Doctor’s smartphone solution to child sport injuries

Paediatric hospital backs new guide to ‘doing the right thing’ on the sidelines

No parent standing on the sidelines watching their children play sport wants to imagine having to witness a serious injury on the scale of footballer Seamus Coleman’s double leg break in the recent Republic of Ireland’s World Cup qualifier game against Wales.

If you thought about it too much – and some risk-averse parents do – you would probably want to keep your little darlings away from all contact sport. But knowing the enjoyment and benefits it gives them, we keep our fingers crossed and cheer them on.

However accidents do happen and at most children's games the "first responders" will not be a team of paramedics in hi-vis jackets but rather onlooking parents. From years of standing on the sidelines watching his own children play sport, paediatric consultant Prof Alf Nicholson is all too familiar with the cry "is there a doctor here?" when a player goes down – and stays down.

“People seem to panic really when somebody faints or falls or does something unusual. There is the sense of ‘oh my God, could this be something really serious?’,” he says.


Believing that parents and coaches could benefit from advice on first aid for children’s sports injuries, he has been a driving force in establishing a new website to guide them.

“It is something I have felt for a long time that is needed, if there is no medical person at a match,” says Nicholson of Temple Street Children’s University Hospital in Dublin, where there is a “huge number of injuries coming through – sprains, cuts, bruises, ear injuries, concussion – from all sports”.

It would be nice if their parents or coaches “knew what the right thing to do is before they even got to us”, he remarks. While the term “first aid” is often taken to mean dealing with minor cuts and bruises, it is also about recognising potentially serious injuries and taking appropriate steps before medical help arrives.

Rather than produce a booklet, the idea was that, as a website, this free resource would be quickly accessible in the pockets of anybody on the sideline via a smartphone. If your child comes home with an injury, it’s a reference point for guidance on whether or not a trip to a hospital emergency department is needed. It is also going to be updated and developed in response to user feedback.

“There was nothing out there of this type,” says Nicholson. There was no trouble securing the domain name for what is a multi-disciplinary collaboration funded by the Temple Street Foundation, which enables it to be free of advertising and commercial vested interests.

No one wants to make sport so sanitised that there is no contact and it is basically just running around in circles.

He acknowledges that there is increased parental concern about the risk of injury, particularly concussion in contact sports such as football and rugby. But “no one wants to make sport so sanitised that there is no contact and it is basically just running around in circles”, he suggests.

However, there is no doubt that at the high end of schoolboy rugby for instance, players are much bigger and stronger and are therefore sustaining higher injuries than before. Do governing bodies need to look at rule changes?

“I think they probably do. I think the high level tackle is an issue,” replies Nicholson who believes that not allowing any tackling above the waist in schools rugby might be a good idea.

In all the debate about the risks of contact sports for children, the one thing that is missing is hard data. The Irish Medical Organisation has called for the mandatory reporting of injuries incurred by students playing sports in schools.

Dr Ray Walley, a north Dublin GP and former IMO president who proposed a motion on this issue, which was passed at the organisation's agm last year, points out that many rugby accidents happen in a school setting. If there is an injury to any employee in a workplace, it has to be reported to the Health and Safety Authority, yet there is no legal requirement for schools to do the same if a child is hurt on a sports field. (Nor do they have to report incidents of injuries to children to the Department of Education and Skills. )

He is not, of course, suggesting every graze should be mandatorily reported but we should have data on pupils who suffer fractures, neck and head injuries “and the State does not”. Whereas in Canada, for example, analysis of data from its Hospitals Injury Reporting and Prevention Programme, showed that ice hockey accounts for almost half of sports-related brain injuries among children aged five to 19, with soccer second on the list at 19 per cent and rugby fourth at 5.6 per cent.

We should know the extent of children’s sports injuries, Walley argues because “then you can plan for remedial action”. He cites the example in New Zealand where, in an effort to reduce rugby injuries, they have people within a certain weight range playing the sport together. “One has to ask, why have they done that?”

As Allyson Pollock, Prof of Public Health Research and Policy at Queen Mary, University of London, asked at the time of the publication of her book Tackling Rugby, What Every Parent Should Know About Injuries in 2014, "how can we prevent injuries if we don't know what they are or how often they occur?" She argued that all schools and rugby unions should be collecting data.

Her passionate crusade for rugby to be made safer for children was driven by the combination of the personal and the professional. After her eldest son had, by the age of 14, suffered three serious injuries – broken nose, leg and cheekbone – playing rugby, she decided to research the sport at schools level.

In a pilot study of six schools in Edinburgh, she found that over the course of a season, the average risk of injury to a player was one in six. In a 2014 Daily Mail article, headlined "Why NO mother should let her son play rugby", she wrote of discovering "that there is a culture of letting boys play on with a concussion, despite the fact that it can leave them brain damaged, and can prove lethal".

In 2011, Peter Robinson and Karen Walton saw their son Benjamin (14) pay the ultimate price for being allowed to play on with concussion when he died after a rugby match in Co Antrim. Their determination since to raise awareness about the dangers and the need for safety protocols has probably helped to prevent other deaths or, at least, serious injuries.

Of course rugby is not the only sport that carries a significant risk of concussion and Walley stresses that he is not singling it out. “What the IMO is looking for is an even playing field for all sports.” Likewise, although has a separate section on concussion, and parents are “very exercised” about it, Nicholson says that the website’s advice is very wide-ranging, covering topics from nutrition and playing sport with medical issues to first aid and conditions affecting young athletes in particular.

