When Can A Child Return to Learning?

Patient Presentation
A 9-year-old female came to clinic in the morning with a headache that began 4 days previously after a fall at school onto a concrete surface. The patient had been pushed down backwards and hit the posterior part of her head. Witnesses and the patient denied loss of consciousness but the patient said she was slow to get up. Ice was applied and the patient returned to her class, but a headache made her go to the school office and her parents were called to take her home. Over the next 24 hours she remained alert and appropriate but continued to have a constant headache including at night. Over the next 2 days, which were the weekend, her headache improved but would return after playing with her brothers or when watching TV. The family came to clinic because the headaches had continued over the weekend and she had scheduled dance lessons in the evening. She denied any nausea, emesis, dizziness, tinnitus, photo- or phonophobia, clumsiness or difficulty doing activities, or sleep problems. She denied problems with reading or taking longer to think. She had not had a headache yet today. The past medical history was positive for a febrile seizure as a 16 month old. There were no other head injuries or neurological problems. The family history was positive for an aunt with depression.

The pertinent physical exam showed a well-appearing female with normal vital signs and growth parameters were in the 10-25%. Her neurological examination was normal as was the rest of her examination. The diagnosis of head trauma with minor concussion that was improving was made. Since the headaches still had occurred the evening before and the child hadn’t been up in the morning for long, the physician said it was difficult to tell how the child might do at school that day. However, he recommended to keep her out of school for the rest of the day and to not go to dance in the evening. Then he said that she could return to school, but the parents and school would need to be aware that her symptoms could return. He recommended they talk with the school today to make sure that the school could have her do quieter activities for shorter times and that if her symptoms returned that she could go to the office. He told the parents that light, noise and the concentration of doing school work could make the symptoms return. He went over symptoms for the parents to monitor and instructions about when to call the office. The physician did not hear back from the family and they returned to clinic about 10 days later for an unrelated problem. They said that she had one more headache on the day of presentation but none since. She had returned to school and dance without any problems. About the same time, the pediatrician learned that the American Academy of Pediatrics had released new guidelines on returning to learning after a concussion and then he reviewed them because of this patient.

Discussion
Head injury whether because of athletics or other trauma is a common problem in pediatrics. Fortunately most are benign because they are low impact that may not even result in edema or bruising. However, others cause concussion or traumatic brain injuries. There are an estimated 1.7 million traumatic brain injuries in the US yearly. Concussion can be very difficult to diagnose because there may not be external signs and the symptoms are highly subjective. For example, difficulties with concentration and thought processing speed are concepts that can be difficult for patients to understand, can be variable, and highly individualized. It can be even more difficult with younger children who really may not understand what a provider or parent is trying to ask them. There are symptoms scales available that can help with initial diagnosis and monitoring that were developed for concussion after athletic injury. These are the SCAT 3 for patients 13 years and older and the Child SCAT 3 for patients 5-12 years. The American Academy of Pediatrics Clinical Report also has symptom checklists available.

The school setting itself can provide challenges to student after a concussion. Schools are often noisy, visually stimulating, and require differentiated attention and behavioral standards which may be difficult for a concussed student to manage without adjustments being made. Fortunately most students with concussions recover within 1-3 weeks and adjustments in the classroom and other school settings can often be easily made by the regular education teachers and adminstrators. Examples would be frequent breaks, change of classroom seating, having lunch/recess in a quiet area, allowing extra time for assignment/assessment completion, giving prepared notes, etc.. For students with more prolonged symptoms, they would need more intensive evaluation and/or monitoring by concussion specialists, and in the school may or may not need a more formalized plan of adjustments or longer term accommodations or modifications in the school setting. For these students it is important to realize that these adjustments, accommodations and modifications need to carry over into the broad range of extra curricular activities also such as music, speech and debate, chess or language clubs, robotics or theatre.

Educational terminology that health care providers should be familiar with include:

  • Adjustments are usually short term changes to the physical or educational environment and instruction. These do not require a formalized educational plan and are the normal changes that teachers and administrators make allowing for each individual student’s circumstances.
  • Accommodations allow a student to complete the same tasks as their typical peers but with some variation in time, format, setting and/or presentation. The purpose is to provide the student with equal access to learning and an equal opportunity to show what he knows and what he can do. It does not change the instruction level, content or performance criteria.
  • Modifications are alterations in instructional level, content or performance criteria (one or more of those elements) for a given assignment. These are change in what students are expected to learn, based on their individual abilities

Formalized educational plans fall under two major different types:

  • IEP – individualized education plan which is often called special education. This comes from US Federal law under the Individuals with Disabilities Education Act or IDEA.
  • 504 plan – this is a formalized plan for students who may not meet the specific eligibility for an IEP, but still need/require accommodations and modifications. This comes from a US Federal Law under the Americans with Disabilities Act and the Rehabilitation Act.
    Students with many chronic medical conditions have 504 plans such as patients with diabetes who need to check glucose levels at school.

