous or vomiting.
Heat stroke: Athletes can have similar symptoms as heat exhaustion, but can also be dry, hot, and flushed, and will also have confusion, delayed response or other change in mental status. Rectal temperature if taken will be >104°F.
8.If your child has any medical problems that may affect their ability to temperature regulate, discuss with your pediatrician.
What should you do if you suspect heat exhaustion or heat stroke?
1. Get the athlete out of the sun, and indoors or into a shaded area.
2. Oral hydration and cooling with active cooling techniques such as removing excess clothing, drinking cool water, sponging the body with cool water, placing ice pack in the armpits, and groin.
3. Have the athlete evaluated by a medical professional as soon as possible.
4. If there is any change in responsiveness or other mental status change, be concerned about heat stroke. Call 911 and initiate rapid cooling if possible.
Wishing everyone a safe, happy, and fun summer!
Sports-related concussions in children have received a lot of media coverage on the past few years. The understanding of the cause, diagnosis and management, and prevention of sports-related in concussions in children continues to evolve and it may be difficult to keep track of the new research. Here is my quick guide for kids, parents, coaches, and anyone taking care of the young athlete.
What is a concussion?
A concussion is defined as a mild traumatic brain injury that results from a direct or indirect trauma to the brain which causes cognitive and/or behavioral impairment, but no apparent structural changes. This is caused by direct or rotational forces from a blow to the head or indirect forces transmitted to the head from a hit to the body. The most common sports involved are “collision” sports such as american football, ice hockey, boxing, and rugby. Other sports in which concussions can commonly occur include “contact” sports such as basketball, lacrosse, soccer, and wrestling.
What are the symptoms of a concussion?
Common symptoms include loss of consciousness, amnesia, headache, dizziness at the time of injury. These symptoms and new ones, such as light and noise sensitivity, confusion, changes in behavior, emotional lability, difficulty concentrating or remembering, and difficulty sleeping can persist afterward. The symptoms typically improve within 7-10 days in about 90% of kids, but it is not out of the ordinary for symptoms to last 2 weeks or longer. The severity and the duration of symptoms are related to a number for factors including: force of impact, age of child, number of previous conconcussions, whether the child was still recovering from a recent head injury, other underlying medical issues. It is generally known that younger children and those with history of prior concussions can take a longer time to recover. For concussive symptoms that last longer than 2 weeks, it is advised that the athlete be evaluated by a physician who specializes in concussions.
What should I do if my child has a concussion?
Children who suffers a head injury should be evaluated by a trained professional. If a concussion is suspected, he/she should taken out of the current sporting event. He/she should be evaluated and cleared by a physician before returning to play. Generally, the child will not return to play that same day, and should be kept out of sports for at least a week. The dangers of allowing a child to continue playing include the risk of worsening symptoms, prolonged symptoms, and further injury. There is also a risk of second impact syndrome if the child incurs another traumatic blow. This can lead to significant morbidity even death.
In the first week after a concussion or if a concussion is suspected, the best thing for a child is cognitive and physical rest. This can include, but is exclusive to rest from all exertional physical activity such as their sport, running, and jumping. Taking time off from work and school can also be beneficial since cognitive exertion such as being in class, note-taking, exams, and homework can exacerbate symptoms. Lastly and just as important, activities such as video games, movie theaters, sporting events, and loud music should be avoided as these can also worsen and prolong symptoms. Parents should promote continued healthy eating and adequate hydration during recovery, as energy consumption during brain recovery can be increased. Children may sleep more, and this is both okay and encouraged for brain recovery.
When can my child return to sports?
As symptoms resolve, a reintroduction to school and sports should be directed based on symptoms. It is possible to see a worsening of symptoms if too much activity is introduced too soon. A typical return to sport progression follows six steps*:
1. Complete rest from physical activity until resolution of symptoms.
2. Light aerobic activity such as walking or stationary bike.
3. Sport specific aerobic activity such as running, ice skating, swimming, or cycling.
4. Non-contact sport-specific training drills and progressive resistance training.
5. Full-contact training, after medical clearance
6. Return to full contact games.
*Each step should be well tolerated without return or worsening of symptoms for 2-3 days before progressing to the next step. If symptoms do return, drop down a step until symptoms resolve.
Are there addition tests that need to be performed?
In a small percentage of children with concussions, symptoms can last for a month or longer. These children should be evaluated by a concussion specialist. In these situations, a detailed neurologic exam, brain MRI, neuropsychiatric testing, balance testing, and other methods may be used to evaluate the child. Diagnosis and management can be assisted with baseline neuropsychiatric testing. Many schools and sporting organizations are now requiring baseline computerized neuropsychiatric testing prior to starting collision sports. There are a few companies out there that offer this. The one that I use, and am most familiar with, is ImPACT. Medications are also available to help with symptoms of headaches, insomnia, mood changes, and difficulty concentrating.
Can I do anything to prevent this from happening again?
Prevention and early recognition of symptoms is important, and education of all those involved is the key. Coaches, parents and players should be educated about the appropriate and correct use of sport-specific protective equipment, and age-appropriate rules of their sport. Currently, there are no football or ice hockey helmuts that have been shown to prevent or decrease the risk of concussions. There are also no soccer headgear that have been shown to decrease concussions, despite what companies may say. A good strength conditioning program that focuses on cervical neck, and core strength may help in decreasing risk, but that also has not been scientifically proven. Appropriate sport-specific, and age-specific rules can help decrease the incidence.
Overall, there is an inherent risk of head injury in specific sports, and the risk of concussions can not be eliminated, but the awareness of this problem can make playing sports safer for our kids.
The number of children participating in organized and recreational sports increase every year. The number of injuries as such also continue to increase. Taking care of children injured during play can be challenging for everyone involved. With injuries ranging from ankle sprains, to broken bones, and to the challenging issue of concussions, this website will hopefully keep you up to date and add the to discussion of caring for our young athletes.