Houston Area Pediatric Specialists

Independent pediatric specialists aim to serve our community. We want to share news and analysis regarding our specialties and our practices.

Tuesday, December 11, 2012

AAP Recommendations for Childhood Sleep Disorders

It's been said before, but it warrants reminding that when it comes to sleep disorders, children are not little adults.  Pediatric sleep medicine is a highly specialized field where the specialties of pediatric pulmonology and neurology intersect to help address problems unique to children.  Although polysomnnography, or "sleep studies" are very similar to adults.  The techniques, equipment, scoring methods , and even personnel are highly specialized.

 A long overdue update to the American Academy of Pediatrics Recommendations was recently published specifically addressing the problem of childhood obstructive sleep apnea.  This guideline discusses important symptoms for parents and physicians such as chronic snoring, mouth breathing, and pauses in breathing during sleep.  But it also discusses less recognized features of sleep disorders such as inattentiveness and hyperactivity which can also result from disrupted sleep.  Talk to your pediatrician if you suspect a sleep problem in your child.  Dr. Susarla

AAP Recommendations for Childhood Sleep Disorders

Sleep disturbances, including obstructive sleep apneasyndrome (OSAS), are common in children and can result in significant health problems if left untreated.
In a revised clinical practice guideline, “Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome,” published in the September 2012 Pediatrics (published online August 27), the American Academy of Pediatrics (AAP) recommends that all children or adolescents who snore regularly be screened for OSAS.
Additional symptoms can include labored breathing during sleep, disturbed sleep with frequent gasps, snorts or pauses, and daytime learning problems. It is important for children exhibiting signs of OSAS to get a comprehensive diagnosis by having an overnight, in-laboratory sleep study done.
If left untreated, OSAS can result in problems such as behavioral issues, cardiovascular problems, poor growth and developmental delays. Treatments are available that can result in significant improvements in these complications. Adenotonsillectomy is effective in treating OSAS and is recommended as the first line of therapy. Obesity can be a risk factor, so physicians may recommend weight loss in addition to other therapies in overweight or obese children. Post-operatively, physicians should be aware of the criteria suggesting which patients should be admitted and when other treatment should be considered, such as CPAP.

Read article here.

Friday, December 7, 2012

New Genetic Pathway Behind Neurodevelopmental Disorders Discovered

I love good iconoclastic research that blows up our entire way of thinking about disease. -JR

New Genetic Pathway Behind Neurodevelopmental Disorders Discovered

ScienceDaily (Dec. 6, 2012) — Researchers at the Douglas Mental Health University Institute, have discovered a new genetic process that could one day provide a novel target for the treatment of neurodevelopmental disorders, such as intellectual disability and autism.

The research study, which appears in the December issue of the American Journal of Human Genetics, was led by Carl Ernst, a Douglas Institute researcher, an assistant professor in McGill's Department of Psychiatry and a Canada Research Chair in Psychiatric Genetics. Ernst and his colleagues found that genetic mutations that negatively affect brain development can occur in a gene family of previously unknown function in the human genome.

According to the World Health Organization, neurodevelopmental disorders affect one in six children in industrialized countries. Impairing the growth and development of the brain or central nervous system, neurodevelopmental disorders encompass a broad range of conditions, including developmental delay, autism spectrum disorders and cerebral palsy. People with neurodevelopmental disorders can experience difficulties with language, speech, learning, behaviour, motor skills and memory.

Mutations in genes are thought to underlie many neurodevelopmental disorders, but all genes important for brain development found to date are in a single pathway. Genes are coded in DNA that gives way to RNA, which gives way to protein. Proteins form the functional unit of the body and are the major players in all biological activity. Prior to the current study, all genetic mutations important for neurodevelopmental disorders, occurred in genes that make protein.

The work of Ernst and his research team identified an important shortcut in the process of making functional molecules for brain development. By sequencing the genomes of 200 people with neurodevelopmental disorders and chromosomal abnormalities, and comparing the results to more than 15,000 control samples, the researchers made a surprising discovery: some individuals had mutations in a gene that did not make protein.

"Our discovery tells us that mutations in genes that code only for RNA and do not make protein can have a functional impact and lead to neurodevelopmental abnormalities," Ernst says. "In previous studies of brain development, RNA was just considered a middle player -- one that only served as a template for the production of proteins." ....

more here

Does IVF Increase Risk for Asthma?