However, on the subject of concussion, he does add that parents may not be aware of just how important the first couple of days after such an injury are. In particular, they should know that at that stage, to aid recovery, a teenager should avoid or at least minimise any reading and screen activity. So while they may be resting at home from school, they should not be using a phone, computer or TV to while away the hours.

Zita McDermott, a nurse and former children’s officer with Cuala GAA club in south Co Dublin, thinks parents are much more aware of the risks of sports injuries “but being aware and doing something about it can be completely different”.

Although everybody involved in running the Dalkey-based club will always follow protocol in the case of a suspected head injury, occasionally some parents have to be strongly encouraged to refer a child to a healthcare professional afterwards – one of the “six Rs” for concussion (see panel). A child cannot return to playing unless cleared by a doctor – although coaches do take parents at their word on this, she says, and don’t demand to see a note.

Each team at Cuala, which has nearly 1,200 members aged under 18, takes responsibility for their own first aid. The club spent its last grant from the Sports Council on ensuring that every team had a proper first-aid kit, although the most important tool in the box is “common bloody sense”, McDermott suggests.

At every match, a parent will be designated to be in charge and run on to the pitch as necessary. If it is that parent’s child who is injured, another parent will go on.

“It is just easier for everybody,” she explains, “because if it’s an eight-year-old and mummy runs on he will burst into tears or, if it is an 18-year-old and mummy runs on, she will burst into tears!”

McDermott acknowledges that Cuala, which is riding high on the success of winning the All-Ireland Senior Hurling Club Championship in March, as well as being voted Best Sports Club in Ireland by The Irish Times last June, is lucky where it is situated. There are several appropriate medical facilities for an injured  child within a relatively short distance.

She has three sons who play GAA, as well as a husband who manages a team, and in their entire personal experience only once has an ambulance had to be called – for a knee injury. However, she recalls that on one day last year, at Cuala’s Thomastown Road pitch in Dún Laoghaire, two ambulances had to be called within 20 minutes after two incidents. So, as she points out, you just never know when something more serious might happen but mostly the injuries are cuts, friction burns from the astro turf and damaged fingers, wrists, and shoulders.

If we continuously try to eliminate risk, things end up being joyless, and we're not giving enough respect to the need for joy and fun.

Cuala has had defibrillators at its four playing venues since 2010 but has never had to use one on the field. However there’s no room for complacency and “if we come across a training session where a defib is locked there will be wigs on the green”, says McDermott. In reminding team managers to make sure it is unlocked, she points out that it is much more likely that they, rather than one of the children, would need it.

“In hurling they wear helmets and the helmets do work,” she adds, but you don’t want to eliminate risk by keeping youngsters away from contact sports. “The children who play sport absolutely thrive.”

Paranoid parents and their twisted perception of risks to children's safety is a pet subject of Stella O'Malley, a psychotherapist and author of Cotton Wool Kids. She says we are being "sold a pup" by commercial interests that we can live in a risk-free world, and we can't.

“If we continuously try to eliminate risk, things end up being joyless, and we’re not giving enough respect to the need for joy and fun.”

The real risk to our children’s lives is mental health issues, she argues. If we square up the statistics – one in four people has mental health issues, so it is much more likely that our child will have mental health issues than be concussed.

“We just focus on certain risks and we ignore others,” she says, with reports of freak accidents likely to generate parental fears out of all proportion.

“Sadly we don’t hear about the girl up the road who is too anxious to go to school,” says O’Malley who is based in Birr, Co Offaly. She talks about “all the utter misery” she witnesses among teenage clients in what is “an ordinary town in an ordinary country – we are not Aleppo”.

“I think we need to protect happiness – we are losing happiness in the name of health and safety, in the name of a risk-free society.”

She does not stop her seven-year-old son playing rugby because “we are not living in a country where physical risks are a big threat to our children but we are living in a country where mental health issues are more of a risk. I would be much more protective of his mental health.”

If you were to give a child a completely risk-free childhood, you would, ironically, have damaged them, she adds, because they won’t have learned to assess risk.

So the next time you watch in horror as your daughter gets a hockey ball in the face or your son limps off the soccer field, don’t be tempted to try to end their playing career. Instead, heed the advice of Prof Nicholson, who says: “The most important thing is to keep children playing sport – but to do so in the knowledge that if something were to happen, that you know what the first aid should be.”

Sideline sense: do you know?

The six Rs for dealing with concussion are:

Recognise: Learn the signs of suspected concussion.

Remove: If a player has suspected concussion he or she must be removed from play immediately.

Refer: The player should be referred to a qualified healthcare professional.

Rest: Players must rest from exercise until symptom-free and then start a Graduated Return to Play (GRIP). World Rugby recommends a more conservative return to play for children and adolescents.

Recover: Full recovery from concussion is required before return to play is authorised.

Return: The player should complete the GRIP protocol.

* A tooth that has been knocked out should be kept in milk to increase the chances of it being successfully replanted by a dentist.

* The Ricer (Rest, Ice, Compression, Elevation and Referral ) approach  should be taken for all soft tissue injuries.

* With nosebleeds, the child’s head should be tilted forwards rather than backwards and the nostrils pinched firmly for 10 minutes.

* No attempt should be made to push a broken nose back into place at the pitch side.

* Simple lacerations of the lip will heal on their own but the player should go to hospital if the cut significantly disrupts the lip border.

* For ear haematoma (sudden bruising), ice and compression should be applied, and do not be tempted to drain.

* Pain below the knee that is aggravated by exercise may be a sign of Osgood-Schlatter disease, which is extremely common in young, highly active adolescents at the time of their growth spurt.