What is the recommended duration for keeping a child out of play after a mild concussion?

Return to Play Duration for Pediatric Mild Concussion

A child with a mild concussion must be kept out of play for a minimum of 5 days, during which they must first become completely symptom-free at rest and with exertion, then progress through a structured 5-stage return-to-play protocol with each stage lasting at least 24 hours. 1, 2

Immediate Management

• Never allow same-day return to play, even if the child becomes asymptomatic—this is an absolute contraindication 1
• Remove the child immediately from all physical activity when concussion is suspected 2
• Require evaluation by a healthcare professional experienced in concussion management before any return-to-play consideration 1, 2

Initial Rest Period

• The child must achieve complete resolution of symptoms both at rest AND with exertion before beginning the return-to-play protocol 1, 2
• Typical symptom resolution occurs within 7-10 days for most pediatric athletes, though this is longer than college or professional athletes 1
• Some children may require weeks to months for full recovery 1
• During this period, mandate both physical and cognitive rest, including modifications to school workload 1

Structured Return-to-Play Protocol

Once asymptomatic, the child progresses through these stages, with each stage requiring a minimum of 24 hours 1, 2:

Stage 1: Complete physical and cognitive rest (continue until asymptomatic) 1, 2

Stage 2: Light aerobic activity—walking, swimming, or stationary cycling at 70% maximum heart rate with no resistance exercises 1, 2

Stage 3: Sport-specific exercise—drills specific to the child's sport but with no head impact 1, 2

Stage 4: Noncontact training drills—more complex drills with light resistance training permitted 1, 2

Stage 5: Full-contact practice after medical clearance 1, 2

Stage 6: Return to normal game play 1, 2

Critical Management Points

• If any symptoms return at any stage, immediately stop activity 1, 2
• After symptom recurrence, wait until the child is asymptomatic for another 24 hours, then resume at the previous asymptomatic stage 1, 2
• The absolute minimum timeline from starting the protocol to full game participation is 5 days, assuming no symptom recurrence 1, 2
• When accounting for initial symptom resolution (typically 7-10 days) plus the 5-day protocol, most children require approximately 12-15 days minimum before returning to competition 1

Special Considerations

• Children with multiple concussions or prolonged symptoms require longer rehabilitation programs designed by a physician experienced in concussion management 1
• Consider prolonged removal or retirement from sports for any child with 3 concussions in one season or postconcussive symptoms lasting more than 3 months 1
• Pediatric athletes demonstrate longer cognitive recovery periods than older athletes, necessitating a more conservative approach even after becoming asymptomatic 1

Common Pitfalls to Avoid

• Do not rely solely on the child's self-report of being "fine"—children often underreport symptoms to return to play faster 1
• Do not skip stages in the protocol, even if the child feels completely normal 1, 2
• Do not allow progression if symptoms occur with cognitive exertion (schoolwork, screen time) even if physical rest is tolerated 1
• Avoid prolonged complete rest beyond initial symptom resolution, as excessive activity restriction may worsen outcomes 3