The cause of this association is not clear, but premature infants especially under 30 weeks gestation seem to be more prone to develop asthma symptoms like recurrent wheezing.  Dr. Susarla

Fertility treatment 'asthma link'


In a study of more than 13,000 UK children, five-years-olds were about twice as likely to have asthma if they were not conceived naturally.
Children born after fertility treatments, such as IVF, may have a slightly higher chance of developing asthma, research suggests.
The children were also more likely to need medication, which could be an indication of more severe asthma.
The findings were published in the journal Human Reproduction.
The researchers, at the Universities of Oxford and Essex, analysed data from children born between 2000 and 2002.
Researcher Dr Claire Carson said 15% of all the children in the study had had asthma at the age of five, but this proportion had risen to 24% among the 104 of them born through assisted-reproduction technologies.
She said it was interesting that the pattern had emerged, but far too soon to say if IVF treatment resulted in higher rates of asthma. Other explanations, such as genetics, may explain the association.
Dr Carson told the BBC that parents should not be put off IVF.
"Assisted reproduction technologies offer a chance to become a parent when there isn't another option," she said.
"For the majority of children asthma is quite manageable."
Malayka Rahman, from the charity Asthma UK, said: "This study suggests that there might be an association between IVF treatment and asthma developing in children, but the sample size for this study is small and currently the research in this area generally is not conclusive.
"Those considering IVF should speak to their GP about the benefits and health risks in order to make an informed decision."

Tuesday, November 27, 2012

Childhood Obesity Associated with Asthma

Asthma associated with childhood obesity may be unique in other ways since it is often harder to treat. Dr. Susarla

Research Supports Role of BMI in Incident Asthma in Children

(HealthDay News) – Overweight and obese children have a significantly increased risk of incident asthma, with evidence of a dose-response effect of elevated body mass index (BMI), according to a meta-analysis published online Nov. 12 in Obesity Reviews.
Y.C. Chen, from the National Taiwan University in Taipei, and colleagues reviewed the literature and conducted a meta-analysis using a prospective cohort of pediatric studies that analyzed age- and sex-specific BMI (as a measure of childhood overweight) and the primary outcome of incident asthma.
Based on data from six studies meeting the inclusion criteria, the researchers found that, compared with non-overweight children, overweight children had increased risks of incident asthma (relative risk [RR], 1.19). When comparing obese vs. non-obese children, the association was further elevated (RR, 2.02). There was a significant dose-responsiveness of elevated BMI on asthma incidence (P for trend, 0.004). In addition, there was a gender difference noted, with obese boys exhibiting a significantly larger effect than obese girls (RR, boys: 2.47; girls: 1.25), also with a significant dose-dependent effect.
"Our findings support the impact of childhood obesity on incident asthma, and provide information to compel obese children to lose weight," the authors write. "Policy makers for children's health and parents should pay more attention on preventing obesity-associated risk and environments."

Monday, November 19, 2012

Asthma Patients Often Depressed

Adjustment to a chronic disease can be difficult.    This study suggests that patients with asthma should be closely monitored for depressive symptoms.  Every effort should be made to reduce the impact of asthma on daily life.

Asthma Patients Often Depressed

ANAHEIM, Calif. -- Depression and asthma appear to go hand in hand, even in patients whose asthma is relatively mild and who report generally good health, a researcher said here.
Analysis of some 13,000 participants in the Cooper Institute Longitudinal Study indicated that a diagnosis of asthma was a risk factor for reports of significant current depressive symptoms with an odds ratio of 1.41 (95% CI 1.16 to 1.65, P<0.001) after adjusting for asthma severity and self-assessment of overall health status.
Asthma and a previous history of depression also were significantly associated, with an odds ratio of 1.65 (95% CI 1.40 to 1.90,P<0.001), Tim Trojan, MD, of the University of Texas Southwestern Medical Center in Dallas, told attendees at the American College of Allergy, Asthma, and Immunology annual meeting.
Associations between asthma and depression have been reported before, Trojan explained, but those studies could not rule out the possibility that patients were simply sad about feeling sick with asthma.
Consequently, he and his colleagues utilized records from the Cooper Institute Longitudinal Study, begun in 1970 by the institute's founder, Kenneth Cooper, MD, the aerobics advocate. The database has unusually detailed information on patients including spirometry values, scores on the Center for Epidemiologic Studies Depression Scale (CES-D), medical history, body mass index, and lifestyle factors such as smoking and drinking status, as well as standard demographics.
Trojan and colleagues analyzed data on 12,944 study participants, including 1,169 with a diagnosis of asthma. Of these, only 187 were on controller medications, suggesting that the sample mostly included people with relatively mild asthma.
About 81% of the overall sample indicated that their health status was good or excellent, as opposed to fair or poor. Current depressive symptoms (CES-D scores of 10 or higher) were present in 11% and a past history of depression in 14%.
Bivariate analyses indicated that the risk of depressive symptoms was significantly increased, not only by a diagnosis of asthma, but also by female gender, hypertension, and current smoking. It was significantly decreased in nonwhites, those with more than a high school education, age older than 50, and current drinking.
Multivariate analysis produced the odds ratio 0f 1.40 for depressive symptoms with an asthma diagnosis. When expressed as an r2 correlation coefficient, the value of 0.119 suggested that the relationship was only modest at best, Trojan said.
But a classification analysis based on the association correctly categorized 89.5% of study participants, he said.
The same held true for the association between asthma and depression history. The r2 correlation coefficient was 0.110, but the classification analysis categorized 85.7% of participants correctly, Trojan said.
He noted that the study had a number of limitations including the fact that some of the data such as depression history and smoking and drinking status were self-reported, and the Cooper Institute database consists of people who are "mostly white and mostly healthy." Trojan added that they are probably relatively affluent as well, although income data are not collected.
Nevertheless, he said, the study findings "mean that your mild asthmatic ... who doesn't look or feel all that bad still has a significant risk, or could have a significant risk, of having depressive symptoms and should be evaluated for this."

