What is the recommended assessment and stepwise management, including red‑flag evaluation, imaging, concussion testing, rest, medication, and graduated return‑to‑play and return‑to‑learn, for a pediatric patient with a suspected concussion?

Pediatric Concussion Protocol

Immediate Assessment and Red Flag Evaluation

Any pediatric patient with suspected concussion must be immediately removed from play and never returned to activity on the same day, even if symptoms resolve. 1, 2

Red Flags Requiring Emergency Evaluation:

• Loss of consciousness lasting >30 seconds (indicates potential significant intracranial injury) 1
• Severe or worsening headache 3
• Repeated vomiting 3
• Altered mental status or confusion 3
• Seizure activity 3
• Visual disturbances 3
• Scalp deformities suggesting skull fracture 3
• Cervical spine injury concerns (particularly in unconscious patients) 2

Initial Sideline/Clinical Assessment:

• Use standardized Sport Concussion Assessment Tool (SCAT) including symptom checklist (0-6 severity scale), cognitive testing (immediate memory, concentration, delayed recall), balance examination (Modified Balance Error Scoring System), and coordination testing 2, 3
• Document specific symptoms: headache, dizziness, nausea, difficulty concentrating, sleep disturbances, irritability, anxiety, personality changes 1, 4
• Note that loss of consciousness occurs in <10% of concussions and is not required for diagnosis 2

Imaging Decisions

Neuroimaging (CT or MRI) is generally normal in concussion and should be reserved only for suspected intracranial bleeding or structural injury, not for routine concussion diagnosis. 1, 3, 5

• Order imaging only when red flags are present or mechanism suggests significant trauma 3, 6
• Concussion is a functional brain disturbance, not a structural injury visible on standard imaging 5

Concussion Testing and Monitoring

• Neuropsychological testing provides objective data but is only one tool and does not alone diagnose concussion or determine return-to-play readiness 1
• Serial symptom assessments are essential to track recovery 2, 4
• Consider pre-existing conditions (ADHD, depression) that may affect baseline scores 2

Rest and Activity Management

Prescribe complete physical and cognitive rest for the first 24-48 hours after concussion. 3

Cognitive Rest Requirements:

• Coordinate with teachers and school administrators to modify academic workloads 1
• Avoid activities requiring concentration until symptoms resolve 3
• Reduce screen time, reading, and homework as needed 1, 4

Physical Rest:

• No sports, physical education, or strenuous activity until asymptomatic at rest and with exertion 1, 3
• Avoid activities that could result in another head injury 7

Medication Management

The safety and efficacy of medications for sport-related concussion has not been established. 1

• Symptomatic treatment may be considered on a case-by-case basis, but no medications are formally recommended for concussion management 1
• Focus on non-pharmacologic interventions as primary treatment 4, 8

Graduated Return-to-Play Protocol

Once completely asymptomatic at rest, implement a minimum 5-day stepwise protocol, with each stage lasting at least 24 hours: 1, 9, 3

1. No activity: Complete physical and cognitive rest 1, 9
2. Light aerobic activity: Walking, swimming, or stationary cycling at 70% maximum heart rate; no resistance exercises 1, 9
3. Sport-specific exercise: Sport-related drills without head impact 1, 9
4. Noncontact training drills: More complex drills; may start light resistance training 1, 9
5. Full-contact practice: After medical clearance, participate in normal training 1, 9
6. Return to play: Normal game participation 1, 9

Critical Protocol Rules:

• If any symptoms return at any stage, stop immediately 1, 9, 2
• Once asymptomatic for 24 hours, return to the previous asymptomatic stage and attempt progression again 1, 9
• Contact healthcare provider if symptoms recur during progression 1

Return-to-Learn Protocol

Implement graduated return-to-school concurrent with physical recovery: 1

• Begin with partial school days or reduced workload 1
• Gradually increase cognitive demands as tolerated 4
• Provide accommodations such as extended time on tests, reduced homework, and breaks during the day 1, 8

Expected Recovery Timeline

Most pediatric concussions resolve within 7-10 days, though recovery is longer in children than in college or professional athletes. 1, 3

• 80-90% of athletes recover within one month 3
• Some patients may take weeks to months to recover 1, 4
• Persistent symptoms beyond 4 weeks occur in approximately 10% of cases 3

Medical Clearance Requirements

Any pediatric or adolescent athlete must be evaluated and cleared by a healthcare professional experienced in concussion management before returning to play. 1, 2, 3

• Clearance should only be given when completely asymptomatic both at rest and with exertion 2, 3
• More conservative approach is warranted for pediatric patients compared to adults 1, 9

Special Considerations and Referral Criteria

Consider Specialist Referral When:

• Symptoms persist beyond 10-14 days 3
• Multiple previous concussions 1, 2
• Postconcussive symptoms lasting >3 months 1
• Uncertainty about return-to-play timing 1

Consider Retirement from Contact Sports:

• Three or more concussions in a single season 1
• Postconcussive symptoms persisting >3 months 1
• History of multiple concussions with progressively longer recovery times 1, 2, 3

Common Pitfalls to Avoid

• Never allow same-day return to play, even if asymptomatic 1, 2, 3
• Never progress through return-to-play protocol while symptomatic 1, 9
• Never rush pediatric athletes back using adult recovery timelines 1, 9
• Never rely solely on neuropsychological testing to make return-to-play decisions 1
• Never skip stages in the graduated return-to-play protocol 1, 9