For more information about formalized educational plans, click here.

Learning Point
The American Academy of Pediatrics also recommends a team approach to management of students with concussion including health care professionals, educators and the patient/family in helping the patient to return to learning and extracurricular activities. It also recommends that students who are able to tolerate 30-45 minutes of cognitive activity and stimulation can go to school with appropriate adjustments. Students who cannot tolerate this amount of cognitive activity or stimulation should remain home. The patient should be performing at baseline academically before extracurricular activities are allowed.

Many health care providers will recommend cognitive rest and then as symptoms and concentration improves light mental activities such as light reading, watching television, social interactions etc. can be started and increased in intensity and time as the patient tolerates. However, “…to date, there is no research documenting the benefits or harm of these methods in either the prolongation of symptoms or the ultimate outcome for the student following a concussion.”

Questions for Further Discussion
1. What are indications for head imaging in head trauma?
2. Who are the contacts in your local school system who could help to manage educational adjustments for students with concussions?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Concussion, Developmental Disabilities, and School Health.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Consensus statement, SCAT3. Br J Sports Med 2013;47:5 259.

Consensus statement, Child SCAT3, Br J Sports Med 2013;47:5 263.

Halstead ME, Devore CD, Carl R, Lee M, Logan K, Council on Sports Medicine and Fitness and Council on School Health. Returning to Learning Following a Concussion. American Academy of Pediatrics.
Available from the Internet at http://pediatrics.aappublications.org/content/early/2013/10/23/peds.2013-2867.abstract (rev. 10/27/13, cited 11/5/13).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Causes Muscle Weakness?

    Patient Presentation
    A 9-year-old male came to clinic with rhinitis and left ear pain that began 2 days before. The ear pain was intermittent and there was no fever. He had been otherwise well and had not seen a physician for 3-4 years, “Because he’s never sick,” said his father. The past medical history was non-contributory. The family history was positive for stroke and depression. There were no mental, genetic, or neurological diseases in the family. The father had an adult male first cousin who walks on his toes without any other gait problems.

    The pertinent physical exam showed a healthy boy with normal growth parameters. His temperature was 100.6°F. HEENT showed clear rhinorrhea and a normal pharynx. His left ear had a small amount of fluid but was grey and had normal landmarks. During the examination the physician noted that the boy seemed somewhat floppy in the way he walked to the table and got onto it. His neurological examination was remarkable for some mild hypotonia generally, muscle strength that was against gravity and some resistence, but he easily tired. There were 4 beats of clonus in both ankles. He had normal rapid alternating movements, finger-to-nose and no pronator drift. No soft neurological signs were seen during the examination. When asked to heel-toe walk along a line on the tiles he was not able to coordinate it, nor could he duck walk. When walking normally he would toe walk. His heel cords were somewhat tight. When attempting a Gower maneuver he was able to stand without assistance but did rest one hand on a leg. When he got up from a chair he was also observed to push off the father and the chair.

    The diagnosis of otalgia with serous otitis media was made. The father reported that his son was “not the most athletic or coordinated” and the boy had a lot of problems with handwriting. It took him a long time to write and it was very messy. The father denied him sitting in a “W” position or wrapping his legs around chairs for stability. The diagnosis of a possible underlying neuromuscular problem was considered because of the toe-walking, mild hypotonia and weakness.

    The work-up included calcium, magnesium, phosphorus, potassium, creatinine phosphokinase, lactate dehydrogenase, aldolase and thyroid function tests which were performed and were normal. The physician talked with the family that this could be a mild form of a neuromuscular problem that the child should be evaluated for so that possible treatments and assistance could be offered. The patient was referred to a pediatric neurologist and some exercises to stretch his heel cords were demonstrated. The physician said that other help such as formal physical therapy, occupational therapy, or orthopaedics consultations might be done based on what the neurologist discovered.