Sunday, November 18, 2012

Does Eating Fish During Infancy Cut Asthma Risk?

Yes this does seem... fishy.  There could be other reasons to explain this association.  We will have to wait and see.  Dr Susarla.

Does Eating Fish During Infancy Cut Asthma Risk?

FRIDAY, Nov. 16 (HealthDay News) -- Adding fish to babies' diets during the first year of life might reduce their risk of asthma later on, a study by Dutch researchers suggests.

This window of protection appears to occur between 6 months and 12 months of age. Adding fish to the diet before that or not at all in the first year seems to carry an increased risk of wheezing and shortness of breath, the researchers said.
"This study provides insight into what the optimal timing of introduction can be for fish," said lead study author Jessica Kiefte-de Jong, from the pediatrics and epidemiology departments at Erasmus Medical Center in Rotterdam.
"The results may assist health care workers about the recommendations regarding the introduction of complementary feeding in infants," she added.
Pediatricians may not agree with the findings, however. One expert objects to feeding children fish at such a young age because of potential harms.
"I have never heard that fish is a preventive against asthma," said Dr. Antonio Rodriguez, director of pediatric pulmonology at Miami Children's Hospital.
"There is a danger of an allergic reaction feeding fish to children under 1 year of age," he said. "In addition, there is always concern about the toxicity of mercury in fish."
This is why fish is not fed to infants, he said.
Kiefte-de Jong agreed that before parents start introducing fish to their infants these findings need confirmation in a real clinical trial. She also said the researchers aren't quite sure why eating fish at this age might benefit children's lung health.
For the study, published online Nov. 12 in the journal Pediatrics, the research team collected data from a population-based study of more than 7,200 children born between April 2002 and January 2006 in Rotterdam.
Reviewing questionnaires on overall diet, the researchers looked at when parents introduced fish to their infants' diets. They also looked at symptoms of asthma that developed at ages 3 and 4 years.
Children who started eating fish at 6 to 12 months had a significantly lower risk of wheezing when they were 4 years old compared with children who began eating fish later, Kiefte-de Jong's group found.
For children who started eating fish earlier -- or not at all -- within the first year, the risk for wheezing increased at 4 years, they noted. The risk of shortness of breath increased slightly as well.
The researchers acknowledged that other factors besides when the children started eating fish might have influenced the children's breathing ability at preschool age. And the study did not prove that the introduction of fish during the first year of life prevented asthma later on.

Tuesday, November 13, 2012

Smokers' Kids Don't Get a Break in Cars

The conventional wisdom is probably not enough.  A home smoke-free policy is important, but it is not enough if cigarette smoke exposure occurs in other places, like the car.  Children with asthma and recurrent respiratory infections are especially susceptible.  Dr. Susarla

