Head Impacts in Kids by Jillian Urban

How many of you have kids who play soccer, football, hockey, basketball? Have any of you had a concussion or know someone who has had a concussion, particularly a young athlete? Many of your may know that concussions are an important topic at the moment. Head injuries commonly occur in football, but they also occur in many other sports including soccer, lacrosse, cheerleading, and basketball. 

The Center for Injury Biomechanics at Wake Forest University has been working with the Childress Institute for Pediatric Trauma for the past two years, and that partnership is now entering its third year. In that time, the Institute has provided us with $350,000 to support medical image data collection as part of a pilot study to collect head impact, neurocognitive, and imaging data from 147 youth and high school athletes. We have collected tens of thousands of head impacts and medical images on a larger scale than has ever been attempted. This work has allowed us to apply for and receive a grant from the National Institutes of Health worth $3.5 million to continue this study in youth players for the next five years. The focus of our study is on football but there are many opportunities to study head injuries in other sports, helmeted and non-helmeted, as well as in boys and girls.

Other researchers have studied professional and college football for the past 10 years. There are only 2,000 NFL players and 100,000 college football players, one NFL player for every 50 collegiate players. However, these statistics are just the tip of the iceberg. There are approximately 1.3 million high school football athletes (ages 14-18) and 3.5 million youth athletes (ages 6-13). That is 1,750 youth football players for every NFL player. We have a tremendous number of youth athletes in this youngest age group, and it is the age group about which we know the least.  Young children’s brains are growing and developing so one of the questions we are asking is - what happens to the brain of a young athlete who has 100, 500, or even 1,000 impacts over the course of a football season? What can we do to avoid or mitigate these impacts?

We commonly think of exposure when we are talking about sun exposure.  We can apply this concept to head impacts where the concussion is a single bad event, similar to a sun burn, and a season or lifetime of impacts is analogous to a lifetime in the sun. Much of the focus of researchers for the past 10 years has been on the concussion – something that might happen once or twice over the course of a career.  However, the question at hand is what has a greater effect on the brain: a few concussions or a season or a playing career of subconcussive repetitive head impacts?

We are studying this using two methods. Before, post-concussion, and after the football season we collect medical imaging and neurocognitive data. The kids participating in the study come in for an appointment at the hospital where we perform a computer-based test that measures how fast they think and how well they remember things. We collect medical imaging data including a magnetoencephalography scan, or MEG, which listens to their brain - specifically the magnetic activity of the brain and an MRI, which takes different types of pictures of the brain but with no radiation. These together allow us to measure the functional activity of the brain, along with the structure of the brain.

In between the pre- and post-season scan, they practice and play football. We instrument the helmets of youth and high school football players with a sensor system that fits in the existing helmet. The sensor system sits on the crown of the head of the athlete and wirelessly transmits each head impact to a sideline laptop during all practices and games. We are measuring the location of impact on their helmet and the acceleration, representing the severity of the hit in terms of Gs. We use this data to better understand head impact exposure on the field in order to better inform safety on the field, helmet safety, and to better understand age-specific injury risk and injury mechanisms. Our imaging collaborators measure changes in the brain from the MRI and MEG and are looking to see if they correlate to the number and magnitude of impacts they have received.

We have found that many of our athletes are receiving a greater percentage of their head impact exposure during practices compared to games, which is something our players and coaches have direct control of through modifying practice drills and limiting the number of contact practices. Additionally, by studying two different groups with different league rules on contact practice with our partners at Virginia Tech, we have found that one league significantly reduced the head impact exposure of the athletes without affecting how hard they hit during games. 

The study has many opportunities to go beyond youth and high school football. There is a lot we do not know about female athletes and even non-helmeted sports such as soccer where we see a high incidence of concussion. The results of this study will help us to better understand how to reduce head impact exposure and ultimately keep our kids safe. 

