What are the guidelines for a pediatric patient to return to play or gym activities after a concussion?

Pediatric Return to Play Guidelines After Concussion

Pediatric and adolescent athletes must never return to play on the same day of concussion and require a minimum 5-day graduated protocol, with each stage lasting at least 24 hours, only after becoming completely asymptomatic both at rest and with exertion. 1, 2

Absolute Contraindications to Return

• Same-day return to play is prohibited under all circumstances in pediatric athletes, regardless of symptom resolution. 1, 2
• Athletes cannot begin the return-to-play protocol until completely asymptomatic at rest AND with exertion. 1, 2
• Medical clearance from a licensed healthcare professional trained in concussion management is mandatory before full return to play. 1, 2

The Graduated 6-Stage Protocol

The American Academy of Pediatrics endorses this stepwise progression, requiring a minimum of 24 hours per stage: 1, 2

Stage 1: Complete Rest

• Complete physical and cognitive rest until asymptomatic at rest. 1, 2
• Restriction from schoolwork that may exacerbate symptoms. 2
• Athletes should avoid activities that worsen symptoms (loud music, bright lights, driving if reaction times are slowed). 1

Stage 2: Light Aerobic Activity

• Walking, swimming, or stationary cycling at ≤70% maximum heart rate. 1, 2
• No resistance exercises permitted at this stage. 1, 2

Stage 3: Sport-Specific Exercise

• Sport-specific drills without head impact. 1
• Activities should simulate sport movements but avoid contact. 3

Stage 4: Non-Contact Training Drills

• More complex training drills with progression of exercise. 1, 2
• Light resistance training may begin at this stage. 2

Stage 5: Full-Contact Practice

• Return to normal training activities after medical clearance. 2
• Participation in all typical practice drills including contact. 2

Stage 6: Return to Play

• Normal game participation. 1, 2

Critical Timing Considerations

Pediatric athletes require significantly longer recovery than adults—typically 7-10 days or longer for full cognitive recovery, even after becoming asymptomatic. 1, 2

• The minimum timeline is 5 days to progress through all stages if no symptoms recur. 1, 2
• Most pediatric athletes become asymptomatic within one week, but cognitive recovery extends beyond symptom resolution. 1, 2
• This longer cognitive recovery period necessitates a more conservative approach compared to college-aged or professional athletes. 1

Management of Symptom Recurrence

If symptoms return at any stage, immediately cease that activity level. 2

• Wait 24 hours after becoming asymptomatic again. 1, 2
• Resume at the previous asymptomatic stage before attempting progression. 1, 2
• Athletes should contact their healthcare provider if symptoms recur during the protocol. 2

Return to School Integration

• Athletes must achieve full return to school before progressing through later stages of the return-to-play protocol. 4
• Cognitive rest may require temporary school absence and/or modified classwork or homework load. 4
• Teachers and administrators must modify workloads to avoid symptom exacerbation during cognitive recovery. 2

High-Risk Populations Requiring Extended Protocols

Athletes with multiple concussions or prolonged symptoms require longer, individualized rehabilitation programs created by physicians experienced in concussion management. 2

• Consider prolonged time away from sports for any athlete with 3 concussions in one season. 2
• Athletes with postconcussive symptoms lasting more than 3 months require specialized management. 2

Critical Pitfall to Avoid

"When in doubt, sit them out" is the paramount principle in pediatric concussion management. 1, 2

The longer cognitive recovery period in children compared to adults makes conservative management essential for preventing long-term complications. 2 Rushing return to play risks symptom exacerbation and prolonged recovery. 1