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Counterpoint: minor injuries may not be all that minor
  1. Frederick Rivara
  1. Correspondence to Dr Frederick Rivara, Harborview Injury Prevention and Research Center, University of Washington, Box 359960, Seattle, Washington, USA; fpr{at}

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I agree with many of the points that Molcho and Pickett1 make in their commentary published in Injury Prevention (see page 147); I like their table outlining acceptable and non-acceptable injuries to children. I have long ignored injuries that do not make it to medical attention. Injuries requiring a band-aid and a mother's kiss are a part of growing up.


It is important that we are very careful what we call ‘non-severe’, to use the author's terminology. What was not viewed as severe last year may, in fact, carry the risk of significant disability, especially if recurrent. Concussion is an important case in point. Youth playing American-style football, ice hockey, rugby, soccer and basketball can and do sustain concussions during practice and play.2 In the past, getting ‘dinged’ or ‘getting your bell rung’ was viewed as a normal part of the game, something to be ‘sucked up’ and treated at the most by sitting out for a few plays.

Recent data have changed both the medical profession's and public's attitudes about these injuries. Concussions do not require, and in fact most do not have, a loss of consciousness.3 Impacts to the head resulting in abnormal brain function with a normal head CT scan are concussions. After sustaining a concussion, the brain undergoes a series of molecular changes,4 which appear to be more vulnerable to both repeat concussion and the risk of more serious injury,5 such as the second impact syndrome.6 There is now a well-described set of symptoms that may occur after concussion and may last for many weeks or months.7 More concerning are sophisticated imaging studies, such a functional MRI or diffusion tensor imaging, which can show abnormalities in the brain for months after a concussion, and long after symptoms have resolved.8 9

The long-term effects of repeated concussions are still unclear, but are of concern. Reports of prolonged symptoms,10 especially for those with multiple concussions,11 are concerning. Individuals can have impaired performance on neurocognitive tests even after symptoms have resolved.12 Chronic traumatic encephalopathy has been described in the brains of American football players on post-mortem examination, including some individuals in the third decade of life.13 Repeated concussions are also associated with dementia, including Alzheimer's disease.14

Some critics may believe that these long-term problems are just seen in professional athletes and not in children and adolescents. My response is twofold. First, nearly all those professional athletes started playing in their youth, some at very young ages. Therefore, some of those concussions almost inevitably occurred during their childhood. Second, this area of investigation has far more questions than answers; we honestly do not know what these concussions in youth mean long term.

The other issue about severity is that the difference between a severe injury and a non-severe injury may be more a matter of luck than a fundamental difference in activity or exposure. A fall from a bicycle may result in a scratched arm requiring the band-aid and mother's kiss, or the same fall in an unhelmeted child may result in a serious brain injury.

‘Normative’ behaviour

The author of the commentary also believes that injuries are acceptable if the behaviour engaged in while injured is ‘regular/normative’. Whose norms? When I make rounds on the trauma ward of our regional trauma centre, I am constantly amazed at what many parents consider to be normative. Is riding a motorised dirt bike or all-terrain vehicle at the age of 10 years normative? For some families it is. Dad did it, so did uncle and brother. So what is wrong with it, doc? Some one-third of households in the USA have guns in the home, a practice that increases the risk of homicide and suicide substantially.15 16 For this country, gun ownership may be described as normative, but it clearly also carries risks.

Psychic toll of trauma

In the past, we have all too often ignored the effects of injuries on the mental health of children and their parents. Acute stress disorder is not uncommon in children and parents after a motor vehicle crash, and can occur in the absence of injuries.17 Post-traumatic stress disorder does occur in children after trauma, and can impair function and recovery from trauma. Few physicians screen for such emotional consequences of injury, and even fewer children receive treatment for it.

Our profession

I agree that our field of injury control should not take the stand that every injury must be prevented. Being ‘prevention fanatics’ risks us being ignored. Advice to ‘baby proof’ a home to avoid all injuries probably does little good. Specific advice to avoid the big injuries such as using a child seat restraint, wearing a bike helmet and installing a smoke detector are both more likely to be followed and more likely to do good. Following common sense is usually the right thing to do.

We do not want to foster a ‘nanny state’, but neither do we want to disregard injury problems that may have hidden, but serious, consequences. Our efforts should be based on scientific evidence and not opinion.



  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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