Fran Lowry

October 20, 2011

October 20, 2011 (Boston, Massachusetts) — There is a "Return to Play" protocol for young athletes who have suffered a concussion during a sporting activity.

Now, a pediatrician in private practice in Scituate, Massachusetts, has created a "Return to the Classroom" protocol to facilitate communication between physicians and school officials on a child's readiness to get back to the classroom after a concussion.

"It is so difficult to communicate information on a student-by-student basis exactly what that particular student should be doing from one week to the next because it is going to constantly change," David P. Morin, MD, who practices pediatrics in the Scituate Pediatric Group, told Medscape Medical News.

"Having a protocol or guide is especially important when you take care of 50 to 60 kids who are in various stages of concussion. The schools will have 10 to 15 every week with hockey, football, soccer, basketball, lacrosse, and cheerleading," he said.

Dr. Morin unveiled his new protocol here at the 2011 American Academy of Pediatrics (AAP) National Conference and Exhibition.

There are 4 stages to the protocol. They are as follows:

  • Red: No school, lots of cognitive rest

  • Orange: Half-day of school; avoid taking the school bus and lugging textbooks; skip nonessential classes; no tests, homework, or quizzes

  • Yellow: Full day of school; gradual resumption of responsibilities for homework, tests, quizzes, and make-up work

  • Green: Full academic load and return to normal physical activity

The protocol stresses the importance of cognitive rest. Cognitive stimulation at home is to be limited, and children should avoid video games; computers; text messaging; cell-phone use; loud, bright environments; television; and reading.

Dr. David P. Morin

"If we had our druthers, the kids would stay in a dark bedroom for 2 weeks," he said. "It's up to the parents to enforce this, and it can be really tough to do with teens, who are social animals."

In the Orange stage, as kids start going back to school, they should audit classes and should not take notes. They should also keep their teachers updated as often as possible, keep current copies of assignments and handouts, and have lunch or rest in the nurse's office, if needed.

At this stage, no band, chorus, or physical education is allowed because of high noise levels; no sports are allowed, either.

"At home, it's rest, rest, and more rest!" Dr. Morin said. Kids should go to bed early, and should limit their time on the computer or watching videos or TV to 1 hour at a time, and 2 hours total per day.

In the Yellow stage, kids are allowed to return to full-time attendance at school. They should complete as much homework as possible in 15-minute blocks of time, rather than all at once, and should take only 1 test per day. They should also communicate with teachers and the nurse if symptoms reappear.

Finally, in the Green stage, the child can resume normal activities.

The school nurse or team captain (or both) should be provided with neurocognitive testing scores. A return to sports is allowed only if the child is cleared by a physician and is able to manage school work well.

Physical activity should be slowly ramped up, and physical well-being should be self-monitored. "Never play through symptoms," Dr. Morin emphasized. "Kids should continue to be their own strong advocate."

Awareness of Concussion Growing

Dr. Morin said he hopes that the growing awareness of concussion will continue and that children who are affected will get the treatment they need.

In the early 2000s, the estimates of concussion were around 300,000 per year. Ten years later, the estimate has increased 10-fold, he said.

"Now we are beginning to appreciate how serious they are, both in the short-term and in the long-term. I hope that there will be enough pediatricians or pediatric care givers that every child who gets a concussion can be recognized, evaluated, and then have an individual treatment plan developed so that they can get back to school and normal activity as safely and as quickly as possible," he said.

Commenting on the study for Medscape Medical News, Cindy Devore, MD, a pediatrician in private practice in Pittsford, New York, and chair of the Council on School Health symposium, lauded Dr. Morin for his work.

"I am thrilled that Dr. Morin is heightening awareness of the importance of cognitive rest in schools in situations where children have suffered concussion and require not just physical rest but also rest from academic demands," Dr. Devore said.

She added that it is particularly notable that his work is done in the context of a community pediatrician's office and is attempting to work with school districts and school officials "in a collaborative fashion to safeguard children."

Dr. Morin and Dr. Devore have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition. Abstract # 13914. Presented October 15, 2011.


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