Smokers' Kids Don't Get a Break in Cars

Most parents who smoke don't make strong efforts to protect their kids from it in the car, a trial-based survey showed.
Less than a third reported having a policy of keeping the car smoke-free, said Jonathan Winickoff, MD, MPH, of Massachusetts General Hospital for Children in Boston, and colleagues.
Nearly half of those who had no such policy said they smoked with their child in the car, the group reported in the December issue ofPediatrics.
While there is "no safe level of exposure" to tobacco smoke, secondhand smoke inside a vehicle is especially problematic.
"Studies have shown that smoking one cigarette in a confined space such as inside a car creates unsafe levels of respiratory suspended particles," Winickoff's group pointed out.
Rolling the window down doesn't help much. One experiment showed that air quality was still as bad as in a smoky bar, and that residual toxins remain on surfaces in the car even when a cigarette isn't actively lit.
Aside from raising their risk of cancer, exposure contributes to children's risk of lower respiratory infections, sudden infant death syndrome, and ear infections as well as worsening asthma.
The researchers examined exit interviews with smokers who served as controls as part of the larger Clinical Effort Against Secondhand Smoke Exposure, a pediatric office-based intervention trial.
Among the 795 parents with a car who were interviewed, 73% said they or someone else had smoked in the car in the prior 3 months. The researchers reported that of the 562 parents who did not have a smoke-free car policy, 48% smoked in the car when their children were present.
Fewer than one in three parents (29%) reported having a smoke-free car policy. Only 24% reported having a strictly enforced (no tobacco in the prior 3 months) smoke-free car policy.
By comparison, 57% of the parents reported having a strictly enforced policy of no smoking in the home.
Smoke-free cars tended to go along with smoke-free homes, as 82% of smokers with a strictly-enforced car policy stuck to such a strategy at home too.
However, the association didn't go the other direction. Most parents (66%) who kept their kids from being exposed in the home didn't do so for the car, "suggesting that parents may not recognize tobacco smoke exposure in cars as an important exposure source for their children."
Conversations with pediatricians on the topic appeared to be uncommon.
Although about one in five parents reported having been asked about their smoking status, just 14% had been asked about whether smoking was allowed in their vehicle, and 12% were advised to have a policy of no smoking in the car.
After adjustment for other factors, smokers with an infant under 1 year of age were 64% more likely to have a strict no smoking in the car policy.
Lighter smokers (≤10 cigarettes per day) were substantially more likely to forgo smoking in the car, with an adjusted odds ratio of 3.59. However, having more than one smoker in the home lowered the chances of a strictly enforced smoke-free car policy by 44%, with an aOR of 0.56.
"Childhood tobacco smoke exposure in confined spaces should be considered an intervention priority in the pediatric setting because children's exposure to tobacco smoke is involuntary, and no one other than the child's healthcare provider may have the opportunity to advocate for smoke-free cars," the researchers concluded.
They cautioned that the study results were based on self-reporting that may have been subject to recall and response bias and without implying causality.

Sunday, November 4, 2012

Study Finds Premature Babies More Likely to Have Sleep Apnea

This large study from Australia tells us that something about prematurity predisposes babies to develop obstructive sleep apnea.  This condition is caused by obstruction of the upper airway during sleep that can lead to daytime problems with cognition and behavior.  Dr. Sarat Susarla

Study Objectives:

Investigate the relationship between gestational age and weight for gestational age and sleep apnea diagnosis in a cohort of children aged up to 6 years old.


A cohort study, using record linked population health data.


New South Wales, Australia.


398,961 children, born between 2000 and 2004, aged 2.5 to 6 years.


The primary outcome was sleep apnea diagnosis in childhood, first diagnosed between 1 and 6 years of age. Children with sleep apnea were identified from hospital records with the ICD-10 code G47.3: sleep apnea, central or obstructive.


A total of 4,145 (1.0%) children with a first diagnosis of sleep apnea were identified. Mean age at first diagnosis was 44.2 months (SD 13.9). Adenoidectomy, tonsillectomy, or both were common among the children diagnosed with sleep apnea (85.6%). Children born preterm compared to term were significantly more likely to be diagnosed with sleep apnea (< 32 weeks versus term hazard ratio 2.74 [95% CI: 2.16, 3.49]) this remained even after adjustment for known confounding variables. Children born small for gestational age were not at increased risk of sleep apnea compared to children born appropriate for gestational age, hazard ratio 0.95 (95% CI 0.86-1.06).


This is the largest study investigating preterm birth and sleep apnea diagnosis and suggests that diagnosis of sleep disordered breathing is more prevalent in children born preterm, but not those who are small for gestational age.

Saturday, October 27, 2012

Hand Hygiene Cannot Stop Asthma, Study Shows

Although viruses are one of the main triggers of asthma exacerbations, aggressive hand hygiene did not appear to be enough to stop 'attacks'.  Dr. Susarla

School 'hand hygiene' plan shows no asthma benefit

An arsenal of hand sanitizers, hygiene education and good old-fashioned soap failed to prevent asthma attacks among school children in one Alabama county.

For children with asthma, the common cold is the top trigger of symptom attacks. So in theory, cleaner hands at school could mean fewer colds being passed around - and fewer asthma attacks.

But in a new clinical trial, researchers found that kids at schools with a "hand hygiene" plan, including alcohol-based hand sanitizers, suffered asthma attacks just often as their peers at other schools.

