To whom would you refer a child with post-concussion symptoms?

Referral for Children with Post-Concussion Symptoms

Children with post-concussion symptoms should be referred to a pediatric neurologist or a specialist with expertise in sport-related concussion management, especially if symptoms persist beyond 1-6 weeks. 1

When to Refer

• Any child with post-concussion symptoms lasting longer than expected (1-6 weeks) should be referred to a specialist with expertise in sport-related concussion 1
• Children who have sustained 3 concussions in an individual season or have had postconcussive symptoms for more than 3 months should be referred for specialized evaluation 1
• Children with suspected concussions should first be evaluated by a healthcare professional, ideally a physician with experience in concussion management 1, 2
• If the primary care provider is not comfortable making determinations about return to sports or is contemplating permanent removal from sports, referral to a specialist is recommended 1

Appropriate Specialists for Referral

• Pediatric Neurologist: The most common subspecialist referral for post-concussion management 3
• Concussion Specialist: Physicians with specific expertise in sport-related concussion management 1, 4
• Pediatric Neurosurgeon: For cases where there is concern for structural brain abnormality or if neuroimaging shows abnormalities 1
• Multidisciplinary Concussion Clinic: For complex cases requiring coordinated care 4

Additional Specialist Referrals Based on Specific Symptoms

• Vestibular Therapist: For children with persistent dizziness, balance problems, or vestibular-ocular dysfunction 4, 5
• Vision Specialist/Neuro-ophthalmologist: For persistent visual disturbances or vision-related symptoms 4, 5
• Neuropsychologist: For cognitive assessment and management of cognitive symptoms 2, 4
• Mental Health Professional: For emotional symptoms, which can be treated with cognitive behavioral therapy 4, 5
• Physical Therapist: For cervical pain or dysfunction associated with post-concussion syndrome 5

Timing of Referral

• Initial evaluation should be done by a primary care provider or emergency department 1, 2
• If symptoms persist beyond 1-6 weeks, referral to a specialist is indicated 1, 6
• Immediate referral to emergency department is warranted if an athlete experiences worsening symptoms, repeated vomiting, severe headache, or deterioration in neurological status 1

Considerations for Primary Care Providers

• Many primary care pediatricians report barriers to diagnosis and treatment of concussions, resulting in referrals to specialists 3
• Nearly half of pediatric providers report inadequate training in performing neurocognitive assessments 3
• 76.6% of primary care pediatricians report referring some or all of their concussion patients for ongoing management 3

Management Before Referral

• Athletes with concussion should rest both physically and cognitively until symptoms have resolved 1, 2
• Athletes should never return to play while symptomatic at rest or with exertion 1, 2
• Return to play should follow a graded protocol with at least 24 hours between steps 1
• Teachers and school administrators should work with students to modify workloads to avoid exacerbation of symptoms 1

Cautions and Pitfalls

• Never allow return to play on the same day of concussion, even if symptoms resolve 1, 2
• Avoid premature return to cognitive or physical activities, which can exacerbate symptoms 1
• Be aware that pediatric and adolescent athletes generally have a longer recovery course than college and professional athletes 1, 2
• Consider that some symptoms may be pre-existing and not solely attributable to the concussion 6