    Discussion
    Muscle tone is the slight tension that is felt in a muscle when it is voluntarily relaxed. It can be assessed by asking the patient to relax and then taking the muscles through a range of motion such as moving the wrists, forearm and upper arm. Muscle strength is the muscle’s force against active resistance. Impaired strength is called weakness or paresis. There are 5 levels of muscle strength.

    • 0 = No muscle contraction detected
    • 1 = Barely detected flicker of contraction
    • 2 = Active movement with gravity eliminated
    • 3 = Active movement against gravity
    • 4 = Active movement against gravity and some resistance
    • 5 = Active movement against full resistance. This is normal muscle strength.

    Toe walking is common in toddlers who are learning to walk. It becomes less common as children age. The most common reason for toewalking is tight heel cords or an undiagnosed neurological problems such as mild spastic diplegic cerebral palsy, muscular dystrophy, or spina bifida occulta.
    Stretching of heel cords can improve the problem.

    Learning Point
    The differential diagnosis of hypotonia with and without weakness includes:

    • Hypotonia with weakness
      • Acute
        • Botulism
        • Diphtheria
        • Hypokalemia
        • Guillian Barre syndrome
        • Mental illness
          • Hysteria
          • Malingering
        • Polyneuropathies
        • Poliomyelitis
        • Transverse myelitis
      • Chronic
        • Muscle or nerve disease
          • Muscular dystrophy – Duchenne’s, Wernig-Hoffman syndrome, myotonic dystrophy
          • Peroneal nerve atrophy
          • Spinal muscle atrophy
        • Autoimmune
          • Dermatomyositis
          • Myasthenia gravis
          • Systemic lupus erythematosis
        • Central nervous system
          • Amyotrophic lateral sclerosis
          • Cervical spinal cord injury
          • Static encephalopathy
          • Space occupying lesions
        • Metabolic
          • Glycogenoses
          • Lipoidoses
          • Mucopolysaccharidoses
          • Myoglobinuria
          • Organic acidurias
          • Parathyroidism – hypo and hyper
          • Porphyria
        • Syndromes
          • Leigh
          • Krabbe
          • Lowe
          • McCardle
          • Refsum
        • Disuse
      • Hypotonia without weakness
        • Cerebral palsy – hypotonic form
        • Benign congenital hypotonia
        • Metabolic disease
          • Celiac Disease
          • Congenital heart disease
          • Hypothyroidism
          • Hypercalcemia
          • Renal tubal acidosis
          • Rickets
        • Syndrome and Genetic diseases
          • Down syndrome
          • Ehler-Dahlos
          • Marfan
          • Prader-Willi
          • Rett

      For hypotonia in an infant, click here.

      Questions for Further Discussion
      1. What other professionals might be needed by this child?
      2. What are indications for a muscle biopsy?
      3. What are indications for a genetics evaluation?

      Related Cases

      To Learn More
      To view pediatric review articles on this topic from the past year check PubMed.

      Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

      Information prescriptions for patients can be found at MedlinePlus for these topics: Myositis and Muscular Dystrophy.

      To view current news articles on this topic check Google News.

      To view images related to this topic check Google Images.

      To view videos related to this topic check YouTube

      Sheldon SH Levy HB. Pediatric Differential Diagnosis. 2nd Edit. Second Edition. Raven Press: New York. 1985:177-183.

      Bates B. Guide to Physical Examination. Third Edit. Lippincott Company, Philadelphia, PA. 1986:390.

      Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:256-260.

      Huff KR. Hypotonia, in Pediatrics a Primary Care Approach, Berkowitz CD, ed. W.B. Saunders Co. Philadelphia, PA. 1996;369-373.

      ACGME Competencies Highlighted by Case

    • Patient Care
      1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
      2. Essential and accurate information about the patients’ is gathered.
      3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
      4. Patient management plans are developed and carried out.
      5. Patients and their families are counseled and educated.
      7. All medical and invasive procedures considered essential for the area of practice are competently performed.
      8. Health care services aimed at preventing health problems or maintaining health are provided.
      9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

    • Medical Knowledge
      10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
      11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    • Interpersonal and Communication Skills
      19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

    • Professionalism
      20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
      21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
      22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

      Author

      Donna M. D’Alessandro, MD
      Professor of Pediatrics, University of Iowa Children’s Hospital

    • What Causes Acute Urticaria?

