Return to Play Protocol for Pediatric Concussion
Pediatric and adolescent athletes with concussion must never return to play on the same day of injury and should follow a structured 6-stage graduated protocol requiring a minimum of 5 days, with each stage lasting at least 24 hours. 1
Absolute Contraindications to Same-Day Return
- No child or adolescent should return to play on the same day of concussion, regardless of symptom resolution. 1
- Athletes must be completely asymptomatic both at rest and with exertion before beginning the return-to-play protocol. 1
- Medical clearance from a licensed healthcare professional trained in concussion management is mandatory before return to play. 1
The 6-Stage Graduated Protocol
The American Academy of Pediatrics endorses this stepwise progression, with each stage requiring a minimum of 24 hours: 1
Stage 1: Complete Rest
- Complete physical and cognitive rest until asymptomatic at rest. 1
- This includes restriction from school work that may exacerbate symptoms. 1
Stage 2: Light Aerobic Activity
- Walking, swimming, or stationary cycling at ≤70% maximum heart rate. 1
- No resistance exercises permitted. 1
- If symptoms return, stop immediately and restart after 24 hours of being asymptomatic. 1
Stage 3: Sport-Specific Exercise
- Sport-related drills without any head impact activities. 1
- Examples include skating drills in hockey, running drills in soccer. 2
Stage 4: Non-Contact Training Drills
- More complex training drills with progression of exercise. 1
- Light resistance training may begin at this stage. 1
Stage 5: Full-Contact Practice
- Return to normal training activities after medical clearance. 1
- Participation in all typical practice drills including contact. 1
Stage 6: Return to Play
- Normal game participation. 1
Critical Timing Considerations
Pediatric athletes require longer recovery than adults—typically 7-10 days or longer for full cognitive recovery, even after becoming asymptomatic. 1 This necessitates a more conservative approach than protocols used for college or professional athletes. 1
- Minimum 5 days required to progress through all stages if no symptoms recur. 1
- Most pediatric athletes become asymptomatic within one week, but cognitive recovery takes longer. 1
- If symptoms recur at any stage, the athlete must stop immediately, wait 24 hours after becoming asymptomatic again, then resume at the previous asymptomatic level. 1
Management of Symptom Recurrence
If symptoms return during any stage of the protocol, immediately cease that activity level. 1 After remaining asymptomatic for at least 24 hours, attempt the previous stage again before progressing. 1 Athletes should contact their healthcare provider if symptoms recur during the protocol. 1
Special Populations Requiring Extended Protocols
Athletes with multiple concussions or prolonged symptoms require longer, individualized rehabilitation programs created by physicians experienced in concussion management. 1 Consider prolonged time away from sports for any athlete with 3 concussions in one season or postconcussive symptoms lasting more than 3 months. 1
Common Pitfalls to Avoid
Premature return to play is dangerously common: Research shows 39% of pediatric athletes return to play on the day of injury, and 35% of those returning at 2 weeks remain symptomatic. 3 Additionally, 58% return without medical clearance at 2 weeks. 3
The phrase "When in doubt, sit them out" is paramount in pediatric concussion management. 1 The longer cognitive recovery period in children compared to adults makes conservative management essential for preventing long-term complications. 1
Integration with Return to School
While return to school protocols exist separately, children can progress simultaneously through both protocols during early stages (1-3), but full contact sport should be delayed until successful school reintegration is achieved. 4 Teachers and administrators must modify workloads to avoid symptom exacerbation during cognitive recovery. 1