The findings are not, however, the final word, according to Lynn B. Gerald, a professor of health promotion sciences at the University of Arizona in Tucson who led the study.
That's because the trial hit an obstacle when the H1N1 "swine" flu epidemic broke out right at the study's outset: All of the schools in the trial became a lot more vigilant about clean hands, Gerald said.

Schools that weren't part of the hand-hygiene program started putting hand sanitizer on the list of school supplies given to parents.

"Hand sanitizer became ubiquitous in schools," Gerald said.

So, she told Reuters Health, it's hard to draw conclusions about whether hand sanitizers, added to old-fashioned hand washing, might prevent some asthma attacks.

The sanitizers and soap used in the trial were provided to schools for free by Akron, Ohio-based GOJO, which makes the Purell brand hand sanitizers.

GOJO "believes there is great benefit in establishing the effectiveness of hand hygiene interventions under real-world conditions and supports scientific studies that take that approach," the company told Reuters Health.

"We agree with the conclusion that the results of this study were highly confounded by increased overall hand hygiene practices, even in the usual-care schools, as a result of the H1N1 pandemic," they said in an emailed statement.

The findings appear in the Journal of Allergy and Clinical Immunology.

When Should I See An Asthma Specialist To Treat My Asthma, And Do I Need A Pulmonologist?

When Should I See An Asthma Specialist To Treat My Asthma, 

And Do I Need A Pulmonologist? 

Stephen Wasserman, M.D., Professor of Medicine, UC San Diego School of Medicine

Answer: Essentially all patients with asthma should at some point in their medical course see an asthma specialist. An asthma specialist may be someone specially trained in the subspecialty of pulmonary medicine or somebody specially trained in allergy and immunology. But also, many pediatricians and many general internist and many family physicians are well-versed in the management of asthma.
But at some point, particularly if the asthma is proving troublesome, an asthma specialist would be a beneficial person to evaluate the asthma, to look at the treatment plan that's been set forward and to decide if there are modifications.
In addition, when asthma is not responding as expected, it's important to see someone who can differentiate between asthma and things that mimic asthma. The old adage that physician use is, "Not everything that wheezes is asthma." And occasionally, asthma can be misdiagnosised and that is generally best approached by someone who is well-versed in the understanding of asthma.


Our new office mural - Wow!

Thanks to the Montanegro's

Thursday, October 25, 2012

Can Vitamin D Help Asthma?

This research study is one to follow, since it still is not clear if supplementing with vitamin D can help children with poorly controlled asthma if levels are low.  Dr Susarla

New Study Aims To Determine Relation Between Vitamins & Asthma

Previous studies show that lung function is worse in asthmatic children with a vitamin D deficiency, even when treated with inhaled steroids.
But the way these studies have been designed, only a link can be established — not cause and effect.
That’s why doctors at Allegheny General Hospital are taking part in a multi-center, randomized, placebo-controlled clinical trial in adults.

“This is actually your true best test to find a cause and effect relationship,” Dr, Deborah Gentile, an allergist at AGH, said.
Obesity, living in the city, and being African-American are common risk factors for both vitamin D deficiency and asthma.
So is it the vitamin D or some other factor that makes asthma harder to control? That’s what this clinical trial is designed to figure out.
Right now, they’re still screening for 12 participants to be randomly assigned to take 5,000 units of vitamin D daily or placebo.
To participate you must be 18 or older and have asthma and take controller medications, such as an inhaled steroid and still have symptoms several times a week.
You will not be eligible if you’ve smoked within the last year or if you already take high-dose vitamin D.
Aimee Fogarty is being screened today.
“My main things in the fall are ragweed, and dust mites are a killer for me. In the spring, it’s more grass,” she said.
Her inhaled steroids aren’t cutting it.
“They normally do, but right now, I’m having a little bit of a difficult time, and had to double the dose,” Fogarty said. “The taking of the steroids, I just don’t like it. It’s bothering me that I have to take a steroid to breathe better.”
People eligible for the study get a blood test for a vitamin D level, and breathing tests. Then, they are randomly assigned to a treatment group.
“Some will get placebo. Some will get vitamin D,” Dr. Gentile said.
For six months, lung function and symptoms will be closely watched.
“On the one hand, we may find it works, and it very inexpensively improves the outcomes in our patients. On the other hand, if it’s negative and we find out it doesn’t help, we know that it doesn’t help,” Dr. Gentile said.
“My whole family has it,” Fogarty said. “And if this can help people in any way, I’d like to be a part of it.”
Read article here.