      Patient Presentation
      A 4-year-old female came to clinic with a pruritic rash of 1 day duration. She had upper respiratory symptoms for 4 days and the previous evening she began to have a rash on her trunk, upper arms and legs. Her mother described transient lesions, but themselves each appears slightly papular with a lighter center and erythematous base. She had tried a topical steroid without relief. The past medical history was non-contributory. The pertinent physical exam revealed a healthy female with normal vital signs and growth parameters. HEENT showed clear rhinitis and a small amount of fluid in both ears at the bases. Her skin examination had 3-5 mm erythematous macular lesions with a slight papular component centrally. Some seemed to be fading and others progressing. The patient had obviously been scratching areas of the trunk, arms, and legs. The rest of her examination was normal.

      The diagnosis of acute urticaria was made. The mother was told that it was most likely due to the upper respiratory tract infection and the natural history was discussed. She was advised to try a diphenhydramine for the pruritis and to return if there were any problems with swallowing or difficulty breathing or if the symptoms did not resolve in a few days.

      Discussion
      Urticaria or hives is a systemic disease with cutaneous results. An agent triggers a histamine reaction with cutaneous pruritic lesions being the result. Urticaria usually has intact, erythematous lesions with a papular component that is usually paler in color. Lesions are of various sizes and wax and wane. The lesions may coalesce and blanch with pressure. Scratches and excoriations may be seen. Bullae can be seen in certain circumstances.

      Evaluation for systemic reaction is important such as hoarseness, stridor, wheezing, difficulty breathing, arrhythmias, difficulty swallowing or tingling. Acute urticaria is defined as urticaria for less than 6 weeks. Chronic urticaria is defined as wheals that occur at least twice weekly for more than 6 weeks. Because this is a broad definition, some people add that the wheals must be present for more than 1 hour (which distinguishes chronic urticaria from dermatographism) and less than 24-36 hours (which distinguishes it from urticaria-vasculitis). The maintstays of treatment are antihistamines, short-acting ones for acute urticaria and long-acting ones for chronic urticaria.

      Mastocytosis or angioedema may appear similar to urticaria but are different. Angioedema frequently occurs in mucous membranes and may or may not have urticarial wheals present. Mastocytosis is a heterogeneous group of mast cell disorders which may cause wheal-like lesions on the skin.

      Learning Point
      The most common cause of acute urticaria is respiratory viral infections.

      The differential diagnosis of acute urticaria includes:

      • Blood products
      • Contact/Topical exposure – soaps, lotions, detergents
      • Drugs – many including antibiotics, ACE inhibitors, NSAIDS, opiates, radiocontrast, components of biological agents, preservatives
      • Food – peanuts, tree nuts, eggs, milk, shellfish, strawberries, chocolate, etc.
      • Dyes and preservatives
      • Environmental and inhalant
      • Idiopathic
      • Insect bites
      • Infections – hepatitis, Epstein-Barr virus, upper respiratory tract infections, Streptococcus
      • Physical – dermographism, cold, cholinergic, heat or solar, aquagenic

      Questions for Further Discussion
      1. What are indications for evaluation by an allergist?
      2. What are indications for prescribing prophylactic epinephrine (i.e. Epi-Pen®)?

      Related Cases

      To Learn More
      To view pediatric review articles on this topic from the past year check PubMed.

      Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

      Information prescriptions for patients can be found at MedlinePlus for these topics: Hives.
      To view current news articles on this topic check Google News.

      To view images related to this topic check Google Images.

      To view videos related to this topic check YouTube Videos.

      Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:352.

      Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:221.

      Leech S, Grattan C, Lloyd K, Deacock S, Williams L, Langford A, Warner J; Science and Research Department, Royal College of Paediatrics and Child Health.The RCPCH care pathway for children with urticaria, angio-oedema or mastocytosis: an evidence and consensus based national approach. The RCPCH care pathway for children with urticaria, angio-oedema or mastocytosis: an evidence and consensus based national approach. Arch Dis Child. 2011 Nov;96 Suppl 2:i34-7.

      Marrouche N, Grattan C. Childhood urticaria. Curr Opin Allergy Clin Immunol. 2012 Oct;12(5):485-90.

      ACGME Competencies Highlighted by Case

    • Patient Care
      1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
      2. Essential and accurate information about the patients’ is gathered.
      3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
      4. Patient management plans are developed and carried out.
      5. Patients and their families are counseled and educated.
      8. Health care services aimed at preventing health problems or maintaining health are provided.

    • Medical Knowledge
      10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
      11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

      Author

      Donna M. D’Alessandro, MD
      Professor of Pediatrics, University of Iowa Children’s Hospital