Tackling the No. 1 killer of kids: Traumatic brain injury
As a fullback on offense and outside linebacker on defense, Zackery Lystedt almost never left the football field for his junior high team near Seattle. But that same tenacity turned tragic during a game in October 2006.
Just before halftime, the 13-year-old hit his head on the field while tackling another player. Zackery shook off the woozy feeling and returned to the field for the second half, suffering multiple additional head-jarring hits in the typical rough and tumble of football. By the end of the game, his condition suddenly grew much worse.
"He started shaking and you could tell something was extremely wrong," says his father, Victor. Zackery fell into his arms, told him how much his head hurt and uttered the last words he would speak for nine months: "Daddy, I can't see."
The same scene plays out with regularity on playgrounds, sports fields and backyards across the country: kids hitting their heads and adults not realizing the severity.
Traumatic brain injury, also called TBI, is the leading cause of death in children ages 1 to 19 and it's the reason about 435,000 kids visit the emergency room each year, according to the federal Centers for Disease Control and Prevention. TBI accounts for an estimated 50 percent of pediatric trauma-related deaths, far more than other causes such as drownings, burns, poisoning and suffocation.
'Hard to identify'
Head injury prevention
dos and don’ts
DO: Buy your children a helmet that fits snugly and with proper padding. And make sure your kids wear helmets when biking, skateboarding or playing contact sports such as football.
DON’T: Buy sweatshirts or shorts with drawstrings. They tend to catch on playground equipment and lead to falls.
DO: Check your child’s playground equipment. Make sure there’s shock-absorbing surface material such as wood chips, mulch, sand or pea gravel and rubber mats around playground equipment.
DON’T: Encourage your kids to “play hurt” or “suck it up” after they get dinged in the melon.
Experts think many more TBI cases are never reported, as parents and coaches often don't recognize the symptoms.
"Head injuries can be hard to identify and extremely dangerous," says Michael West, president of the California Athletic Trainers' Association, a group of professionals trained to prevent and treat injuries of all kinds in young athletes.
Zackery had suffered a concussion called second-impact syndrome. After the first hit, Zackery's brain didn't have time to heal. Other impacts during the game caused increased brain pressure, leading to strokes and permanent brain damage. He lost his memory and his ability to speak, walk and feed himself.
The affliction of head injury stretches across generations and singles out no race or class of people. Infants are susceptible. So are the elderly. Amateur skiers fall victim. So do soldiers at war.
However, kids experience head injuries at the highest rate and they're uniquely susceptible to long-term damage, as the skull doesn't fully form until late adolescence or early adulthood.
"A hard skull is a good thing," says Dr. Nathan Kuppermann, chair of the emergency medicine department at University of California-Davis. "If the skull cracks, it means the skull took the blow so the brain doesn't have to. In young kids, they can have brain injury without skull fracture because the skull is poorly calcified,"
When to call
Seek medical help if, after a head injury, a child is:
• Tired or listless
• Irritable or cranky
• Not eating or nursing
• Not sleeping or sleeping at irregular times
• Doing worse than usual at school
• Not interested in favorite toys or activities
• Walking or crawling unsteadily
• Experiencing memory loss
• Having vision or eye disturbances, such as dilated pupils
Source: U.S. Centers for Disease Control and Prevention
Getting the right treatment
Inadequate treatment of kids with TBI plays a role in long-term effects that doctors could have prevented. Kuppermann estimates that 90 percent of kids who seek urgent care for any problem go to general emergency rooms, as they vastly outnumber emergency pediatric care centers, especially in less-populated areas.
Doctors used to treating all ages, he says, don't always understand the intricacies of young people's brain and skull development, which affects the quality of care.
To get a handle on the growing problem, doctors across the country are coordinating their efforts on how best to treat kids with brain injuries through the Sarah Jane Brain Project. Together, these experts are developing the National Pediatric Acquired Brain Injury Act in the hopes that Congress will establish Centers of Excellence in every state that will be accessible to all individuals and families, regardless of where they live.
The plan, which they hope will pass this year, will develop standards in TBI research, prevention, care and recovery, and rehabilitative and educational services through schools and community agencies.
Laws promote training and prevention
To CT, or not to CT?
A computer tomography (CT) scan can be very effective in identifying brain injuries. But a recent study found the scans may be used more often than necessary, especially in children.
Use of CT scans doubled nationally from 1995 to 2005, according to the study led by Dr. Nathan Kuppermann, chair of the emergency medicine department at University of California-Davis. Kuppermann and his colleagues analyzed more than 42,000 patients younger than 18 with minor head trauma in 25 U.S. hospitals. They found that a fifth of children older than age 2 and almost a quarter younger than age 2 with minor head trauma who had CT scans were at very low risk of serious brain damage. In these children, a CT scan is unnecessary and potentially dangerous long-term, Kuppermann says.
