What are the management and treatment options for a suspected concussion in a 2 1/2-year-old boy?

Management of Suspected Concussion in a 2½-Year-Old Boy

For a 2½-year-old with suspected concussion, immediately assess for high-risk features requiring emergency imaging (altered mental status, GCS ≤14, palpable skull fracture), provide 24-48 hours of complete physical and cognitive rest, then gradually resume normal activities while monitoring for concerning symptoms, with strict avoidance of any return to high-risk activities until fully asymptomatic. 1, 2

Immediate Assessment and Risk Stratification

Use PECARN criteria to determine imaging needs and severity:

• High-risk features in children <2 years include GCS score of 14, any signs of altered mental status, or any palpable skull fracture (4.4% risk of clinically important injury requiring immediate CT imaging) 2
• Intermediate-risk features include GCS of 15 with normal mental status but loss of consciousness >5 seconds, severe mechanism of injury (high-speed motor vehicle accident, fall from significant height), or not acting normally per parent (0.9% risk of clinically important injury) 2
• Very low-risk features include GCS of 15, no palpable skull fracture, nonfrontal scalp hematoma only, loss of consciousness ≤5 seconds, non-severe mechanism, stable vital signs, and normal behavior 2

Red flags requiring emergency medical attention include loss of consciousness, severe or worsening headache, repeated vomiting, altered mental status, seizures, visual changes, or scalp deformities 3

Imaging Decisions

• Obtain immediate non-contrast CT for any high-risk patient with GCS ≤14, altered mental status, or palpable skull fracture 2
• CT is first-line imaging due to rapid acquisition, excellent sensitivity for acute hemorrhage and fractures, and no sedation requirement 2
• Do not use skull radiographs as they miss up to 50% of intracranial injuries and cannot evaluate brain parenchyma 2
• Maintain low threshold for neuroimaging in children <1 year with any concerning findings, or any child with unexplained injuries or inconsistent history suggesting non-accidental trauma 2

Acute Management Protocol

Initial rest period (first 24-48 hours):

• Complete physical and cognitive rest for the first 24-48 hours after concussion 3
• This means no running, jumping, rough play, screen time, or cognitively demanding activities 1

After initial rest period:

• Gradually resume light activities as tolerated without symptom provocation 1
• Avoid strict prolonged rest beyond 48 hours as evidence shows this may be detrimental to recovery 1
• Monitor for symptom exacerbation with any activity and pull back if symptoms worsen 1

Medication Considerations

Avoid NSAIDs and aspirin in the immediate post-injury period due to theoretical risk of potentiating intracranial bleeding, though no studies have documented actual harm from sport-related concussions 1

• Acetaminophen may be used cautiously for headache management if needed 1
• No evidence supports NSAIDs or acetaminophen for shortening concussion course 1
• Animal studies suggest chronic ibuprofen may worsen cognitive outcomes after traumatic brain injury 1

Monitoring for Concerning Symptoms

Seek immediate medical attention if the child develops:

• Persistent or worsening vomiting 2
• Increasing drowsiness or difficulty waking 2
• Seizure activity 2
• Worsening headache 2
• Excessive irritability or behavior changes 2
• Unsteady walking or coordination problems 2
• Unequal pupil size 2

Reassuring signs include:

• Return to baseline behavior and activity level 2
• Stable vital signs 2
• Normal eating and sleeping patterns 2

Recovery Expectations and Follow-up

Typical recovery timeline:

• Most children recover within 7-10 days, though some may take weeks to months 4, 3
• Pediatric patients generally have longer recovery than older athletes 4
• Approximately 80-90% recover within one month 3

Follow-up care:

• All children with diagnosed concussion should be evaluated by a healthcare professional experienced in concussion management before returning to high-risk activities 4
• Consider referral to concussion specialist if symptoms persist beyond 10-14 days 3
• Provide written discharge instructions including warning signs, expected symptom course, monitoring instructions, and clear follow-up plan 2

Special Considerations for Toddlers

Age-specific challenges:

• Toddlers cannot reliably report symptoms, requiring heavy reliance on parental observation of behavior changes 1
• Look for irritability, changes in eating or sleeping patterns, loss of interest in favorite toys or activities, and regression of developmental milestones 1
• Maintain higher index of suspicion in very young children due to ongoing brain development 1

Return to Activities

For a 2½-year-old, gradual return to normal play activities:

• Start with quiet play activities once asymptomatic at rest 1
• Progress to light physical activity (walking, gentle play) 1
• Advance to normal play activities only when completely asymptomatic with exertion 1
• Never allow return to high-risk activities (playground climbing, running, rough play) while any symptoms persist 1

Critical Pitfalls to Avoid

• Do not discharge without providing written instructions on warning signs and follow-up 2
• Do not assume normal behavior rules out concussion in the acute setting, as symptoms may evolve over hours 1
• Do not rely on loss of consciousness as a diagnostic criterion, as it occurs in less than 10% of concussions 4
• Do not prescribe prolonged strict rest beyond 48 hours, as this may delay recovery 1