Tuesday, October 23, 2012

Asthma attack led to teen's death

The rule is asthma-related deaths are avoidable, which makes stories like this shocking.  Even mild asthma requires routine evaluation.  Dr. Susarla

Asthma attack led to teen's death

Family and friends remember JheVontae Davis

CHESAPEAKE, Va. (WAVY) - Family members of a Chesapeake teen who died after football practice say the teen complained of chest pain before he collapsed earlier this week.
According to family members, 14-year-old JheVontae Davis, who played JV football at Oscar Smith High School, complained of a cough and chest pain before he collapsed at practice. Davis was diagnosed with severe asthma when he was a baby. 
"Early on, it was more intense, and he had to frequent the hospital multiple times," said Jamal Vaughn, Davis' cousin. "But as he grew older, the asthma became more controllable, to the point where he was able to just have his inhaler."

Davis used a breathing machine to sleep at night, but the asthma never crippled his competitive nature or his love for sports, especially football.

At Friday's varsity football game, Oscar Smith's team took a knee and prayed over Davis' jersey. The announcer called for a moment of silence and, in the fence, students used cups to draw a heart around the number Davis wore when he played.

"The moment of silence and the player that wore his jersey, it was just like, man, it was a very touching moment for myself, because he touched so many hearts," said Vaughn, who was a father figure in Davis' life.
He remembers Davis' plans to go to college. He says the teen had so much living left to do.

"We had our whole life planned out and what we wanted to do," said Zyuanya Laguerre, Davis' younger cousin. "I never thought that was the last time I was going to say goodbye to my cousin." 

Cognitive rest for concussion management lacks data

Good debate on concussion treatment data! I suspect that the ER docs and pediatric neurologists are talking about different clinical scenarios. Who would argue with avoiding vigorous athletics or contact injury just after leaving the ER?

But, let's consider a sample of typical school recommendations following a concussion:

Treatment/ Rehabilitation    

"XX ISD athletes who sustain a head injury will be instructed to rest, both 
physically and cognitively.  This means that the athlete will be restricted from athletic 
participation, and should be restricted from recreational exercise, video games/television 
viewing, computer usage, including text messaging"

This can go on for months in some students.

Some school recommend that students avoid spicy foods.


Where is the pediatric data?

- JR

Cognitive rest for concussion management lacks data

  • Infectious Diseases in Children, October 2012
    Joshua Rotenberg, MD; Marc P DiFazio, MD, FAAN; Michael W Kirkwood, PhD
Raising awareness among pediatricians about how to best manage concussions in children and adolescents is important and more information is beginning to appear in various media. However, reports that encourage “cognitive rest” as the cornerstone of concussion treatment are not yet validated.
Unfortunately, although sports-related concussion is common in childhood, there is a paucity of empirical literature to support rest — cognitive or otherwise — as a management approach. Adding to the confusion, media reports implicate concussion in debilitating neurologic conditions and long-term neurodegenerative conditions; although to date, the evidence here remains speculative based on single case studies or survey data rather than controlled studies.

‘Second-impact syndrome’

There are reasons to briefly interrupt a child’s participation in contact sports after concussion. Patients may be at greater risk for injury, in general, if balance is affected and it allows time for adequate assessment of the injury. However, management during the past decade has emphasized removal from sports participation to lessen the risk for so-called “second-impact syndrome.”
Marc P. DiFazio
Marc P. DiFazio
This condition reportedly puts the individual at risk for fatal brain edema after a second concussion while still symptomatic from the first. However, critical analysis of the purported syndrome emphasizes the nebulous nature of this condition and even questions its existence. Catastrophic outcomes from sports-related concussion are much more likely to stem from acute intracranial bleeding after single concussions than diffuse edema or back-to-back concussions. Regardless of the exact pathology, death from sports-related head trauma in youth, although tragic in every case, is also several times less likely than death from sports-related cardiovascular events — and even less likely than death from lightning strikes.
Although physical exercise itself has never been implicated in worsening recovery from concussion, complete physical rest is commonly recommended. Additionally, many practitioners now recommend “cognitive rest” to supposedly hasten recovery. Cognitive rest remains ill-defined and usually entails a removal from school and cognitively stressful activities. A return of symptoms (pain, dizziness) upon reintroduction of activity, physical or otherwise, is considered causative of more injury, and further rest is prescribed. Patients are often told to rest until asymptomatic, often resulting in weeks missed from school, sports or extracurricular activities.
Michael W. Kirkwood
Michael W. Kirkwood
Currently, there is no evidence that the brain can be “put to rest” by refraining from such activity, and the increase in symptoms that may be associated with cognitive stress does not imply a worsening of the underlying concussive injury. That is, head pain and other nonspecific symptoms have not been shown to be definitive markers of ongoing cerebral injury. Although cognitive rest certainly sounds logical, brain activity is continuous and is generally uncontrolled by conscious means, and even during sleep intense brain remodeling and activity is evident.
Additionally, there is no good evidence in humans that rest results in brain healing or improved outcomes, and some data actually suggest that activity relatively soon after injury or while symptomatic has no effect on outcomes. Clearly, a standard-of-care guide regarding rest after sports-related concussion does not yet exist.

