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The question

My 12-year-old just got his second concussion in a year. Should we pull him out of hockey?

The answer

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In the past, some child athletes had coaches who were quick to dismiss concussions. But recently, we've collectively become more cautious, as we learn about the long-term damage related to these injuries.

Symptoms of concussions vary widely and include confusion, headache, poor coordination or balance, dizziness, difficulty determining time, date and place, a vacant stare, feeling dazed, feeling stunned, slurred speech, slowness to answer questions or follow directions, ringing in the ears, sleepiness, blurry or double vision. Over the long term symptoms can include troubles with memory and concentration.

Symptoms of mild concussion may be missed altogether.

The Canadian Pediatric Society advises that "an athlete with a concussive injury should not be allowed to return to activity until all signs and symptoms have resolved and the athlete has been cleared to do so by a physician." The CPS does acknowledge that the ideal length of the symptom-free period has not been established.

They suggest a multi-step return-to-play protocol:

Step 1: complete rest

Step 2: light exercise such as free-play, walking or stationary cycling

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Step 3: a sport-specific activity for 20 minutes

Step 4: on ice practice with no contact; and then finally a practice with body contact.

The management of multiple concussions remains controversial. There is no single position paper where all the experts in the field come to a common recommendation.

Because it is impossible to measure the degree of damage, one should err on the safe side (brain biopsies may be definitive, but that is an unrealistic route).

The bottom line: Be conservative for now, at least until we learn more about the long-term damage induced by concussions.

Send pediatrician Peter Nieman your questions at pediatrician@globeandmail.com. He will answer select questions, which could appear in The Globe and Mail and/or on The Globe and Mail web site. Your name will not be published if your question is chosen.

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Read more Q&As from Dr. Peter Nieman.

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The content provided in The Globe and Mail's Ask a Health Expert centre is for information purposes only and is neither intended to be relied upon nor to be a substitute for professional medical advice, diagnosis or treatment.

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