The CT scans expose people to significant amounts of radiation, which in the long-term can lead to cancer in some, Kuppermann says. Young children are particularly susceptible to the damaging effects of radiation, as they’re alive longer for the radiation to catch up with them.
“Our message is not to decrease CTs per se but to decrease unnecessary CTs,” Kuppermann says. “It’s not a riskless procedure.” The study recommends doctors look for a collection of factors that indicate a very low risk for serious brain injury, including, acting normally, not having lost consciousness, having no signs of skull fracture, and no severe blunt-force injury, such as a fall.
There also has been steady progress to change how athletes with head injuries are treated. In early December, the National Football League adopted a new policy requiring players who show even mild symptoms of concussion to stop playing during the game and not return until cleared by a licensed medical professional.
Last May, the legislature in Washington state became the first in the nation to pass a similar law for young athletes, which was named after Zackery.
Dr. Stan Herring, team physician for the NFL's Seahawks, and his colleague at the Washington School of Medicine, Dr. Scott Laker, were strong supporters of the bill, which requires school districts and youth sports organizations to follow a "when in doubt, sit it outî policy and inform parents and kids about the risks of head injuries.
"It is almost impossible to prevent the initial concussion, as contact sports always carry a risk," Laker says. "We are trying to put an end to preventable problems when an athlete sustains a second concussion."
A similar law that requires youth coaches to be trained in the signs and risks of concussion passed the Oregon Legislature about a month later in June, and others like these are being proposed in New Jersey, Texas and California. One thing the laws won't do is curtail unstructured play by kids such as skateboarding and biking or just having fun on the playground, a source of many unforeseen injuries.
Diann Finley, an Angie's List member in suburban Chicago, got a call one day from the day care about her son, Tyler, who was 4 at the time. He had a golf ball-sized welt on his forehead, between his eyes. He was crying and inconsolable. Finley rushed her son to the doctor.
After an extensive evaluation, he was found to have only a mild concussion and cleared to go home. But the experience showed Finley that accidents can happen anywhere. Her son was waiting for the slide, standing a few feet up on a metal step, when a girl raced by him, knocking him face-first onto the step.
"I hadn't thought of kids being able to hit their heads that hard," she says. "Even though there are adequate numbers of teachers watching your child, another child's rough behavior can do a lot of damage."
While kids can't avoid all danger, they can learn how to recognize dangerous situations developing and remove themselves, she adds.
Learn the signs of brain injury
Neurologists suggest that parents and caregivers become familiar with the signs of brain injury.
"Any anomaly in behavior must be evaluated," says Dr. Joseph Tepas, a professor of surgery and pediatrics at the University of Florida.
If your child has symptoms, Tepas says to stabilize the head with a neck brace so it doesn't move prior to getting medical care. The child's breathing should also be monitored.
TBI can cause a wide range of changes in mental, physical and psychological conduct. Essentially, a part of the brain no longer functions as it should, and depending on which part is injured, it can lead to diminished ability to think, speak, learn, process emotions, behave properly or experience the senses, according to neurologists.
It also can cause epilepsy and increase the risk for conditions such as Alzheimer's disease, Parkinson's disease and other brain disorders that come with aging.
Rehabilitating from TBI
For those with TBI, it may be too late to think about prevention, but they never give up devoting long hours to the rehabilitation process. Zackery's relearning basic abilities such as mobility and speech with the help of a diverse team of health care professionals at the University of Washington's Department of Rehabilitation Medicine and Harborview Medical Center.
"We're advancing, but it's an extremely slow process," Victor says.
Zackery, who's regained some speech and seen significant improvements in memory in the past year, relies on a wheelchair to get around and goes to daily therapy sessions. "We spend about 40 to 45 hours a week continuing with the hope he'll walk again," Victor says. "We'll never give up on that,"
In October 2008, Zackery had to be lowered into a swimming pool and be supported to move, his dad says. A year later, he could wade chest-deep into the pool and walk the width of it on his own power, a process that takes about three minutes. But it's improvement, and the family is thankful to see incremental progress.
He's even back in school, having passed proficiency tests that allowed him to advance to his current junior-year standing academically. Dr. Kathy Bell, a rehab doctor involved in Zackery's outpatient therapy, is among those working with therapists and teachers to help Zackery apply new thinking, writing and speech skills he learned in rehab to the classroom.
"Rehabilitation of traumatic brain injury, especially as severe as Zackery's, starts while a patient is still in the intensive care unit," Bell says. Returning to school and family life and even getting into a little teenage mischief is important, she adds, as is adjusting to a new normal.
"Zack and his family and everyone knows that he's not going to be the same kid who was injured in that football game," Bell says. "So part of what we do is kind of discovering who the new Zack is. It's not exactly the life he planned to have, but he's a great kid and he's going to do really well,"
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