What is the recommended evaluation, imaging criteria, and stepwise return‑to‑school and return‑to‑play protocol for clearing a pediatric patient after a suspected concussion?

Clearing a Pediatric Patient from Concussion

Immediate Removal and Assessment

Any child with suspected concussion must be removed from play immediately and cannot return to activity on the same day, even if symptoms resolve completely. 1, 2, 3

Red-Flag Evaluation Requiring Emergency Care

• Loss of consciousness >30 seconds indicates potential significant intracranial injury and warrants emergency evaluation 1
• Other red flags include severe headache, repeated vomiting, altered mental status, seizures, visual changes, or scalp deformities 1
• Use standardized sideline assessment tools (e.g., SCAT6) to evaluate symptoms, cognitive function, balance, coordination, and neurological status 1

Imaging Criteria

Routine neuroimaging (CT or MRI) is not indicated for uncomplicated concussion and should only be performed when red-flag signs suggest possible intracranial bleeding or structural injury. 1, 3

• Neuroimaging is typically normal in concussion; reserve it exclusively for cases with concerning mechanism or red-flag symptoms 1

Initial Management Phase

Cognitive and Physical Rest (First 24-48 Hours)

• Complete physical rest: no sports, physical education, or strenuous activity 1, 4
• Complete cognitive rest: coordinate with school to modify academic workload, reduce screen time, reading, and homework 1
• May require temporary school absence during this initial period 5, 6

Important Timing Considerations

• Pediatric athletes typically require 7-10 days or longer for full recovery—significantly longer than collegiate or professional athletes 1, 3
• Most pediatric concussions resolve within 7-10 days, though approximately 10% experience persistent symptoms beyond 4 weeks 1
• Cognitive recovery takes longer than symptom resolution, even after the child feels asymptomatic 3

Graduated Return-to-Learn Protocol

Begin return-to-school concurrent with physical recovery, starting once the initial 24-48 hour rest period is complete. 1

• Start with partial school days or reduced workload 1
• Provide accommodations: extended test time, reduced homework, scheduled breaks 1
• Progress gradually as symptoms allow 1
• The athlete must achieve full return to school before beginning the return-to-play protocol 5

Graduated Return-to-Play Protocol

Implement a minimum 5-day stepwise protocol only after the athlete is completely asymptomatic both at rest AND with exertion. 1, 2, 3

The 6-Stage Protocol (Each Stage Minimum 24 Hours)

1. Stage 1: Complete Rest

   • No physical or cognitive activity until asymptomatic at rest 3
   • Restrict schoolwork that may exacerbate symptoms 3

2. Stage 2: Light Aerobic Activity

   • Walking, swimming, or stationary cycling at ≤70% maximum heart rate 2, 3
   • No resistance exercises permitted 2, 3

3. Stage 3: Sport-Specific Exercise

   • Football-specific drills without head impact 2
   • No contact activities 2

4. Stage 4: Non-Contact Training Drills

   • More complex training drills 2, 3
   • May begin light resistance training 2, 3

5. Stage 5: Full-Contact Practice

   • Return to normal training activities after medical clearance 2, 3
   • Participate in all typical practice drills including contact 3

6. Stage 6: Return to Play

   • Normal game participation 2, 3

Critical Protocol Rules

If ANY symptom recurs at ANY stage, stop activity immediately. 1, 2, 3

• After remaining symptom-free for 24 hours, return to the previous asymptomatic stage before attempting progression again 1, 2, 3
• Contact healthcare professional if symptoms reappear during progression 1, 2
• Never skip any stage of the protocol 1

Medical Clearance Requirements

A qualified healthcare professional with expertise in concussion management must evaluate and clear the pediatric athlete before any return to sport. 1, 3

• Clearance should only be granted when the athlete is completely asymptomatic both at rest and with exertion 1, 2
• A more conservative approach is mandatory for pediatric patients compared with adults 1

Specialist Referral Criteria

Refer to a concussion specialist when: 1

• History of multiple prior concussions 1
• Post-concussive symptoms persist >3 months (or >10-14 days per some guidelines) 1, 4
• Uncertainty regarding appropriate timing for return-to-play 1

Sport Retirement Considerations

Consider retirement from contact sports if: 1, 3

• The athlete sustains ≥3 concussions in a single season 1, 3
• Symptoms persist >3 months 1, 3
• Pattern of multiple concussions with progressively longer recovery periods 1

Common Pitfalls to Avoid

• Never allow same-day return to play, even if the athlete feels completely asymptomatic 1, 2, 3
• Never progress through the RTP protocol while the athlete remains symptomatic 1
• Never apply adult recovery timelines to pediatric athletes—children require longer recovery periods 1, 3
• Never rely solely on neuropsychological testing to make RTP decisions; it cannot diagnose concussion or determine readiness for return-to-play 1
• Never skip any stage of the graduated RTP protocol 1
• Remember: "When in doubt, sit them out" 3

Role of Neuropsychological Testing

• Neuropsychological testing can provide objective baseline and follow-up data but cannot be used alone to diagnose concussion or determine RTP readiness 1
• Most concussions can be managed appropriately without neuropsychological testing 7
• Consider comprehensive neuropsychological evaluation for athletes with persistent symptoms or complicated courses 7

Medication Considerations

• No medications are formally recommended for sport-related concussion; safety and efficacy have not been established 1
• Symptomatic treatment may be considered case-by-case, emphasizing non-pharmacologic interventions 1