- Jillian Urban, Wake Forest University Center for Injury Biomechanics

Long-term Goals for Kids by Dr. Meredith

The National Institutes of Health (NIH) is an agency within the Department of Health and Human Services and is the principal biomedical research arm of the Federal Government. The NIH is comprised of 27 institutes and centers focused on various health issues facing Americans. The institute that is focused on children’s health issues is the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

It is a very good thing, in my opinion, that the NICHD formed the Pediatric Trauma and Critical Illness Branch (PTCIB) in 2012. It demonstrates a recognition that, in our nation, one of the most serious public health problems for children is injury, and that injury in children requires and merits some focus by our nation's most important federally-funded research support structure. I'm very gratified to see that Valerie Maholmes has been appointed as the chief of this division. She has a lifetime of commitment to children, to children's health issues, children's injury issues. I believe she will exhibit great leadership for this branch.

In late April, Dr. Maholmes convened a strategic planning group that met in Bethesda to
clarify what its mission should be going forward and to advise the new branch on how it can best accomplish its mission.  It was a group of fantastically bright and dedicated people interested in the well-being of children, particularly children’s injury issues.  Over the course of two days in multiple brainstorming sessions, the group identified a set of issues and developed a set of recommendations that I think will serve as a great architecture to both define and begin the process of executing the strategic plan for children's injuries within the branch.

Personally, I believe that all of the parties in our country, who are interested in improving the care for children's injuries and changing outcomes for the most common cause of death and disability of our children, need to get behind this effort at the NIH. Furthermore, we need to approach this journey with a long-term view.

At its core, pediatric injury is a huge health problem in our country and we need to assist, support and foster this branch with a vision toward its long-term success.  Long-term success means it would be a highly-funded source for research information and for convening and deliberating on all research issues that relate to pediatric injuries for our country; a national resource.

It will take years for that vision to be realized; years of research productivity; years of matriculation through the NIH institutes; years of well-meaning grassroots efforts by those of us who are in trauma centers and pediatrician's offices, and families and churches and synagogues that are interested in making sure that we do something about the plague of death that trauma represents amongst our children.

It's going to be worth the long-term ride and if we all try to assure the investments that are made are not aimed at short-term studies, short-term turnarounds, short-term goals but, instead, are aimed at long-term, big vision, strategic efforts, I believe this branch will turn out to be something great.

- Dr. J. Wayne Meredith, Wake Forest Baptist Medical Center, Chair of the Department of Surgery and Medical Advisor to the Childress Institute for Pediatric Trauma

NICHD Pediatric Trauma and Critical Illness Branch

The Eunice Kennedy Shriver National Institute of ChildHealth and Human Development (NICHD) was established by President John F. Kennedy n 1962 to better understand processes of human development and how they affect health from preconception through adulthood. Over the course of its 50 year history, the NICHD has continued to advance scientific knowledge to further its mission to help children have the chance to achieve their full potential for healthy and productive lives, free from injury, disease or disability. 

I joined the NICHD family to contribute to this important mission. Initially my work focused on efforts to understand the impact of exposure to various types of violence on children’s development.  

Some of the research we support helps us understand the traumatic experience of child maltreatment and how it affects children not only in terms of the associated injuries, but also how it affects a child’s ability to make friends, perform well in school and establish productive relationships later in life. We also support prevention and intervention research efforts that address global violence, trauma and injury.

Through a visioning process, the NICHD listened to the community of researchers, practitioners and advocates to identify additional priorities that we could undertake over the next 10 years. An outcome of this process was that a new Branch was needed to focus specifically on critically ill and injured children.

In 2012, the Pediatric Trauma and Critical Illness Branch was established and I was named Chief in late 2013. The goal of the Branch is to look at the continuum of influences on child health outcomes. So, we not only focus on the prevention of childhood injury and trauma, but we also study processes that help critically ill and vulnerable children reach their highest potential in life.

To accomplish this goal, we plan to hold a series of meetings to help us identify important priorities that we will address over the next 3- 5 years. We have already held a scientific meeting on such important issues as abusive head trauma. We are very excited about a conference we held in April that shed light on the special health care needs of children in military families.    

Most importantly, we will collaborate with our colleagues and partners to call attention to help us achieve the NICHD mission to have children live free of disease or disability and lead productive lives. 

- Dr. Valerie Maholmes, Chief of NICHD Pediatric Trauma and Critical Illness Branch