What is the immediate management for a 6-year-old child diagnosed with a brain concussion?

Immediate Management of Brain Concussion in a 6-Year-Old

For a 6-year-old child with a diagnosed concussion, immediately implement strict physical and cognitive rest for the first 3 days, provide comprehensive family education about warning signs and expected recovery, and schedule close follow-up with gradual return to activity thereafter. 1

Initial Rest Period (First 3 Days)

The child should observe more restrictive physical and cognitive activity during the first several days after injury. 1 This includes:

• Allow the child to sleep as needed - sleep itself poses no risk to appropriately evaluated children without red flag symptoms 2
• Limit screen time, reading, and cognitively demanding activities 1
• Keep the child home from school during this initial period 1
• Avoid all sports and physical exertion 1

The evidence strongly supports that immediate rest (within the first 3 days) improves recovery outcomes - children who started rest immediately recovered 4.6 days sooner than those who delayed rest 3. However, prolonged inactivity beyond 3 days may actually worsen symptoms in most children 1.

Critical Family Education (Level A Recommendation)

You must provide comprehensive discharge instructions covering: 1

Warning Signs Requiring Emergency Evaluation:

• Severe or worsening headache 2
• Clear or bloody fluid from nose or ears 2
• Loss of consciousness or inability to wake the child 2
• Repeated vomiting or seizures 2
• Weakness, numbness, or decreased coordination 1

Monitoring Instructions:

• Check on the child periodically to ensure they can be aroused to baseline consciousness 2
• Track postconcussive symptoms (headache, dizziness, confusion, sleep disturbances) 1
• Document symptom number and severity daily 1

Expected Course:

• Describe the injury mechanism and typical recovery timeline 1
• Most children recover within 2-4 weeks 1
• Emphasize prevention of reinjury during the vulnerable recovery period 1

Gradual Return to Activity (After Day 3)

Following the initial restrictive period, resume a gradual schedule of activity that does not exacerbate symptoms, with close monitoring of symptom expression. 1

Stepwise Progression:

1. Light cognitive activity - short periods of reading, homework (15-20 minutes) if symptoms remain stable 1
2. Light aerobic activity - walking, light stationary cycling at <70% maximum heart rate, no resistance training 1
3. School reintegration - partial days initially, with accommodations as needed 1
4. Sport-specific exercise - only after full return to school without symptoms 1

Critical rule: If symptoms worsen at any stage, return to the previous level for 24 hours before attempting progression again. 1

Active Rehabilitation Program

After successful gradual activity resumption, offer an active rehabilitation program of progressive reintroduction of noncontact aerobic activity. 1 This is a Level B recommendation with high-quality evidence. 1

• Begin when the child tolerates school and daily activities without symptom exacerbation 1
• Progressive aerobic exercise below symptom threshold actually reduces postconcussive symptoms 1
• Continue close monitoring of symptom number and severity 1

Return to Full Activity Criteria

The child may return to full activity only when: 1

• Symptom-free at rest for at least 24 hours 1
• Symptom-free with increasing levels of physical exertion 1
• Returned to premorbid performance levels in school and activities 1
• Cleared by a physician 4

Follow-Up Schedule

Arrange clear follow-up within 3-5 days to reassess symptoms and adjust the activity plan. 1 Earlier follow-up is needed if:

• Symptoms worsen or new symptoms develop 1
• Sleep disturbances persist (difficulty falling asleep, excessive sleep, nonrestorative sleep) 2
• Symptoms persist beyond 2 weeks 1

Common Pitfalls to Avoid

Do not enforce prolonged complete rest beyond 3 days - this can worsen outcomes through physical deconditioning and psychological consequences of activity restriction. 1, 5 The outdated practice of "cocoon therapy" (complete isolation and rest) is not supported by current evidence. 6, 5

Do not prevent the child from sleeping - the old practice of waking children every 2 hours is unnecessary if they have been appropriately evaluated and show no red flags. 2

Do not allow premature return to contact sports - the reinjury threshold is lower during recovery, and reinjury during this vulnerable period can result in greater symptom burden. 1