Negative effects of cognitive rest

Joshua Rotenberg
Joshua Rotenberg
Some might wonder whether there is really a downside to recommending cognitive rest. The implicit idea in the recommendation for rest is that if this is not followed, problems can be expected. In fact, prospective controlled studies demonstrate that most athletes recover well and relatively quickly with or without rest. More generally, psychoeducation and early reassurance after injury appears to reduce the chance of persistent symptoms after mild traumatic brain injury. This appears to support the clinical impression that patient or parental anxiety after a concussion can exacerbate symptoms and delay a return to typical functioning.
Adolescent obesity leads to midlife morbidity, and correspondingly, middle-aged adults who are obese have increased cardiovascular and neurologic health risks. Additionally, involvement in youth sports has long demonstrated physical and psychological benefits.

Individual approach to assessment

Given the lack of evidence supporting rest or even a symptom-free waiting period subsequent to a concussion, we approach our children and adolescents in a positive and reassuring fashion, avoiding rigid adherence to any particular management strategy. We recommend a return to exercise in a staged fashion, with an allowance for a self-determined escalation in activity, as tolerated. Regarding cognitive stress, we encourage a child’s return to school, albeit with temporary accommodations for headache and any cognitive difficulties that may occur. Frequent breaks and forgiveness for time and work missed are strongly recommended to avoid placing more stress on the student.
Children who experience concussion with recalcitrant symptoms or a previous history of neuropsychiatric difficulties are offered early psychological or medical intervention targeting anxiety, depression, fatigue, sleep difficulties or attentional challenges. Children are seen frequently and are encouraged and reassured that most who experience a mild traumatic brain injury have complete resolution within several weeks. We employ a number of indicators to craft an individual approach to assessment, including physical examination, symptom report, balance assessment, neurocognitive screenings, neuropsychological evaluation and screening for previous neuropsychiatric challenges. This approach is typically welcomed by parents, who are often relieved and reassured by the individualized care.
We hope that professional discourse among pediatric specialists will result in a data-driven approach to management of this common neurologic problem. Allowing anecdotes, popular beliefs or the media to dictate how we address this very frequent and long-standing sports-related complication is imprudent. Recommendations to avoid sports participation or exercise are potentially dangerous — given that more than 20% of children are obese — and as such are at greater risk for neurologic and cardiovascular complications during the lifespan, according to a 2012 study by Dattilo and colleagues.
Pediatricians should encourage exercise and sports participation while offering prudent counseling regarding concussion and brain protection throughout the life span.

  • Marc P. DiFazio, MD, FAAN, is the Medical Director of the Regional Outpatient Center and Assistant Professor of Neurology at Children’s National Medical Center in Washington, D.C. He is also Assistant Professor at the Uniformed Services University of the Health Sciences in Bethesda, Md. DiFazio can be reached at: marcdifazio@gmail.com.
    Michael W. Kirkwood, PhD, is from the Department of Physical Medicine & Rehabilitation at University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colo. Kirkwood can be reached at: Michael.Kirkwood@childrenscolorado.org.
    Joshua Rotenberg, MD, is Board Certified in Child and Adolescent Neurology and works with the Texas Medical & Sleep Specialists in Houston. Rotenberg can be reached at: pedzzz@gmail.com.
  • Disclosure: DiFazio, Kirkwood and Rotenberg report no relevant financial disclosures.

