What are the guidelines for concussion clearance in pediatric patients?

Concussion Clearance in Pediatric Patients

Pediatric athletes must never return to play on the same day of concussion, must be completely asymptomatic both at rest and with exertion, and must complete a minimum 5-day stepwise return-to-play protocol before receiving medical clearance from a healthcare professional experienced in concussion management. 1, 2

Immediate Management and Removal from Play

• Any child with suspected concussion must be immediately removed from play and evaluated by a healthcare professional, even if symptoms appear mild 1, 2, 3
• The phrase "When in doubt, sit them out!" is paramount—no same-day return to play is permitted under any circumstances, even if the child becomes asymptomatic 1, 2
• Loss of consciousness lasting longer than 30 seconds may indicate more significant intracranial injury requiring emergency evaluation 1

Initial Rest Period and Symptom Resolution

• Children require 24-48 hours of complete physical and cognitive rest immediately after concussion 1, 3
• The athlete must remain completely asymptomatic at rest before beginning any return-to-play protocol 1, 2
• Most pediatric concussions resolve within 7-10 days, but recovery in children takes longer than in college or professional athletes, often requiring weeks 1, 2
• Cognitive rest includes modifications to schoolwork, avoiding video games, computers, television, and loud music 1

Mandatory Stepwise Return-to-Play Protocol

Each stage must last a minimum of 24 hours, making the entire protocol at least 5 days before full game participation: 1, 2

1. No activity: Complete physical and cognitive rest until asymptomatic 2, 3
2. Light aerobic activity: Walking, swimming, or stationary cycling at 70% maximum heart rate; no resistance exercises 2
3. Sport-specific exercise: Football, soccer, or other sport-specific drills without head impact 2
4. Noncontact training drills: More complex drills; may start light resistance training 2
5. Full-contact practice: After medical clearance, participate in normal training 2
6. Return to play: Normal game participation 2

Critical Protocol Rules

• If any symptoms return at any stage, the athlete must immediately stop all activity 1, 2
• Once asymptomatic for 24 hours, return to the previous asymptomatic stage and attempt progression again 1, 2
• The athlete cannot skip stages or accelerate the timeline, even if feeling completely normal 1

Medical Clearance Requirements

• Medical clearance must be obtained from a healthcare professional experienced in concussion management before returning to play 1, 2
• Clearance should only be given when the athlete is completely asymptomatic both at rest and with exertion 1, 2
• Neuropsychological testing can be used as one tool to assist return-to-play decisions but alone does not determine clearance 1
• Structural neuroimaging (CT/MRI) is generally normal with concussion and does not guide return-to-play decisions 1, 3

Prolonged Symptoms and Specialist Referral

• Symptoms persisting beyond 10-14 days require multidisciplinary management and specialist referral 1, 3
• Approximately 10% of pediatric patients experience symptoms lasting more than 3 months 3
• Athletes with postconcussive symptoms for more than 3 months should be strongly considered for prolonged time away from sports 1

Retirement Considerations

• Any athlete with 3 concussions in a single season should be strongly considered for prolonged removal from sports 1
• Athletes with multiple concussions or long-term symptoms may require permanent retirement from contact or collision sports 1, 2
• If uncertain about retirement decisions, refer to a specialist with expertise in sport-related concussion 1

Common Pitfalls to Avoid

• Never allow return to play without medical clearance: Research shows 58% of athletes returned to play at 2 weeks without medical clearance, and 35% were still symptomatic 4
• Never permit medication masking: Athletes should not return to play while taking medications for concussion symptoms 1
• Never rush pediatric recovery: Children require more conservative management than adults due to longer cognitive recovery periods 1
• Never ignore cognitive symptoms: Academic accommodations are essential, as teachers may underestimate difficulties the student is experiencing 1