  • We thank Dr. DiFazio and colleagues for their editorial about cognitive rest as a treatment following concussion. Approximately 75% to 80% of traumatic brain injuries are mild and there is robust evidence that these seemingly minor injuries result in poor neurocognitive outcomes in an important proportion of pediatric patients.
    We agree with Dr. DiFazio’s group that there is equivocal evidence supporting, and significant controversy surrounding, ‘second-impact syndrome,’ and that this potential risk of death is extremely rare. However, we do not identify fatality risks due to second-impact syndrome as the driving force behind the recommendation for cognitive and physical rest following concussion. Instead, our focus is on the far more common morbidity and short-term disability following concussion due to metabolic mismatch and associated symptoms in the acute phase immediately following the injury.
    In this early phase, activities that place demands on brain metabolism (ie, physical exercise, learning or recreational activities such as school, video games and texting) divert metabolic resources away from the healing process. Research on pediatric concussion has demonstrated increased energy demand with decreased cerebral blood flow immediately following these injuries. Due to the time course of this physiologic process, treatment in the acute phase differs from management in the chronic stages of concussion. Patients with acute injury are more likely to seek emergency medicine and general pediatric care prior to referral to a subspecialist for more persisting symptoms from concussion. It is during the early initial acute phase post-injury when cognitive rest may be helpful in light of our current understanding of the pathophysiology of concussion.
    While we agree that the evidence surrounding the effectiveness of this treatment is still emerging, there are data supporting cognitive and physical rest immediately following concussion. Animal studies of exercise following traumatic brain injury demonstrate worse outcomes with early exercise, and better outcomes with later exercise. Other research on children with concussion shows increased symptoms and poorer cognitive testing performance with cognitive and physical disability in the early phase following injury, and improved performance with reduced symptoms following cognitive rest.
    Rather than being prescriptive about the absolute duration and of cognitive rest, we emphasize that it is variable, personalized to each specific child and directed by the elicitation of symptoms. We follow a gradual approach to “return to learn” with subsequent “return to play,” whereby patients and their families can continue a self-paced approach to recovery. Patients can progress to the next step in their recovery if symptoms resolve, and revert to a prior step if symptoms are elicited. Our steps, modeled after the Zurich Return to Play guidelines, include a graded re-entry into cognitive activity.
    Rest can vary from a day to a week or more, and is highly individualized. However, after the acute phase a few weeks following injury, cognitive rest has not been demonstrated to be helpful, and may actually be counterproductive. Rather, patients in this stage benefit from active rehabilitation including directed vestibular therapy as well as a graded aerobic therapy program. Of note, as our recommendation for cognitive rest is not synonymous with bed rest, includes a graded return to cognitive activity and is not meant to last indefinitely, we do not think a reasonable period of rest following injury would at all contribute to the emerging obesity epidemic as the authors suggest. Our aim in sports medicine is to return patients back to full participation in sports and other activities as safely and expeditiously as possible given our current understanding of pediatric and adolescent concussion.
    We believe prescribing a combination of appropriate initial rest with a progressive increase in activity in the acute phase, followed by active rehabilitation would in fact minimize the duration of symptomatology, while facilitating a timely return to both cognitive and physical activity.
    We agree with the authors that there is a great amount of needed research on this topic, including identifying the optimal time of rest and risk factors for poor outcomes. We fully support ongoing biomolecular and animal research focused on pathophysiology, biomechanical study of injury mechanisms, epidemiologic analysis of existing patient data, and clinical trials of various treatments in order to further the field of mild traumatic brain injury management. We would encourage that, while further data emerges, recommendations should focus on a “moderate” standpoint, whereby neither strict cognitive and physical rest for a pre-determined time, nor immediate resumption of physical or cognitive activities are recommended following injury. Instead, providers should first ‘do no harm’, and allow, during the acute phase of injury, the brains of acutely concussed children to rest for a reasonable duration that is primarily driven by individual symptomatology, with appropriate rehabilitation for children with chronic, prolonged symptoms.
    Kristy B. Arbogast, PhD
    Matthew F. Grady, MD
    Christina L. Master, MD
    Roni L. Robinson, RN, MSN, CRNP
    Douglas J. Wiebe, PhD
    Douglas J. Wiebe, PhD
    Mark R. Zonfrillo, MD, MSCE,
    • Kristy B. Arbogast, PhD, is from the Center for Injury Research and Prevention and the Division of Emergency Medicine at the Children’s Hospital of Philadelphia. Arbogast can be reached at arbogast@email.chop.edu.

      Matthew F. Grady, MD, is from the Sports Medicine and Performance Center at the Children's Hospital of Philadelphia. Grady can be reached at gradym@email.chop.edu.

      Christina L. Master, MD, is from the Sports Medicine and Performance Center at the Children's Hospital of Philadelphia. Master can be reached at masterc@email.chop.edu.

      Roni L. Robinson, RN, MSN, CRNP, is from the Sports Medicine and Performance Center at the Children's Hospital of Philadelphia. Robinson can be reached at robinsonr@email.chop.edu.

      Douglas J. Wiebe, PhD, is from the Center for Clinical Epidemiology and Biostatistics at the Perelman School of Medicine, University of Pennsylvania. Wiebe can be reached at dwiebe@exchange.upenn.edu.

      Mark R. Zonfrillo, MD, MSCE, is from the Center for Injury Research and Prevention and the Division of Emergency Medicine at the Children’s Hospital of Philadelphia. Zonfrillo can be reached at zonfrillo@email.chop.edu.

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